Abstract
Canadian healthcare facilities are poised to benefit from the tools of precision health. To do so effectively, however, it is crucial that we align changes in how healthcare professionals are educated in order to ensure they have the skills, knowledge, and training to fully engage with its tools. Here, we propose that the design, development, and delivery of novel educational programs focused on precision health should be prioritized for healthcare professionals, and we suggest some essential curricular considerations to that end. Additionally, it is crucial to see engagement on the part of health leaders, who will ultimately be most responsible for managing the changing needs of frontline staff as the tools of precision health become increasingly available. By engaging directly with educators in establishing new programs for precision health, we can ensure that its promise is fully for healthcare facilities, practitioners, and patients.
Introduction
Precision healthcare (which is similar, and sometimes synonymous with, “precision medicine,” “personalized medicine,” “stratified medicine,” and others) generally refers to the clinical implementation and use of “big data” tools in molecular biology and computer science in order to improve healthcare delivery and patient wellness. Its framework focuses in particular on the application of tools from “omics” fields (such as genomics) of molecular biology, and integrating “personal” information about each patient into strategies for more effective diagnoses, treatments, and disease prevention. 1
One uniting feature of precision health is the scale of data production and the resulting necessity of bringing computational analytical tools to bear. 2,3 The promise of embracing “precision healthcare” in Canada is to significantly improve the quality of care, 4 the efficacy of prevention 5 and the economy of healthcare delivery. 6 As the infrastructure and clinical support systems are developed, however, there remains a central challenge, which is to ensure there are aligned changes in program development for healthcare professional education. 7 This will be especially significant for administrators and facility decision-makers, who will be responsible for assessing future infrastructure needs (eg, information technology equipment, data storage/privacy support, bioinformatics analytical support). Additionally, clinical staff will need new expertise in how to utilize, and make decisions around, precision health tools as they become increasingly available. 8,9 Already, results from direct to consumer testing platforms (such as 23andMe) are commonly raised with clinicians, most of whom lack the background in genomics to be able to confidently assess those results when making their own diagnostic and treatment recommendations therefrom. 7
This necessarily raises several questions: What subjects need to be taught in professional education programs in order to facilitate the development and establishment of precision health in Canada? What specific training programs (eg, MD, registered nurse, pharmacist) should be targeted and how should those programs be structured and delivered? For health administrators, two questions in particular stand out: How can they best manage these changing training needs for themselves and their clinical staff while effectively navigating, and anticipating, the system demands of the population they are serving? And how will government demands be articulated as precision health becomes integrated into healthcare infrastructure?
Here, we lay out a case for supporting the development and establishment of new educational programs that target frontline healthcare professionals, while emphasizing the importance of engaging health leaders across Canada in that process. We have surveyed available literature on both the development of precision health in Canada, as well as programs focused on precision health (or similar subjects, such as “Genomic Medicine”) from around the world. First, we will briefly assess the educational needs associated with precision health; second, we will propose some broad scale curricula that should be covered in programs for frontline health professionals (including, but not limited to, core subjects, skills, and knowledge); and third, we discuss change management in facility administration, presented within the LEADS framework. 10
The next decade promises significant advancements and disruptions in how healthcare is delivered in Canada and around the world. In preparation, it behooves leaders to be proactive in ensuring both they, and the healthcare professionals with whom they work, are adequately supported and trained.
Assessing the educational needs for precision health in Canada
New and disruptive technologies are in the process of being adopted in Canadian healthcare facilities because they offer significant improvements, in both cost and quality of care. 11 They often, however, necessitate some degree of revision and/or novelty in how staff are trained and educated. 12 Broadly speaking, this is a fairly uncontroversial statement, and most educational programs and professional organizations are well structured to accommodate it via systems like “Continuing Medical Education” (CME) requirements for MDs. In the case of precision health, however, we are presented with not only one or a few disruptive technologies but a more significant restructuring of the ways in which clinical care is delivered. 12,13 Commensurate with the scale of projected disruption, the educational needs of frontline healthcare staff should be expected to be greater than the typical “update” or “revisions” that are presently addressed by the current systems of CME. The challenge facing medical educators lies in designing effective (both in cost and time), meaningful, and well reasoned courses and programs that can begin to address the training needs that precision health entails.
In doing so, there are two broad sets of questions that must be addressed: First, who should be trained? Should educational programs be specific to particular specialties for which precision health is expected to have particular relevance (eg, pharmacology, oncology)? Should general MD undergraduate education programs be revised to include significant new elements of precision health? And how should educational programs be tailored to the community of frontline healthcare professionals, such as Registered Nurses/Nurse Practitioners and pharmacists? Second, what are the best program-wide level subjects and learning objectives for educational programs focused on precision health? What are the critical skills and knowledge that need to be imparted? And what sorts of profession-level distinctions should be made? Finally, to what degree should clinical training be integrated with the training of basic researchers? Answering these questions will, in part, require engagement from healthcare administrators, in order to ensure that novel educational programs and initiatives are appropriately directed to the needs and constraints of frontline healthcare staff so they may provide innovative, collaborative, and meaningful care.
Luckily, there are several precendent-setting educational programs that can provide useful guidance in answering some of these questions, some of which have been summarized previously. 14 In examining the first set of considerations (ie, “who to train”), most of the programs that presently exist are designed in the “continuing education” sphere, and target a broad swath of healthcare and health research fields, including MDs, nurses, pharmacists, nutritionists, and graduate students in the health sciences. 15 Integrating precision health material into the undergraduate medical curriculum will be critical, as it represents a marked departure in the culture of medicine, and so new MDs will need to be properly inculcated in their primary education. This integration will require significant buy in from medical education faculty and administrators; beyond that, however, it will also take significant time and effort to integrate into the existing course structure. As such, in the immediate near-term, we advocate here for the establishment of new continuing-education programs along the lines of those cited previously, as they allow easier scalability (by including many different professions) that could allow them to exist as stand-alone programs. This will also serve to support the difficult task of opening the existing curricula for professional medical education programs by providing a chance to vet new courses, teaching material, and teaching methods. To this end, we advocate for the laddered structure of a post-graduate certificate, diploma, and master’s in precision health (Figure 1), such as that offered at many universities across the United Kingdom. 16 This would allow for enrollees from a wide variety of backgrounds to engage with subject material with a level of flexibility, offering the added benefit of integrating different areas in which precision health is being developed (ie, at level of both basic research and clinical delivery). 16 Additionally, successful programs have been designed to facilitate enrolment by practicing professionals by embracing atypical course structures, such as “mixed mode learning” (which uses both in-class and on-line approaches) and with classroom time scheduled around typical working hours. 15,17 Given the diverse needs of Canadian programs and professional backgrounds of those within them, it is advisable to follow a similar approach.
An example of a potential “laddered” post-graduate program in precision health. In this type of program, one can begin with a four-course certificate that covers the core subjects and essential foundations of precision health. That certificate can be subsequently “laddered” into a eight-course diploma by selecting four addition courses that allow for greater specialization, depending on interest and area of work. Finally, the diploma can be “laddered” into a Master’s by adding a dedicated research project or thesis.
What subjects should be prioritized for precision health education programs in Canada? The first, and most important, are the broad foundations of the field: “Omics” and modern molecular biology, “big data” integration in healthcare, and the legal and ethical implications of Precision Health. For medical and professional training programs, these could ideally form the basis for a single “Introduction to Precision Health” course. Offering a course of this type through continuing medical/professional education systems would be beneficial on its own. Ideally, however, Canadian universities would begin to explore ways in which greater depth and a more fulsome exploration of the specific tools (and, in particular, analytical output) can be used in a clinical environment (Figure 1). While many of these elements are in the process of being established, the field of pharmacogenomics, in particular, is worth emphasizing now.
Pharmacogenomics provides an approach for addressing variability in drug efficacy and tolerability via identification and tailoring of treatment for an individual based on their genetic information. To date, this approach has been implemented in numerous health systems 18 and is steadily diffusing into general practice due to the increased availability of commercial laboratories offering pharmacogenetic testing. 19 This relatively rapid uptake into practice can, in part, be attributed to clinical practice guidelines developed by expert groups such as the Clinical Pharmacogenetics Implementation Consortium (cpicpgx.org) 20 and easy access to the current state of the evidence curated by the Pharmacogenomics Knowledgebase (www.pharmgkb.org). 21 There are currently 65 medications, ranging from antidepressants to statins, for which actionable clinical pharmacogenetic guidelines and evidence exists. 22 However, to fully leverage the potential clinical impact these clinical guidelines and freely available pharmacogenomic resources can provide, training on the principles of pharmacogenomics, its limitations, and application in clinical practice is required.
Any courses and programs in precision health will also have to be adaptable, and educators involved in their implementation should recognize that many elements of this field are in the process of being established. We should expect both the subject material and the design of specific programs to be revised continually over the next 10 years.
Managing changing educational needs for precision health
As with any system-level change, there will necessarily be a prominent role for health leaders in managing its disruptive impacts. To that end, being proactive about staff education on precision health is one of the best steps that can be taken to mitigate those impacts, and to ensure that the tools of precision health are productively and beneficially integrated into clinical practice.
The additional educational needs, however, are worthy of recognition in their own right. In addition to the review and evaluation of opportunities to integrate precision health training into primary health are professional degrees, there will be a clear need for educational engagement of current healthcare professionals, through CME and other related mechanisms. How can health leaders best manage and address these needs moving forward? The LEADS framework, a Canadian leadership capabilities framework designed for innovative healthcare needs, 10 can provide opportunities to best assess which concrete steps are required to move forward successfully.
Lead self
The first step for the leader is to understand their own perceptions of the change, the anticipated needs, and how they feel about leading the initiative within their organization. 23 He or she must demonstrate his or her own willingness to learn and grow as both an individual and team member. 23 While all will likely be supporting a culture shift within the organization, there will also be a shift within themselves as leaders as they embark on this new and evolving initiative.
Engage others
Health leaders must determine who will be a part of this change, both within the organization and within the health sector at a system level (provincially, federally). 24 They will be working with many stakeholders (eg, nurses, pharmacists, physicians, patients, and the patients’ families) from a variety of different backgrounds and varying ability levels so a variety of approaches will be key to successful collaboration. Thus, a critical question is: Are there current champions of precision health that might be interested in supporting this change? While every organization views change differently, it will be important for the leader to consider what support and buy in might be expected, and which communication styles and approaches are preferred within the team. 24 The physicians might understand the details of precision health in general, but will benefit from understanding a patient’s perspective and what views and challenges might be experienced by frontline staff. By teaming up with nurses, for example, a collective benefit is achieved through collaboration to better meet the needs of everyone involved.
Each of these groups will ideally engage directly with the medical schools, universities, and colleges that offer degree programs for healthcare professionals. This could also involve volunteering to act on advisory committees (eg, patient and family advisory groups) and boards in order to ensure that these programs are being appropriately prioritized, in line with the strategic priorities of each group, and that they include the level of clinical focus and applicability that is needed to ensure that staff enrolled in them are best prepared to use precision health tools in their practices.
Achieve results
It will be important for the health leader to set the direction for his or her team and ensure there are agreed upon measurables to better understand the effectiveness of educational opportunities that are undertaken. 10 These could include monitoring how precision health education has impacted their practice, for example by asking: Has it facilitated their use of genetic/genomic testing platforms, or has it aided in their assessment of direct-to-consumer results from platforms such as 23andMe? Leaders should articulate what the desired future state should be, and then use that to direct the steps that will allow the team to successfully support the desired outcomes. The organization should determine which tools and processes are already available and which new areas or additions might be required. Whenever possible, processes should be developed and implemented through the involvement of a variety of team members, including involved stakeholders and even the patients themselves. Team collaboration will be required to enable buy in and sustainability of the vision and desired results. Do all members understand the current and future state 24 of the organization through a precision health lens? As an example, precision health education could consider a partnership with similar engagement on opioid strategies to reduce the number of medications a patient is taking by using pharmacogenomics tests to identify ineffectual or adverse drugs that are specific to each person. This sort of partnership would be mutually beneficial also from the perspective of monitoring quality improvement.
Health leaders should strategically align decisions with both the vision of the organization and of the change initiative, the organizational values, 24 and the evidence within the field of precision health and other professional best practices (eg, nursing). By focusing on results and using a collaborative approach, the team members, including the patients, will better understand and buy in to the purpose and benefits of precision health both at a system and individual level. 24
Develop coalitions
The organizational team should determine which external stakeholders should be involved and what roles they might play in the initiative. 24 Have the stakeholders previously done work in this area? What matters to them and why should they care about this initiative? Perhaps collaborating with pharmacists, nurses, and physicians to decrease the number and type of medications (eg, opioids), patients are taking in order to achieve a collective desired outcome. Ideally, different healthcare professions will work together to determine stakeholder benefits and which communication strategies would best support a collaborative, engaged, successful, and meaningful approach. While this field is certainly up and coming, the ever-evolving nature of precision health will require ongoing relationships, 24 within a likelihood of changing political environments, to continue on the shared path of health innovation.
Systems transformations
In the long term, new healthcare professional positions will likely need to be established, such as that of the “clinical bioinformatician” 25 as has been done by the National Health Service in England. 16 We have much to learn from other health jurisdictions in this field and can work together to make joint advancements. Attendant with this should be the revision and expansion of present training in bioinformatics and its allied fields (particularly computer science, data science, and statistics), as well as the coordination and integration of those programs with the new programs focused on precision health training for current healthcare professionals. By directly engaging in the development and implementation of precision health training programs and courses, healthcare administrators will have the best opportunity to ensure that their design and delivery are best suited to the needs of frontline healthcare professionals.
Organizations must orient themselves strategically to the future 24 to anticipate both the needs of the population at large and the individuals within the organization. Service delivery will require change as the needs of the system shift in order to support ongoing innovation in the field. By challenging the status quo, continuing a collaborative approach, and staying aligned with the vision, 10 the team at all levels will be best set up for success.
Conclusions
The tools and approaches of precision health stand to significantly impact the process of clinical care in Canada. This will come with major benefits, and necessarily involve disruption as these changes are managed in terms of both the core infrastructure needs and in the education of healthcare professionals. While most economic models project significant cost savings over the long term, there is little doubt that it will also require significant short-term investment. 6 This is clearly the case when it comes to training both emerging and existing healthcare professionals.
For the benefits of precision health to be fully realized, it will be critical to see current health administrators and professionals deeply engaged in the process of training and retraining, and in the design, development, and delivery of new courses and programs focused on precision health. Disengagement will mean that these programs will likely be less well designed and certainly less well supported, and as a consequence less likely to address the changing needs of frontline healthcare professionals. This will surely require an investment of time in retraining, but in the end, this will be necessary if the full benefits of precision health are to be realized for healthcare facilities, professionals, and the patients they ultimately serve.
