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Implementing Pharmacogenomics.

Hand in hand with efforts to do more genetic screening for conditions such as cancer and heart disease are attempts to implement pharmacogenomics programs in primary care to make sure patients aren't being adversely impacted by drug-gene interactions.

Researchers have found out the hard way that some medications don't process the same in all patients' livers. Looking at the different ways that genetics effect our liver enzymes tells us that our liver might not be able to effectively clear a medication or activate a medication, explains Melissa Murfin, PharmD, associate professor and chair of the Department of Physician Assistant Studies at Elon University in North Carolina. "The implications for primary care are that medications for depression and anxiety, and even for opioid pain relief are all processed by different liver enzymes, and if we could know ahead of time that the patient's liver works differently, we could choose a different drug or address the dosing, so the patient doesn't have any problems with it."

Pharmacists tend to have more knowledge about pharmacogenomics than physicians, but most primary care groups don't have a pharmacist in house. So how are health systems approaching the issue?

"We developed our own pharmacogenetic testing in house," says Cassie Hajek with Sanford Health. "We focused on one specific drug, Plavix. I think that was a nice way to do it, because it was less daunting to have a single test. Plavix is one where there is a great story. We know the gene involved in the metabolism of Plavix; we know it doesn't work great in some people. The 'so-what' is that when you use that information pre-emptively and the patient has a catheter and gets a stent placed, they will do a lot better and have fewer complications than when you don't pre-emptively genotype and change your medication based on that. That is a good cause-and-effect story."

Since Sanford started with Plavix, it has since expanded and now offers a pre-emptive screen that includes a full 8-gene pharmacogenetic panel. "We put the pharmacists in charge," Hajek says. "We replicated our health system's clinical governance and applied it to all the decisions we make in the genomic screening program, and pharmacy is no exception." A committee looks at all the evidence and whether or not to add new genes to the panel, and that goes through the clinical governance decision-making process. The pharmacists drive that process, review all the pharmacogenetic results and will evaluate the patients on a medication that might be impacted by the results they get back. They review it and reach out to a patient's physician about how they might use that information. "All pharmacogenetic results are discretely entered in the EHR so we can fire decision support off it," she adds. If my medical record says I am not going to respond appropriately to Plavix, if my prescriber prescribes Plavix, they get a warning."

Sanford is not alone in thinking through this work flow. UPMC is expending a lot of effort to develop integrated clinical decision support into the EHR, and that is the gold standard for addressing pharmacogenomics, says UPMC's Mylynda Massart. "At the point of care for prescribing, a physician can have all the information needed to determine which medication to use for someone's genomics. That is the ultimate goal, and we have a research project where we are working on that at UPMC."

Geisinger's Christa Martin says many health systems are struggling with pharmacogenomics for a couple of reasons: First, most individuals will carry one of those genetic changes that could have a pharmacogenomic effect, so instead of providing genetic counseling to 2 or 3 percent of the population, you are talking about almost the entire patient population having a positive result. Another issue is that although we are getting better at data integration and informatics, people still bounce from health system to health system and their health data doesn't follow them. "Groups are trying to identify the most common ones or the ones that have the most medical actionability," she says. "Pharmacogenomics is important, but it is a matter of mechanics and trying to figure out how to get that information into the EHR and use it effectively when patients are prescribed a particular drug."
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Publication:Healthcare Innovation
Date:Nov 1, 2019
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