Transcript Document

Welcome
State of the GMI
State of the GMI
Lerner Research Institute 2007 Operations Report
1
2009 LRI STAR Award Winners
This program recognizes individuals who have taken special initiative
to help others and enrich the workplace
Peter Balint
Petra Platzer
There were
31 nominations submitted for 2008.
Of the 10 winners chosen, GMI had 2 STARs – we’re very proud!
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GMI Employee of the Quarter Winners
This award program offers an opportunity for GMI members to recognize peers
for their accomplishments and contributions to GMI and being a pillar of
Teamwork, Quality, Service or Innovation.
Christina Rigelsky
3rd Quarter, 2008
Nichole Prescott
4th Quarter, 2008
Todd Romigh
1st Quarter, 2009
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State of the Cleveland Clinic
Highlights
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State of Cleveland Clinic - 2009
Quality:
patient experience (ie. medical, physical & emotional)
Status
• Increased accuracy in medical care (EMR) and pharmacy data entry (CPOE)
• Increased compliance and decreased delinquent medical records
• Improved patient access with new facilities
• Decreased complaints and increased patient satisfaction scores
(above national average, but there is more work ahead)
Innovation:
Status
• Research funding (including NIH) up 6% in 2008; publications up 5%
• Building of a new, national Reference Lab Center by 105 th St.
• Partnerships with:
Google and Microsoft for home monitoring
CVS’s “Minute Clinics” for increased patient volume
• Increased media coverage, brand awareness & non-Ohio presence
(CC Abu Dhabi, Sheik Khalifa Medical Center, and Lou Ruvo Center for Brain Health)
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Contributors to Premature Mortality
45
40
35
30
%
%
25
20
15
10
5
0
Behavior
Genetics
Social
Medical Access Environmental
D.M. Cosgrove, MD, State of the Clinic, 2008
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State of Cleveland Clinic - 2009
Teamwork:
Key areas: HR, IT, Wellness, Patient Experience, Quality & Safety
Status
• Strategic Council’s 4 main initiatives in 2009:
1.
2.
3.
4.
Patient Experience
Operational Excellence
Growth
Integration of the Health System
• Current strategic investments:
1.
2.
3.
HR – employee engagement
IT – integration, upgrading, and streamlining multiple systems
Wellness – employee and patient benefits
• Improving communication and messaging to all employees
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State of Cleveland Clinic - 2009
Service:
patient and employee services given and received
Status
• Reduction of overall wait time for outpatient appointments by 5 days
(Same day Appt Initiative)
• Improved employee-focused benefits and wellness initiatives
– Weight Watchers program (lost 75,000 pounds so far)
– Smoking Cessation
– Increased tuition reimbursement programs
• Nursing Magnet Status for main campus & Fairview
• 23andMe, a free service for physicians to participate in genomic screening
• Increased Environmental Stewardship, by recycling medical waste, exploring alternate
energy sources and reducing energy consumption
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State of Cleveland Clinic - 2009
Finances:
Status
• CC is strong overall and Florida is turning a profit for the first time
• 90% of CC’s $5 billion revenue from patient revenue;
patient portion is declining due to costs of expanding the facilities and payor mix change
• Guiding Principles for handling the current economic crisis:
1.
2.
3.
4.
•
Maintain Patient Care
Preserve Jobs
Maintain compensation
Invest in the Future
Expense reduction actions taken thus far are working;
Unlike other healthcare institutions, CC has not been forced to lay off any personnel
For every $50,000 the Clinic can “save”, that translates to one job saved
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State of Cleveland Clinic - 2009
Key take-aways:
• Initiatives overall are heading in the right direction
• We should not get too comfortable with our successes
• Take advantage of this opportunity and let it stimulate us to achieve
our best
Tom Brokaw:
… “we cannot waste the opportunities that lie within this crisis;
it isn’t what divides us that’s important; it’s what unites us –
and we should continue to “Act as a Unit”….”
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State of the Genomic Medicine Institute
2008 Annual Report
Charis Eng, MD, Ph.D., FACP, Chair & Director
June 22, 2009
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GMI Core Values
To be the expert base for the principles and practice of
genomic medicine
To promote scholarly activity (research), academic
clinical practice and education
To provide a work culture that enables us to bring
genetics and genomics, through our research and clinics,
into all subspecialties of the Cleveland Clinic’s healthcare
system
To foster innovation ultimately directed at personalized
genomic-based healthcare
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The Research Triad
Research
Labs
“Cores”
GMB
IGAC
Genomics
CPGH
GMI’s interdisciplinary design as a one-stop shop is aligned with the
LRI’s Research Triad Mission and CC’s Tripartite academic mission
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New Personnel
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New Investigator
Effie Sehayek, MD
arrived June 2, 2008
• Research Focus
Genetics of sterol metabolism and atherosclerotic
cardiovascular diseases
Genetics of fat absorption from the intestine
• Academic Appointments
Effie Sehayek, MD
Assistant Professor, Dept of Molecular Medicine, CCLCM
• Funding / Awards
Scored in top 15th percentile for recent R01 submission
Laboratory
Members:
Mike Greenberg
postdoc
Katie Lintner,
Res Tech
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New Clinicians
Marc Shapiro, M.D.
Primary Appointment: Taussig Cancer Center
• Specialty:
Lung, Breast, GI cancer
• CPGH role:
Breast Cancer Clinical Geneticist
Holly Pederson, M.D.
Primary Appointment: Center for Specialized Women’s Health
• Specialty:
Breast Cancer
• CPGH role:
Cancer Genetics Fellowship
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Other Recruitment Highlights in 2008
• Stephanie Fritz, Patient Service Representative
• Kristi Bennett, Eng lab postdoc
Stephanie
Kristi
Deb
Jessi
Tom
Kathleen
• Deborah Zygmunt, Aldred lab Sr Technician
• Jessi Mester, Genetic Counselor
• Tom Oravec, Labmatrix Data Entry
• Kathleen Babb, Research Admin Coordinator
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Other Recruitment Highlights in 2008 (cont’d)
• Gina Keeler, Clinical Manager
• Joshua Cowgill, Serre lab Technician
Gina
Josh
• Jim Hester, Serre lab Computing
• Jessi Moline, Genetic Counselor
Jim
Jessi
• Michelle Maurer, Medical Secretary
• Shirley Tao, Zhang lab postdoc
Michelle
Shirley
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Other Recruitment Highlights in 2008 (cont’d)
• Charissa Peterson, Eng lab Sr Technician
• Patty Arscott, Genetic Counselor
Charissa
Patty
Jason
Hui-Hui
Shingo
Toni
• Jason He, Eng lab postdoc
• Hui-Hui Liu, Zhang lab postdoc
• Shingo Ashida, Eng lab postdoc
• Toni Bartling, Ting lab postdoc
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Other Recruitment Highlights in 2009 (cont’d)
• Theresa Welgs, Genomics Core
• Junying Lei, Eng lab Sr Technician
Theresa
Junying
Min
Monika
Yi-Ran
Meredith
• Min Zhu, Zhang lab postdoc
• Monika Hanus, GC Assistant
• Yiran Yang, Eng lab postdoc
• Meredith Holt, Project Manager
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Other Recruitment Highlights in 2009 (cont’d)
• Jeannie Choi, Ting lab Technician
• Hadley Miller, Serre lab Technician
Jeannie
Hadley
Since 2007, we have had 31 people join GMI!
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Translational Disease-Oriented
Research & Clinical Programs
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GMI’s Disease-Oriented Research Programs
Disease Emphasis of GMI Laboratories
 Cancer
 Cardiovascular
 Pulmonary
 Neuro-Psych
 Type 2 Diabetes
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Adjunct Staff:
Complement GMI’s Research and Clinical Programs
Cancer
Heart, Vessels, Blood
Bioethics & Health Policy
*Wilson Tang, M.D.
Cell Biology
*Jonathan Smith, Ph.D.
Genomic
Medicine
Opthamology
*Ruth Farrell, M.D.
*Eric Kodish, M.D.
*Richard Sharp, Ph.D.
Lung
Brain & Spine
*Elias Traboulsi, M.D.
*Bruce Lamb, Ph.D.
Pediatrics, Obstetrics & Specialties
*Ruth Farrell, M.D.
*Staff members with adjunct appointments in GMI.
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Outreach to other Research and Clinical Programs
Multidisciplinary Programs
• Asthma and Pulmonary Hypertension (Erzurum)
GMI: Michaela Aldred, Christina Rigelsky
• Barrett Esophagus/Esophageal Adenocarcinoma Consortium (Eng)
GMI: Charis Eng, Brandie Leach
• Heritable Colorectal Cancer Multidisciplinary Research Group & High Risk Cancer (Church)
GMI: Charis Eng, David Serre, Angela Ting, Brandie Leach
• Endocrine Neoplasia Genomics Research Group and Multidisciplinary Clinic (Eng)
GMI: Charis Eng, Emily Edelman
• Head and Neck Neoplasia Genetics & Genomics Research Group & High Risk Clinic
GMI: Michaela Aldred, Charis Eng, Emily Edelman
• Von Hippel-Lindau Disease Multidisciplinary (Virtual) Clinic (Eng)
GMI: Charis Eng, Amy Shealy
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Outreach to other Research and Clinical Programs
(cont’d)
• Gorlin Syndrome (Virtual) Clinic (Eng)
GMI: Charis Eng, Amy Shealy
• Marfan Syndrome Multidisciplinary Clinic (Greenberg)
GMI: Rocio Moran, Christina Rigelsky
• Tuberous Sclerosis Multidisciplinary Clinic (Gupta)
GMI: Rocio Moran, Charis Eng, Amy Shealy
(new in 2008)
• Gene Dosage and Disease Susceptibility Research Group (Nadeau)
GMI: David Serre, Angela Ting
• Diabetes Genomics Research Group (Serre)
GMI: David Serre
• Neurofibromatosis Multidisciplinary Clinic (Rothner)
GMI: Vickie Zurcher, Rebecca Mitchell, Allison Schreiber
• Hearing Management Clinic
GMI: Rocio Moran, Allison Schreiber
• Vascular Anomalies Multidisciplinary Clinic
GMI: Rocio Moran, Amy Shealy
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Satellite Genetics Clinic Expansion
• CORS/DDI
Colon Cancer
GC: Brandie Leach
• Hillcrest
Prenatal/Preconception
GC: Diane Clements
(new in 2009)
• Vascular Surgery Clinic
GC: Christina Rigelsky, Patrica Arscott
• Vascular Medicine Clinic
GC: Christina Rigelsky
• Fairview Moll Pavilion
Breast Cancer
GC: Kate Lynch, Shanna Gustafson
• Beachwood
Cancer
Prenatal/Preconception
GC: Kate Lynch, Shanna Gustafson
GC: Diane Clements
• Shaker
Developmental & Behavior Pediatrics APN: Rebecca Mitchell
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Publications & Education
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Publication Highlights
2006
2007
2008
Total Publications
30
24
38
Articles
29
22
36
4
7
8
1
2
2
(Impact Factor >10)
Books / Chapters
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Teaching:
Cleveland Clinic Lerner College of Medicine
Course Instructors
Primary Personnel
Secondary Personnel
• Michaela Aldred, Ph.D.
• Marvin Natowicz, M.D., Ph.D.
• Charis Eng, M.D., Ph.D.
• Ruth Farrell, M.D.
• Pieter Faber, Ph.D.
• Donna Hansel, Ph.D.
• Banu Gopalan, M.S.
• Eric Kodish, M.D.
• Shanna Gustafson, M.S.
• Wilson Tang, M.D.
• Rocio Moran, M.D.
• Elias Traboulsi, M.D.
• Mohammed Orloff, Ph.D.
• David Serre, Ph.D.
• Amy Shealy, M.S.
• Angela Ting, Ph.D.
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Teaching:
Molecular Medicine Ph.D. Program
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Admissions Committee:
GMI Representative: Michaela Aldred, Ph.D.
Two of nine inaugural class students rotated in the Eng lab and one
selected this lab for their thesis work.
Ying Ni
Inaugural Class
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Funding
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LRI Research Funding
Total Research Funding
(Internal & External)
$300
$245
$200
$166
$180
$202
$258
$223
$150
$150
$ In Millions
($ in Millions)
$250
Federal Funding Trend
$100
$50
$0
$100
$69 $68
Federal
'04
'05
Non-Federal
'06
CCF
'07
'08
$90
$85 $91
$101
$97
$82
$75
$50
$-
'03
$73 $76
$84
2003
2004
2005
NIH New Awards
2006
2007
2008
Total Federal Revenue
Treasury
Declines in NIH funding are being offset by gains in other federal
non-NIH sources (i.e., DOD, NASA, DOE, etc.)
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Research Funding Highlights
New Grants in 2008
• Charis Eng, M.D., Ph.D., NIH – PO1: “Genetic alterations that initiate follicular
carcinogenesis” ($223 ADC, 5 yr); BCRF: “Genes that affect mitochondrial function as
novel mediators of beast cancer susceptibility” ($129K ADC, 1yr); BCRF: “Differential
biallelic expression of PTEN in patients with heterozygous germline PTEN mutations as a
novel mechanism of modulation of breast cancer risk” ($79K ADC, 1yr); Hearst
Foundation: “Inherited Breast Cancer Research Program ($150K ADC, 2 yr)
• Aldred, Michaela, Ph.D., AHA: “Progenitor Cells in Pulmonary Hypertension” ($70K
ADC, 4yr)
• Zhang, Bin, Ph.D., NIH – March of Dimes: “Receptor-mediated ER-to-Golgi
transport of Coagulation factors V and VIII: Deficiencies in the early secretory pathway as
pathogenic mechanisms of congenital disorders” ($68K ADC, 2 yr); RO1: “Receptormediated ER-to-Golgi transport of Coagulation factors V and VIII” ($225K ADC, 5yr)
New extramural funding in CY 2008 ~$1.1M ADC, or ~$5.9 million total funding
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Philanthropic Funding
2006
2007
2008
# of donations
1
2
5
Amount (total)
$100,000
$8,000
$410,000
• Ambrose Monell Foundation: ($100K ADC, 3yr)
“Cancer Genomics Training Fellowship Program”
• Arthur Blank Foundation
• William W. Baker Family Foundation
• Norma & Albert Geller
• Roger & Sharon Vail
Dr. Eng received first endowed chair in Cancer Genomics Research:
$1.5 million endowed chair funded by Sondra and Stephen Hardis to
further Cancer Genomics Research
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Clinical Revenue
• New Genetic Counseling service reimbursement model implemented;
utilizes first genetic counseling-specific billing code
• Decoupling Geneticist and Genetic Counselor billing schema has:

increased patient access

decreased patient appointment wait times

provided opportunities for satellite clinic service expansion
• Two recent Cleveland Clinic initiatives:

Same Day Appointments

Provider-based billing
• Net effect on clinical revenue is being analyzed
GMI’s Center for Personalized Genetic Healthcare is a pioneer in transforming
traditional clinical genetics services to a financially self-sustainable model with:

increased patient access

improved patient service
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Innovations & Commercialization
• “eGMI”

Patient-entered family history
tool

Collection of personal and
family medical history
information

Creation of pedigree

Automated risk assessment

Utilizes MyConsult/eCC and
Progeny
• 4 provisional patents filed

Charis Eng, M.D., Ph.D. (3)

Effie Sehayek, M.D. (1)
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Employee Engagement
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Gallup Employee Engagement Survey
March, 2008
GMI*
LRI
CC
Gallup
50th%
Gallup
75th%
Overall Engagement
3.54
3.81
3.80
3.94
4.27
Overall Satisfaction
3.43
3.71
3.68
3.93
4.29
5-point scale: 1= Highly disagree  5= Highly Agree
* 38 GMI employees
GMI Strengths
Committed to Quality
4.26
4.04
3.94
4.11
4.44
Have Materials & Equip
4.18
4.22
3.22
4.00
4.38
GMI Opportunities
Know what’s Expected
3.34
4.26
4.43
4.50
4.71
Mission/Purpose
3.82
4.11
4.44
3.32
3.74
GMI Commitment:
“to make GMI the best workplace for GMIers”
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Engagement Initiatives
• Communication Improvement:

Increased forums (Town Hall, open staff meetings, Newsletter, etc)
• Employee Recognition:

GMI Employee of the Quarter award
• Socializing Opportunities:

Summer Picnic and Table 45 Happy Hour
• Job Expectation Clarification:

Review and redefining of all position’s key job responsibilities (KJR)

Creation of a Job Specification and Performance Roadmap (JSPR)
• Organizational Chart Refinement:

Defining subunit structures and mission statements
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THE GENOMIC MEDICINE INSTITUTE
Dr Eng
Chair
Key:
Admin Support Staff
Director,
Transl Devel
Rerko
Business
Advisory Board
Management Team
Admin Asst
Blount
Executive Team
Manager,
Integ Devel
Platzer
Admin Asst
Wilcox
Research Admin
Coordinator
Babb
Genomics
Core
P Faber
Research
Clinical Research Program
Mgr: X
Res Admin Cdtr
Babb
PI Admin Assts
Blount/Wilcox
Eng
Lab
Aldred
Lab
Zhang
Lab
Ting
Lab
Serre
Lab
Sehayek
Lab
Research
Study/Prog
Coordinators
Biorepository
Mgr: X
Computing
Balint
Center for Personalized
Genetic Healthcare
Dir: Eng
Cancer Genetics / General Genetics
Clinic Med Dir: Eng / Moran
Clinical Mgr: Keeler
MDs
Int Genomics &
Analysis
Mgr: Gopalan
Bioinformatics/
Biostatistics
Labmatrix
Genetic
Counselors
GMI Enterprise
Rerko
Project Mgr
Holt
eGMI
Platzer
Genetics
Educ Cdtr
X
IT
Architect
X
ANP
Reimbursement
Specialist
PSRs, GC Assts, Med Sec
Database
Proj Mgr
GC
Engagement: Next Steps
• Completion of all employee JSPRs
• Continued implementation of constructive and regular performance
feedback
•
•
•
•
Continued focus on improving communications
Continued supervisor/manager training to be “engaging managers”
Next round of subgroup meetings to identify next action item plans
2009 Gallup survey: June 24 - July 17
 LRI goal: improve scores by 5%
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Community Benefit & Wellness
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Institute Diversity Program
• GMI Members on Diversity Council
2008: Banu Gopalan, Coordinator
Kylie Drake
• Conversational English Program (CEP)
- Todd Romigh (coach)
- Several GMI participants
Institute Wellness Program
• Commit10 Challenge Program
Rebecca Mitchell
GMI TRIes
• Triathlon Club (runners, bikers, swimmers)
Nichole Prescott
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Community Benefit
• United Way campaign
– Last year, CC raised $1.8 million for local community resource centers
– In 2008, GMI had 45.2% participation
– 2009 campaign about to begin; GMI team captain is ?
– 2 GMI folks participated in “United Way Day of Caring”
• LRI’s Harvest for Hunger- generated 215 pounds of food, $2,400 in
donations
• Bolton School Supplies- generated ~$16,000 of supplies
• GMI Feature in Cleveland Clinic-Community Breakfast & the Community
Service Booklet
• Rebecca Mitchell, M.S.N, C.N.S., camp nurse at Knox County 4-H Camp
resulted in Caitlin Pugh Scholarship Fund donations.
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Educational & Outreach Highlights
• 6th Intl Conference on the Biology of Childhood Renal Cancers
Invited Lecturer: Michaela Aldred, Ph.D.
• Genetics Education Campaign Kickoff
Dr. Eng, Dr. Traboulsi, Dr. Moran, Cheryl Scacheri and Champions
“Genetics in Health and Disease” symposium
• Cold Spring Harbor Laboratory
Invited Lecturer: David Serre, Ph.D
• 8th Intl Anticancer Research Conference
Invited Lecturer: Angela Ting, Ph.D.
• 27th Annual Meeting of National Society of Genetic Counselors
Session Co-chair: Emily Edelman, M.S., CGC
Educational Breakout Session: Amy Shealy, M.S., CGC
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Educational Highlights
(Continued)
• 18th Annual Symposium of Society of Black Academic Surgeons
Invited Lecture: Charis Eng, M.D., Ph.D.
• Aspiring Physicians & Research Scientists Conference
Invited Panelist: Mohammed Orloff, Ph.D.
• Neurofibromatosis: A 21st Century Perspective
Invited Participants: Vickie Zurcher, M.D., Rebecca Mitchell, MSN, C.N.S.,
Allison Schreiber, M.S., CGC
• 6th Annual Pediatric Neurology Update Seminar
Invited Presenter: Rocio Moran, M.D.
• American Society of Human Genetics Invited Science Session:
“Organismal and Cellular Phenotypes of Breast Cancer Susceptibility Genes”
Chair: Charis Eng, M.D., Ph.D.
• The CPGH Genetic Counseling Internship program trained 2 GC students
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Special Events & Community Outreach
• WKYC: Family Health History Day
Dr. Eng, Shanna Gustafson
• Cleveland Museum of Natural History
• Exhibit: “RACE: Are we so different?”
•
Dawn Caraballo
Genomics Town Hall
Dawn Caraballo, Drs. Moran and Serre, Cheryl Scacheri
• PBS: “In the Family” documentary
Cheryl Scacheri (message board)
• Minority Men’s Health Fair
Dawn Caraballo
• School, Library and Support Group talks in 2008
Over a dozen educational talks given by various GMI personnel in 2008
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Awards & Honors
• GMI was honored as the featured member of the month (August) by the
Personalized Medicine Coalition
• Charis Eng, MD, PhD, Chair GMI, named Chair of the Clinical Science
Committee of the Personalized Medicine Coalition.
• Charis Eng, MD, PhD was elected to the 2008-2009 Best Doctors in
America database for her work in Clinical Cancer Genetics and Cancer
Genomic Medicine.
• Charis Eng, MD, PhD was a Visiting Professor in the Human Manpower
Development Planning Programme of Singapore’s National Cancer Center
• Charis Eng, MD, PhD was awarded the LRI Excellence Award for
Outstanding Science and Marvin Natowicz, MD, PhD was awarded the
LRI Excellence Award for Outstanding Educator
• Kristi Benett, PhD and Ying Ni, MS were both awarded entry into the
AAAS/Excellence in Science Program award for 2008-2009
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Awards & Honors
• Stacy Williams and Crystal Sterling were awarded the McNair
Undergraduate Summer Research Scholarship for Minority Students
Excelling in the Sciences
• Shireen Ganapathi was awarded the American Cancer Society Joseph F.
Silber Undergraduate Research Fellowship
• Guillaume Assie, MD, PhD was named a Finalist for the Cotterman Award
for Best Trainee-First Authored Paper published in Am J Hum Genet
• Rebecca Mitchell, RN and Patricia Pritchard were awarded LRI Star
Awards in 2008
CONGRATULATIONS
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2009 Brief Updates
• Angela Ting, Ph.D. received a Wilson Foundation grant
($91K ADC, 2yr)
• Bin Zhang, Ph.D., received an R01 summer student
supplement ($8.5K)
• Brandie Leach, MS, CGC and group received a National
Society of Genetic Counselor SIG grant ($2K)
• Published our first GMI Newsletter, “Translations”
• Met with CC Employee Health Plan to develop a model for
appropriate genetic testing recommendations and
reimbursement schemas
• Providing education to CC surrounding direct-to-consumer
genomics companies and their utility
• Highlighted by the Advisory Board Company in their Genomic
Centers of the Future Presentation
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GMI Goals & Challenges
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Short-term Goals for 2009
• Meet budgetary expectations
• Increase clinical revenue and satellite services
• Increase GMI grant funding by >20%
• Implement Cancer module of eGMI prototype in GMI and Taussig Cancer
Center
• Improve employee engagement by at least 5%
• Improve developmental opportunities for Assistant Staff and employees
• Recruit key personnel in Clinical Research Study and Genetics Education
Programs
• Increase quantity and quality of publications
• Obtain next generation high-throughput sequencer
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Continuing Objectives
• Reduce GMI’s dependency on CC operating revenue across all
units by 2011
• Further increase depth and breadth of research programs
• Continue to re-examine clinical genetics and genetic counseling
process to standardize and implement the best models
• Develop and implement relevant eGMI modules to integrate
genetic screening processes into CC patient care
• Continue outreach and education efforts for understanding and
utilizing genetics and genomics processes in patient care
• Further train next generation of biomedical researchers in CCLCM
and Molecular Medicine programs
• Increase endowment funding and philanthropic support
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Challenges ahead
• Stagnant NIH budget
• Small annual allocation of capital funding for research from CC
• Growing Federal regulations lead to compliance concerns
• Lack of unassigned laboratory, office and clinic space
• Integration of genomic medicine into CC processes and medical
specialties
• Scarcity of qualified clinical geneticists or genomic medicine physicians
• Legislative reform for Genetic Medicine
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GMI Goals & Successes:
Quality
Service
Innovation
Teamwork
Thank you all
for your hard work and a productive year!
We are on the right trend and together as a unit, we will accomplish our mission.
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Questions?
Now for a visual highlight of 2008 from Peter ….
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