Integrating pharmacogenomics into electronic health records with clinical decision support

Abstract

Purpose Pharmacogenomics is an important component of precision medicine. Informatics, especially clinical decision support (CDS) in the electronic health record (EHR), is a critical tool for the integration of pharmacogenomics into routine patient care. The purpose of this paper is to describe existing pharmacogenomic informatics models, identify key implementation steps, and discuss emerging resources to facilitate the development of pharmacogenomic clinical decision support in the EHR. Summary Effective integration of pharmacogenomic CDS into the EHR can address implementation barriers, including the increasing volume of pharmacogenomic clinical knowledge, the enduring nature of pharmacogenetic results, and the complexity of interpreting results. Both passive and active CDS provide point-of-care information to clinicians that can guide the systematic use of pharmacogenomics to proactively optimize pharmacotherapy. Key considerations for a successful implementation have been identified including clinical workflows, identification of alert triggers, and tools to guide interpretation of results. These considerations are described along with emerging resources from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and National Academy of Medicine. Conclusion Pharmacogenomic CDS in the EHR is essential to curate pharmacogenomic data and disseminate patient-specific information at the point of care. These tools facilitate prescribing optimal drug therapy based on a patient’s inherited genetic profile and ensure that genotype-guided therapy is used whenever available. Multiple model practices have demonstrated the feasibility of developing pharmacogenomic CDS within commercially available EHRs. In some situations, ancillary systems and applications outside the EHR may be integrated to augment the capabilities of the EHR.

Precision pharmacotherapy: Integrating pharmacogenomics into clinical pharmacy practice

“…Several groups and organizations have developed methodologies to support the integration of pharmacogenomic data into the EHR, including CPIC, the Implementing Genomics in Practice network (IGNITE; https://ignite-genomics.org/spark-toolbox), and the Electronic Medical Records and Genomics Network (eMERGE; https://emerge.mc.vanderbilt.edu/ and https://cdskb.org/). Efforts have focused on curating discrete pharmacogenomic data in a patient‐centric, time‐independent manner to support active and passive CDS . Active CDS tools focus primarily on interruptive “pop‐up” alerts that provide clinicians with meaningful information at the point of care (eg, drug‐genotype‐specific recommendations) .…”

Preemptive Panel-Based Pharmacogenetic Testing: The Time is Now

“…(3,15,16) Specifically, mechanisms must exist within the EHR to allow for documentation, interpretation, and storage of genetic data with appropriate drug-specific recommendations provided at the point of prescribing and/or dispensing. (15) Clinical laboratory tools or platforms that are self-contained or able to be integrated into the existing EHR are in use in some specialty areas (e.g., oncology) and may be an option to bridge this gap in some practice environments.…”

“…(3,15,16) Specifically, mechanisms must exist within the EHR to allow for documentation, interpretation, and storage of genetic data with appropriate drug-specific recommendations provided at the point of prescribing and/or dispensing. (15) Clinical laboratory tools or platforms that are self-contained or able to be integrated into the existing EHR are in use in some specialty areas (e.g., oncology) and may be an option to bridge this gap in some practice environments. However, integration of meaningful, durable clinical recommendations into the EHR is particularly challenging in pharmacogenetics given the growing evidence base for clinical utility with some gene-drug pairs, the changing nomenclature (e.g., star-allele naming conventions) for communicating pharmacogenetic test results, and ethical and legal concerns that may arise regarding tested pharmacogenetic variants that are later found to be clinically relevant.…”

Feasibility of clinical pharmacist-led CYP2C19 genotyping for patients receiving non-emergent cardiac catheterization in an integrated health system

“…The uptake in pharmacogenetics in clinical settings is being driven by the availability of evidence-based guidelines for valid and clinically actionable drug-gene pairs, as well as the incorporation of genetic information in EHR and development of associated clinical decision support tools 33. Clinical implementation of CYP2C19 genotyping is relevant to several other medications such as selective serotonin reuptake inhibitors, tricyclic antidepressants, proton pump inhibitors, and voriconazole 5,34,35.…”