Development and use of active clinical decision support for preemptive pharmacogenomics

Abstract

BackgroundActive clinical decision support (CDS) delivered through an electronic health record (EHR) facilitates gene-based drug prescribing and other applications of genomics to patient care.ObjectiveWe describe the development, implementation, and evaluation of active CDS for multiple pharmacogenetic test results reported preemptively.Materials and methodsClinical pharmacogenetic test results accompanied by clinical interpretations are placed into the patient's EHR, typically before a relevant drug is prescribed. Problem list entries created for high-risk phenotypes provide an unambiguous trigger for delivery of post-test alerts to clinicians when high-risk drugs are prescribed. In addition, pre-test alerts are issued if a very-high risk medication is prescribed (eg, a thiopurine), prior to the appropriate pharmacogenetic test result being entered into the EHR. Our CDS can be readily modified to incorporate new genes or high-risk drugs as they emerge.ResultsThrough November 2012, 35 customized pharmacogenetic rules have been implemented, including rules for TPMT with azathioprine, thioguanine, and mercaptopurine, and for CYP2D6 with codeine, tramadol, amitriptyline, fluoxetine, and paroxetine. Between May 2011 and November 2012, the pre-test alerts were electronically issued 1106 times (76 for thiopurines and 1030 for drugs metabolized by CYP2D6), and the post-test alerts were issued 1552 times (1521 for TPMT and 31 for CYP2D6). Analysis of alert outcomes revealed that the interruptive CDS appropriately guided prescribing in 95% of patients for whom they were issued.ConclusionsOur experience illustrates the feasibility of developing computational systems that provide clinicians with actionable alerts for gene-based drug prescribing at the point of care.

Primary-care providers’ perceived barriers to integration of genetics services: a systematic review of the literature

“…63 This model has been effective for pharmacogenomics. 64 Finally, medical decision support systems must continue to be designed-current applications in progress relate to pharmacogenomics 56 -so that health professionals can access up-to-the-minute relevant information and respond appropriately to the concerns they hear when interacting with their patients. 57 With the advancement of genetic technologies and continued workforce shortages of geneticists and genetic counselors, 58 PCPs will need to assume a greater responsibility in genetics medicine related to the anticipatory guidance and disease prevention that lie within their purview.…”

Pharmacogenetics for Safe Codeine Use in Sickle Cell Disease

“…41 Pretest (pregenotype) alerts are presented when a prescriber orders codeine for a patient for whom there is no CYP2D6 test result in the EHR (Fig 4A). This alert communicates that a CYP2D6 genotype should be obtained before prescribing codeine, and a CYP2D6 test may be ordered directly from the alert screen.…”

“…(Fig 2) and clinical decision support (CDS) alerts that are presented via the EHR. 40,41 For those patients who do not have a CYP2D6 result available through PG4KDS, a single gene test for CYP2D6 may be ordered as a routine clinical laboratory test to guide codeine prescribing, an option that has a turn-around time of ∼5 to 7 days. 42 St. Jude hematologists often order a CYP2D6 genotype before codeine is prescribed, anticipating the future use of codeine as a potential therapeutic option for patients with SCD.…”

Primary Care Providers’ Use of Pharmacist Support for Delivery of Pharmacogenetic Testing

“…In personalized and precision medicine, provider knowledge and decision support have been identified as key issues to the integration of new genetic and genomic applications [20]. While some groups are developing EMR-based PGx CDS alerts [21,22] PGx consultation service staffed by a pharmacist and a physician geneticist [23]. Previous studies have demonstrated that pharmacists are well suited to provide support, able to create effective relationships with providers and achieve high provider acceptance of pharmacist recommendations [24,25].…”