Bringing Genetics to the Forefront of Primary Care
As consumer genetic testing continues to pick up steam—with the idea that patients are becoming more interested in how their inherited health impacts their future wellness—hospitals and health systems have also taken to finding ways to incorporate genetic information into primary care.
In Evanston, Ill., about 12 miles from downtown Chicago, NorthShore University HealthSystem is aiming to provide “advanced primary care” by integrating genetics as part of each patient’s care plan. Indeed, prior to a patient’s annual physical, he or she gets the opportunity to complete a genetic and wellness assessment—a questionnaire that asks the patient about his or her personal or family history of certain medical conditions.
Based on the patient’s responses, his or her physician may recommend a referral to one of NorthShore’s personalized medicine clinics or be recommended to have certain lab tests performed in order to find out additional information related to their DNA. This information would then be used to create a customized care and treatment plan based on the patient’s unique genetic characteristics and health history, according to NorthShore officials.
John Mark Revis, M.D., a primary care physician at NorthShore University HealthSystem, says that the Center for Medical Genetics at Northshore has been around since 1997, but things really kicked off about eight years ago since technology has evolved, and the breadth of testing has become more available. Revis credits Peter Hulick, M.D., the medical director of the Center for Personalized Medicine at NorthShore, for having the vision to bring genetics and genetic testing to the forefront of primary care. The integrated health system, which includes a 900-physician multispecialty group practice, NorthShore Medical Group, with 130 locations in the Chicagoland area, now has all of its primary care practices engaging in this genetic testing initiative.
Revis says that one of the main things involved in the advanced primary care program is screening out, via the 30-question questionnaire, patients who should be further tested, based on current national guidelines. “The questions are looking for specifically actionable family history items that, following national guidelines, would trigger additional genetic testing,” he says. So you are focusing in on a person’s specific history and getting more information based on that, taking his or her family history, and getting additional genetic information when it’s indicated.”
John Mark Revis, M.D.
Revis gives an example of a patient who tested positive for a specific gene; that person may have a specific screening plan laid out for him or her based on genetic history. What’s more, thanks to the power of NorthShore’s pharmacogenomics program, if the patient has a specific genetic tendency to respond to one medication over another, when the clinician puts the prescription in the EHR (electronic health record), the system triggers an alert, reminding the physician which medicines the patient may best respond to based on his or her genetic information.
There is also the common instance of cancer genetic information that puts certain patients at risk for specific types. The most commonly known, explains Revis, is the BRCA gene test for breast cancer, which would then trigger a whole different series of screening tests for that patient. Another example that Revis recalls involved a patient who was adopted and elected to have additional genetic testing. She came up with a risk for a condition known as Lynch syndrome—an inherited condition that increases cancer risk—which prompted an entire personalized plan for her, inclusive of Lynch-related cancer screenings for her future.
Revis notes that NorthShore’s physicians are very open minded about genetic testing, and everyone is aware of the role that genetics can play in patient care. “There is a lot of interest in this area and there is education that’s needed. But we were able to provide some education, and not just in terms of lectures and seminars, but actually giving our physicians the information they need at the time they need it. And this information is available through the EHR such that they can hit a link and get what they want at the point of care,” he says, adding that any provider in the health system who is seeing the patient has access to this genetic information. “It becomes part of the care record,” he says, noting that those pertinent details are saved and flagged to providers throughout that persons’ lifetime.
Of course, in the realm of genetic testing, patient privacy questions—including their willingness to have the testing done—also come into play. Revis acknowledges that these conversations need to occur, specifically about the value of the information and the privacy concerns that patients might have. “Primary care physicians will often will have those conversations, but they have the support of our genetic counselors to further support those discussions. So that’s a very important part of the decision making,” he says.
As it stands now, when a patient is referred to a personalized medicine clinic, in most cases the insurer will cover the appointment as if it were a specialty visit, says Revis. That said, when additional testing might be required beyond the initial referral visit, insurance coverage can be spotty, depending on the individual. “Some payers do pay for this and some don’t,” says Revis. “But that’s not uncommon when a new approach is brought into healthcare, and hopefully with time, it will expand and there will be more and easier coverage for these services.”
Revis also points out that most patients, in addition to the physicians, are seeing the value in these services. He notes that the initiative serves as a way to further enhance the care that NorthShore gives its patients, getting them more specific healthcare plans to predict, and hopefully prevent, diseases when possible. “When we ask our patients, they say that they find this additional dimension of their care quite beneficial,” says Revis. “The majority of our patients do engage in this genetic wellness assessment and find it valuable when they do. As information and genetic information expands, this will only become a bigger part of their care.”
