Ambulatory Practices Ahead of the Curve with Precision Medicine
As healthcare leaders look toward the future, most envision a clinical environment where providers are equipped and empowered to deliver personalized and precise care to their patients. Advances in genomic science over the past decade have provided insights that will enable organizations to transform the way they diagnose and treat both common and rare conditions.
Yet this progress has been slow to arrive at the point of care. Hospitals, health systems and medical groups are striving to develop strategies that allow their clinicians to leverage this critical information to improve quality of care and patient satisfaction.
Interestingly, ambulatory groups are among the leaders in adopting precision medicine, overtaking many larger organizations and academic centers, especially in pharmacogenomics (PGx). Because it delivers information about how well patients will metabolize specific medications based on their genetic profile, PGx has practical (and highly valuable) application across virtually all specialties. Impacting prescribing decisions in real time, PGx results help clinicians identify the most effective medication first, rather than relying on the traditional trial-and-error approach. In addition, these tests can flag if a drug might cause side effects (which impact how closely a patient follows the care plan) and even if it could prove unsafe or toxic.
Leadership at Murfreesboro Medical Clinic and SurgiCenter (MMC) realized several years ago that genomics and precision medicine were the future of healthcare and would be invaluable in helping provide better, safer therapies. Providers began to order PGx tests when they felt the information would benefit their treatment decisions (and thereby their patients). Initial efforts centered on psychiatric and behavioral health medications (e.g., antidepressants and anti-anxiety drugs) and common cardiovascular treatments (e.g., statins, clopidogrel). Both providers and patients saw immediate value and were excited about the potential for expanded usage.
Three barriers impeded MMC’s ability to scale its precision program, however:
1. The cost of testing. Payer policies around reimbursement are lagging and patients often are required the cover the cost. This proved to be an obstacle. While most patients intuitively recognized how valuable PGx information could be, they understandably balked at the added expense. Although prices have dropped dramatically in the past year or two, it was not so long ago that they ran into the thousands – well out of reach for the average patient.
2. Lack of understanding about how PGx factors into clinical decision making. Again, while the concept of PGx testing is easy to grasp, operational questions remained. Although most medical schools now include coursework on genomics, providers practicing today have varying degree of familiarity with this area of science. And they have a lot of questions such as: When should I order a PGx test? Does every patient need to have one? What happens if a patient’s PGx test indicates that she should change medications – but the alternative is not fully covered by insurance?
3. Lack of convenient – and understandable – access to PGx test results. To date, PGx test results are returned as a paper document or a scanned attachment in the medical record. Since results could not be saved as discreet data or integrated with other patient information, providers had to A) realize/remember the data was available somewhere in the record; B) leave their workflow and find it; and C) figure out what the test results meant in context of their patient’s condition.
It was important to MMC’s leadership and care teams to achieve success with precision medicine, and so MMC proactively addressed each of these barriers.
First, we reached out to a lab partner that specializes in PGx testing and asked if we could negotiate a pricing model to help our patients. The partner was accommodating and agreed on a cap for patients qualifying for financial assistance. Previously, we learned patients seemed to have a $100 threshold for out-of-pocket expenses and were able to stay within that price point.
Next, we began to investigate technology partners that could help MMC bring the PGx results directly into the clinical workflow. Ultimately, we adopted a solution that ingests genomic data from the lab (and can handle additional labs as we expand) and integrates it with clinical information so providers see the complete picture within the patient context. Providers can access the PGx information with one click from their EHR, and from there can dive deeper into test results or link out to evidence-based materials if they want more information.
And, of course, we are training providers and addressing operational issues on an ongoing basis. As the organization becomes more familiar with PGx, we are working out the processes, procedures, workflows and decision support to guide day-by-day precision medicine practices.
Bringing the power of pharmacogenomics to the point of care has produced a multitude of benefits.
· Patients are receiving better care. MMC has had patients diagnosed with depression, for instance, who have spent months working with their physician trying to come up with the best medication at the most appropriate dose. With ready access to genomic insights, providers can prescribe a more effective therapy much earlier in the treatment cycle. Less time is lost and the quality of the patient’s life is better. One patient messaged his physician through the portal saying MMC had “changed his life” through the simple PGx test.
· Providers feel empowered. I like to say that having genomic data available makes us feel more “doctor-y.” Clinicians have been frustrated by having to practice trial-and-error medicine for so long. PGx test results, available within the patient context and connected to current knowledgebases, mean providers have a more complete picture. They can bring all their training and skills to bear when making clinical decisions.
· MMC has differentiated itself within its service area. Patients in our region have many choices for healthcare: Nashville is just minutes away and other urban centers, like Atlanta, are within easy driving distance. Because there are many healthcare providers nearby, MMC is dedicated to leveraging all the talent and technology available to ensure our patients receive superior care. I like to say that, with precision medicine, we are on the bleeding edge, not just the cutting edge. We have had one patient tell us that the reason they chose us as their provider was our PGx program.
It is not often that an innovation of this magnitude comes along. Placing critical genomic information directly into the hands of providers, right at the point of clinical decision making, represents one such breakthrough. MMC and its patients will continue to explore the value PGx can deliver – and look beyond to additional utilization of genomic insights in areas like disease risk identification (e.g., cardiovascular) and targeted therapies for select conditions (e.g., cancer).
A primary care provider, Nicolas Cote, D.O., also serves as Chief Medical Information Officer and President of the Murfreesboro Medical Clinic and SurgiCenter in Tennessee.
