On  January  20,  2015,  as  part  of  his  State  of  the  Union address, President Obama announced the upcoming launch of the White House’s Precision Medicine  Initiative (Initiative).1 The Initiative seeks to allocate $215 million in 2016 toward a series of  efforts aimed at collecting and using genomic, lifestyle and other clinical data in furtherance of  precision medicine research.2 The response to the Initiative has been rapid and significant: in the  short time since its announcement, a two-day workshop on the Initiative has been held, with working  papers and presentations from multiple stakeholders, and an advisory committee has been formed to  help develop and implement a significant portion of the Initiative. Viewed alongside other  noteworthy developments from the past six months, the Initiative exemplifies current trends and  challenges related to health technologies, data privacy and security, and biomedical research, and  provides insight into the future of data-driven medicine.

Precision Medicine Goals

Precision medicine is not new. Sometimes called personalized or tailored  medicine,  precision   medicine  is an approach to diagnosis and treatment that departs from the standard “one-size-fits-all” approach to care.3   Although some in the field argue that the difference  between  the terms “precision medicine” and  “personalized medicine” is negligible, the term precision medicine has been actively developed  and   popularized  within  the  last  10  years  as a way to more accurately emphasize molecular-level  information aiding patient diagnosis and treatment decisions.4 Precision medicine takes as its  starting point the basic idea that an individual’s genetic makeup, environment, lifestyle and other  patient-specific information may be predictive not only to the individual’s future health, but also  to the individual’s responsiveness to treatment alternatives.5  For example, a precision medicine  approach to treating a patient might involve genetic testing to help a treating provider determine  which of several available therapeutic agents for a given condition will yield the best patient  response. Precision medicine therefore prioritizes therapeutic and cost-control objectives by  providing  the best care quickly and without costly missteps.

Aspects of the Initiative

The Initiative  aims to support precision medicine  and its goals in  two principal  resource-building ways. First, the Initiative intends to provide funding to various agencies for  the   evaluation   and   reform   of   existing   processes  and regulations to better address the large-scale data collection and analysis that is foundational to  precision medicine.6 Second, the Initiative seeks to provide research funding to expand  efforts   in  oncology  genomics  and  to  develop a research cohort study of at least one million Americans  who would participate by sharing genomic and clinical data, biospecimens and biofluids, and other  information.7 This collected information would be shared with both researchers and participants in  a variety of ways that might include electronic health record (EHR) and mobile health device  utilization.   Together, these efforts would result in a more coherent and harmonized regulatory  framework to facilitate precision medicine, while building the data and recruitment resources to  leverage that improved framework.

The Initiative also intends to focus on the following goals:

  • Ensuring a commitment to rigorous privacy protections by identifying and addressing precision  medicine data privacy and security-related issues
  • Supporting clinical trials, in partnership with pharmaceutical companies, to test specific drug  therapies selected using precision medicine techniques
  • Developing a new approach to the U.S. Food and Drug Administration’s (FDA’s) approval for next  generation sequencing technologies
  • Supporting new interoperability standards for cross-system data exchanges as part of the national  research cohort8

Funding

President Obama’s 2016 proposed budget plans to distribute the allocated funds to three different  agencies: $130 million to the National Institutes of Health (NIH) to aid in the development of the  national research cohort; $70 million to the National Cancer Institute (part of NIH) to aid the  research and application of the genomic drivers of cancer; $10 million to the FDA to support the  development and regulation of databases 

and next generation sequencing technologies; and $5 million to the Office of the National Coordinator for Health Information Technology (ONC), which helps to  coordinate federal data privacy policy, to develop interoperability standards addressing the  privacy and security of sharing research data.9

These allocations require congressional approval, and there have been early signs of bipartisan  support for the Initiative.10 This funding is part of an overall research funding package proposal  (including a nearly $1 billion increase in funding to the NIH) that reflects the Obama  administration’s intention to invest in biomedical research innovations.11

Developing the Initiative: Workshops, White Papers and Advisory Panels

Many of the Initiative’s specific research aims and measures are understandably still under  development, so it remains unclear how much data the Initiative will gather and the methods it will  use to do so. On February 11 and 12, 2015, the NIH held a workshop  on the creation of the  precision medicine cohort, exploring the opportunities and operational challenges of this  undertaking with experts and leaders from the public and private sectors.12

Prior to the workshop, the NIH also assembled four working groups. Each group developed a white  paper to aid the discussion at the workshop. The focus of these white papers is cohort  identification and recruitment; participant engagement, data privacy and return of results; data  collection and mobile technologies;   and   EHR   opportunities   and   challenges   for  research.13 The  papers  mirror  the  topics  explored  at  the workshop and provide helpful insight into the details that must be resolved before the Initiative  can be fully operational.

For example, the white paper from the working group focusing on cohort building emphasized the need  to utilize subjects and data from existing longitudinal studies in the cohort, envisioning a large  consortium of cohorts with a central infrastructure to minimize the time and cost constraints of  such an endeavor.14 The working group on participant engagement similarly addressed the cost,  participant attrition, data-sharing and governance challenges of the Initiative.15 The white paper  from the working group focusing on EHR opportunities and challenges explored a variety of pathways  by which participants’ clinical data could become available to researchers, including existing  research cohorts, organizational partnerships and individual releases. This paper also focused on  enhancing patients’ access to their own clinical and administrative data, and emphasized that  privacy pathways/consent management systems would be imperative to the Initiative’s  implementation.16 Finally, the white paper from the data collection and mobile technologies working  group emphasized that the widespread use of mobile technology would be key to capturing and  tracking relevant health data for the Initiative.17

During the Initiative workshop, NIH leaders announced the creation  of  a new  working  group  of   the  NIH  Advisory Committee. This group will develop the specifics of the  million-person research cohort envisioned by the Initiative and will make recommendations regarding its implementation to the director of the NIH. Kathy  Hudson, NIH deputy director for science, outreach and policy, and Richard Lifton, Yale University’s  Genetics Department chairman, were appointed to co-chair the group. The NIH plans to name the rest  of the panel in the coming weeks and have the group provide an initial report to the Advisory  Committee by September 2015.18

While its specifics remain under development, the Initiative is another source of public  support  and funding for potential future breakthroughs using precision medicine and other novel approaches;  it aims to create a framework where researchers, and eventually clinicians, can utilize as many  individuals as possible to collect as much data as possible to improve the quality and efficacy of  medicine.

Departing from the Status Quo

The Initiative’s announcement is part of a trend that has emerged during President Obama’s tenure  that shows the current administration confronting and supporting the modernization of U.S. medicine  in the genomic age. Not only has the president issued significant reports on big data and genomic  privacy, the administration has also begun examining and reforming major rules affecting  progressive research, such as the Health Insurance Portability and Accountability Act (HIPAA) and  the Federal Policy for the Protection of Human Subjects (Common Rule). Although the funding  allotted by the Initiative is small compared to the overall budgets for the NIH (around $30.3 billion19), FDA (around $4.4 billion20) and ONC (around $60.4 million21), the Initiative’s real significance may be the national policy recognition  of the need to reconfigure treatment approaches. The Initiative recognizes the public and private  sector’s interest in precision medicine and views precision medicine as a powerful tool, rather  than a passing trend.22  The Initiative also recognizes  the need for multi- stakeholder buy-in and involves the technology, medical, research and patient populations.23 For  example, the Initiative emphasizes patient engagement as integral to success by incorporating  patients and subjects into the planning and research process and building the patient  engagement  concept into most of its endeavors. Even the Initiative’s budget, spread among several different  agencies, may be viewed as a high-level acknowledgment that precision medicine, and the Initiative  itself, requires a coordinated, interdisciplinary effort to accomplish its goals.

The Initiative in Context

The Initiative tracks the current landscape of policy statements and proposed regulations aimed at  modernizing medical data stewardship around three principles—data privacy, data security, and data  utility. It is the latest attempt to balance the potential utility of large-scale data collection  and data sharing against the privacy and security concerns that come with that data, and should be  examined in light of other recent proposals. Some of these other proposals include the following:

  • August 27, 2014: The NIH issued its Genomic Data Sharing Policy, which promotes the sharing of  large-scale genomic data generated from NIH-funded studies and includes new subject data  protections.24
  • November 19, 2014: The NIH proposed a draft policy to ensure all NIH-funded trials are registered  for and submit summary results to clinicaltrials.gov.25
  • January 23, 2015: The FDA permitted the marketing of the first system of mobile medical  applications for continuous glucose monitoring.26 
  • January 27, 2015: The House of Representatives’ Energy and Commerce Committee released its highly anticipated discussion draft of the 21st Century Cures  Initiative legislation. This draft targeted comprehensive research and medical innovation reform,  while incorporating patient perspectives and modernizing regulatory frameworks.27

These regulatory efforts and the Initiative share several common themes. First, they indicate that  the current research infrastructure—for example, the regulations, research modalities, data capture  and sharing pathways, and funding— is anachronistic and inadequate to harness genetic and genomic  data on the scale contemplated by the Initiative.28 They also acknowledge the emerging privacy and  security concerns stemming from large-scale research and data- sharing endeavors, and, in varying  degrees, contemplate updated  privacy  and  security  protections  to  address  these issues. Ultimately, these data stewardship efforts point to shortcomings that cannot be addressed  in a piecemeal fashion and thus require comprehensive change. They are also valuable  acknowledgements that scientific and medical advancements require modernized infrastructure and  better resources to ensure optimal research power, appropriate and relevant security protocols, and  practical and reliable data privacy practices in the future.

In context, the Initiative is also important because it shows a growing interest in data sharing,  aggregation and utilization on a very large scale. This may be evidence that the social and legal  perspectives on clinical/genomic privacy are evolving. This trend may also suggest a general  acceptance of increased data sharing as a necessary driver of innovation. Given this momentum, it  is reasonable to expect continued efforts to modernize the U.S. research system, and to ultimately   expect  a significant  shift  away  from  the  current regulatory framework.