Assistant Director of Pharmacy for Ambulatory Services

Dr. Jennifer A Wick

The Christ Hospital Health Network is a community-based health system comprised of both an inpatient facility and a variety of outpatient clinics and surgery centers.  Beginning in 2019, it implemented and scaled its ambulatory pharmacy program to include coverage across multiple practice areas, including primary care, orthopedics, oncology, and cardiology.  In addition, the program is pioneering comprehensive pharmacogenomic testing in the Cincinnati, OH, area.  Using novel practice models and advanced clinical decision support tools (CDSTs), the network is leading the way in integrated pharmacy care.

What is pharmacogenomics, and how does technology play a role?

Pharmacogenomics evaluates how a patient’s genes may impact the way they respond to medications, including efficacy and metabolism.  For example, patients may have a mutation in an enzyme that breaks down a particular drug.  If that mutation causes a loss of function for that enzyme, the patient will be a poor metabolizer of that drug and may encounter higher than desired drug levels.  This can lead to increased side effects and toxicity.  Conversely, if a patient has a higher than usual metabolism of drugs, they may not achieve sufficient drug levels to treat their condition.

Pharmacogenomics is a relatively new area of practice for most providers.  While the science and data behind pharmacogenomics have long been available, clinical implementation has been a struggle.  Plagued by historically long turnaround times, a lack of gene panel standardization, and a deficit in provider education, it has been an uphill battle to enmesh pharmacogenomics with everyday practice.

Thankfully, as technology has advanced, the processing speed of genetic testing has also greatly improved.  Comprehensive pharmacogenomic testing can be returned in a matter of weeks, and single gene testing can be run in a matter of hours.  In practice, this means that results can often be returned before medications are started, and any genetic interactions can be actively incorporated into the patient's therapy plan.

Providers have struggled with the varied gene panels and laboratories that are available.  Many labs will report on a small number of genes or report on only a small number of affected medications, often restricted by therapeutic area.  While easily digestible for the provider, this provides a false sense of confidence.  Providers may not realize that many indicated genes may not be tested or that interactions outside of a panel's specific therapeutic area may not be reported.  For example, if a patient receives testing for psychiatric pharmacogenomics, even if an identified gene mutation affects another drug used in cardiology, the provider would only be informed on psychiatric drug-gene interactions.  This leaves a great deal of risk for adverse effects beyond the targeted clinical area(s).  Exclusive selection of a panel that includes all guideline-indicated genes and is therapeutically agnostic removes such risk.  This has been the strategy of The Christ Hospital Health Network.  Providers no longer must search for specific panels and laboratories to find the information they are seeking but can select a single, easily located order that covers essentially all indicated genes and reports directly into the electronic health record (EHR) and CDST, where pharmacists work across the care team to optimize medication management.

However, having results available in a standardized and timely manner does not solve the entirety of implementation struggles for pharmacogenomics.  Providers are not routinely educated on pharmacogenomic interactions or the genes that should be tested.  Conducting widespread traditional education to correct this is intensive in terms of both labor and financial costs.  This is where CDST fills a unique niche.  By integrating a CDST within the EHR, The Christ Hospital Health Network provides recommendations, supporting guidelines, and clinical studies directly to the provider.  The CDST is then further supported by a network of pharmacists, who serve as clinical experts for pharmacogenomics to integrate medication management across the care team.

Why are pharmacists an integral part of the program?

Pharmacists have long been hailed as medication experts, being best situated to provide recommendations on safe and effective therapies.  The recent increase in the number of annual drug approvals, and the information which must be assessed to appropriately use these drugs, has further cemented the need for pharmacists to be better integrated into team care.  Over 100 medications have labeling for pharmacogenomic testing, which continues to increase.  Pharmacists certified in pharmacogenomics can assist providers with ordering the correct pharmacogenomic lab test, interpreting genetic results, and then issuing therapy recommendations accordingly for the ordering provider and the entire care team.

This is not only an improved level of care for the patient but also a high workplace satisfaction for providers.  Providers can focus on patient care activities rather than drudging through guidelines and primary literature for a gene interaction that is already well understood and interpretable for pharmacists.  Pharmacists are easily available as a resource for questions and can collaborate with physicians to implement improved treatment plans for various disease states, such as diabetes, hypertension, and asthma.  At The Christ Hospital Health Network, we have seen the value of ambulatory pharmacy services from patient and provider experiences.  We have a team of pharmacists who cover primary care, oncology, cardiology, and orthopedics to support the patients we care for, as well as staff and providers in our clinics and across the care team within and beyond our network.

While pharmacogenomics and pharmacist integration into team-based care have much room for improvement, we are excited to have found a path forward and to be pioneering a higher level of care for our patients.