Clinical leaders at San Francisco Otolaryngology Medical Group identified areas where they could significantly impact the health and quality of life of their senior patients by helping ensure the seniors are able to exercise, are cognitively intact, can engage in social interaction and are safe from falling.

THE PROBLEM

The leaders found they could reverse the effects of early cognition impairment in one-third of their patients by looking closely at diagnoses like diabetes, high blood pressure and depression, as well as the seniors' sensory systems like vision, hearing and balance. 

Medications have a noteworthy influence on these areas and, once patients enter their 60s, many patients take multiple medications, which compounds the risks.

"With these insights, we needed a way to better manage patients on multiple medications, as well as tools to ensure all the drugs our patients took were safe and therapeutically effective," said Dr. Jacob Johnson, president of San Francisco Otolaryngology Medical Group. "This, of course, leads us to pharmacogenomics."

PROPOSAL

At its core, pharmacogenomics (PGx) simply represents another lab test to help providers make better clinical decisions. However, there are key differences when compared to more traditional testing, such as complete blood count and metabolic panels.

"First, genetic/genomic results are returned in a vocabulary that differs from common clinical terminology," Johnson explained. "Today's clinical and lab information systems are unable to translate the data so it is meaningful and useful at the point of care."

Second, PGx results represent a patient's life-long signature. Unlike other common lab tests that reflect a single point in time, PGx results are relevant to care decisions for decades to come and need to be made available in a persistent way.

Third, PGx – and all genetic/genomic science – is advancing at a rapid pace, requiring that providers who use these data sets must have in-workflow access to current knowledge-bases and clinical guidelines, Johnson added.

"It is clear the industry is on the cusp of embracing pharmacogenomics and genetic/genomic testing in general. The first hurdle is to realize the value of precision medicine to close care disparities and improve quality."

Dr. Jacob Johnson, San Francisco Otolaryngology Medical Group

"As San Francisco Otolaryngology began its PGx journey to improve care, we recognized that our current software was not designed to support these activities," he noted.

"This meant that, unless we were willing to manage testing and resulting workflows manually, which is unsustainable in a growing practice, we needed to find an informatics solution designed specifically to help us leverage the opportunity PGx offered."

San Francisco Otolaryngology turned to precision medicine IT vendor 2bPrecise.

"Their platform consumes genetic/genomic data from molecular labs and clinical information from the EHR, synthesizing them into a clinical-genomic ontology," Johnson explained. "The results are accessible to providers within their workflow. Plus, the solution is built to interact with evolving knowledge sources and care guidelines."

MEETING THE CHALLENGE

To expedite implementation, 2bPrecise initially delivered to San Francisco Otolaryngology web-based functionality. Results from tests ordered by clinicians – fulfilled via lab partner Access DX – are sent to the platform, and 2bPrecise emails the provider with an embedded link for physicians to access.

Soon the provider organization will be adopting a different, more typical approach. The precision medicine platform will integrate directly into the organization's Epic EHR desktop via a floating app so providers have one-click access within their workflow.

"We are currently piloting our PGx wellness initiative with a select cohort of patients," Johnson noted. "During Q1 of 2021, we will be rolling PGx out across our entire practice. Our objective is to make precision medicine the standard of care for all patients who are part of our wellness, cognition and falls prevention program."

The organization also is using PGx as a component of its telehealth initiative, which is incredibly important with a vulnerable population like the elderly during a pandemic.

"We can conduct a video visit with our patients to discuss their medications," Johnson said. "Then they are able to use a simple swab in their homes to collect the genetic sample and mail it to the lab. A follow-up virtual visit then allows us to discuss the results and communicate what they mean."

RESULTS

San Francisco Otolaryngology is early in its adoption of pharmacogenomics as a standard of care and the technology that supports it, which means its success metrics are qualitative rather than quantitative.

"When we embarked on this initiative, we set internal goals to: 1) thoroughly train our entire clinical staff in the science and potential of pharmacogenomics, and 2) determine effective methods to pre-screen patients to determine who should be prioritized for testing," Johnson related. "We have accomplished both with in-depth support from the technology vendor."

Not only has the vendor delivered a range of educational opportunities, it has developed and delivered assessment tools to stratify patients who would benefit most from pilot efforts, he added.

"We've received positive anecdotal feedback from clinical staff and patients alike," he said. "In one instance, a senior patient had suffered a minor cardiac event. Because she was on multiple drugs, we ordered a PGx test for her and found that neither her blood pressure nor cholesterol medications were well suited for her based on her genetic profile."

The organization provided the test results to both her primary care physician and her cardiologist, who changed the prescriptions. The patient has communicated how grateful she is that the organization performed the PGx test to help her achieve better health and a higher quality of life, Johnson relayed.

ADVICE FOR OTHERS

"As I speak with my colleagues, it is clear the industry is on the cusp of embracing PGx and genetic/genomic testing in general," he said. "The first hurdle is to realize the value of precision medicine to close care disparities and improve quality. I believe that prescribing and using medications is one of the most dangerous things we do as doctors."

Consider this analogy, Johnson said: Most drivers rely heavily on a map application when they get into their cars to alert them to traffic patterns and hazards. How can physicians prescribe medications and not check the "genetic GPS" for that particular patient? That is what PGx gives clinicians, Johnson said.

"Once healthcare has embraced the opportunity precision medicine presents, we can quickly move towards a real transformation in care," he said. 

"In a very practical sense, using PGx and other types of genetic/genomic information is just like using other tests. And, just like other familiar tests, some doctors want to go deep and want to know all about the science behind the test. Others look at the normal/abnormal results and feel confident acting on that."

Workflow and data management tools are available so providers can get the value they need, no matter how deep they want to get, he added.

"In short, I would simply advise colleagues to get started – keeping the end game in mind, since it is clear we need a new type of technology infrastructure to help us govern and manage the lifelong information precision medicine provides," he concluded.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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