#AGBTPH – Josh Peterson, Scaling precision health across an enterprise

Vanderbuilt University Medical Centre.

Precision medicine can not stand alone.  It needs to be linked to the concept of a larger health care system.  We need to learn from implementations, to ensure that patient outcomes are changed.

A wave of genomic data moving in the direction of the EHR.  How do you integrate that data to make it useful, and not just a PDF?

Emerge network working on this.

Concept of Genomic Escrow, hold data until it’s ready to be used that does not go into an EHR.  Promote data over time, as you interpret that data.

PREDICT model.  Brings up relevant variants when prescriptions are applied.  Took 5 years to get all of this implemented.  6 months for each drug interaction.

Use CPIC guidelines.

Created “advisors”, that notifies when prescribing medication.  Results also in patient portal.  Limited view: is there a variant, and does it apply to a specific medication.

For Clopidogrel: (Medication releasing stent)  Number needed to genotype to potentially avert one adverse cardiac outcome: 25. Relatively strong outcome.  Retrospective studies also bore out similar strong case for using this information.

Clinician response: didn’t get complete adoption.  Some doctors were proactive, others more resistant. Obvious in retrospect:  Many of the panel tests were not ordered by physician that didn’t order.  Asking them to take ownership of something they didn’t know about.

Asked physicians: Who should take responsibility for prescription change:  67% said PREDICT staff should contact providers. 27% thought PREDICT should contact patient directly. Not the intended outcome.

Is it worth it for the institution?  How do you tell?  What’s the value of multiplex testing?

Cost effectiveness of test?  Abacavir, Azathioprine, clopidogrel and Simvastatin are cost effective… Warfarin is not particularly cost effective.  You can leverage cost effectiveness of other genes to add warfarin and make it cost effective.  Not effective on it’s own.

How about panels?  Hard to justify universal testing for pharmacogenomics… but may be used at first indication or targeted preemptive testing.  Both generate advantages, but haven’t been demonstrated to be superior.

Simulations of cost-effectiveness:  Can be modelled, and applied to other drugs.

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