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Maryland Community Health System Expands PGx Testing to All Employees


NEW YORK – Frederick Health is rare among community health systems in its pursuit of universal pharmacogenomics. The Frederick, Maryland-based organization hasn't reached its goal yet but is trying to set an example by providing pharmacogenetic testing for all of its employees for no out-of-pocket cost, as well as for many commercially insured patients in specific programs.

"We believe in this so much that we are covering our employees for the pharmacogenomics testing," said VP and Chief Information Officer Jackie Rice.

Frederick Health has an advantage in that it self-insures its staff. The organization was able to work with its insurance administrator to cover pharmacogenetic testing for all of its workers and medical staff and to negotiate affordable pricing with genomic laboratories, according to Rice. The test, a gene panel, costs the health system less than $300 per employee.

Rice is one of a small number of hospital CIOs with direct responsibility in genomics, as oversight of molecular data largely continues to be outside the scope of CIOs and chief medical informatics officers (CMIOs). However, Frederick Health CMIO Kristin Conley, who also serves as medical director of the organization's weight management program, has been incorporating nutrigenomics into her own internal medicine practice, and thus is also a champion of genetic testing.

Currently, Frederick Health has rolled out precision medicine to behavioral health in primary care and nutrigenomics in oncology. Oncologists and pathologists are able to order genetic tests through Meditech, and the EHR will alert primary care physicians when a test result is available.

Genomics has been more accepted in academic medical systems, cancer centers, and children's hospitals than in community health systems. While Frederick Health does have pediatrics and a cancer center, the organization does not have its own academic research apparatus, though it does have partnerships with the likes of Johns Hopkins University and the University of Texas MD Anderson Cancer Center.

The health system has also launched a partnership with the US National Institutes of Health (NIH), which has a representative at monthly Frederick Health tumor board meetings. NIH provides feedback for patients who have had molecular profiles of their tumors before the board makes recommendations on what kind of care each patient should receive.

Workflow considerations

Conley spoke at the Healthcare Information and Management Systems Society (HIMSS) annual conference in April about how Frederick Health was trying to make genetic testing and clinical decision support fit for physician workflows. She was joined by representatives from electronic health records (EHR) vendor Meditech, since Frederick Health was an early adopter of Meditech's Expanse Genomics add-on and continues to be a model for other Meditech customers looking to embrace precision medicine.

Frederick Health went live in June 2022 with Expanse Genomics, which displays genomic information in the front of the electronic chart for each patient. 

This month, Canton, Massachusetts-based Meditech completed coding to support genomics-driven clinical decision support in oncology. Jennifer Ford, product manager for laboratory information systems and genomics at Meditech, said that the vendor is looking to deliver this upgrade to early adopters in September and make it generally available by the fourth quarter.

This work involves combining the most current variant information from ClinVar and other sources with recommended therapies and available clinical trials, based on each cancer patient's specific biomarkers. This process will be integrated into the workflows of physicians as well as clinical trial coordinators, according to Ford.

"Meditech has been working on a lot of different ways to figure out how to help customers get these [precision medicine programs] off the ground," Ford said. The company has developed several new analytics tools and leveraged other built-in tools like patient registries to support precision medicine through tasks such as identifying candidates for genetic testing. A new suite of genomic analytics tools is due out before the end of the year, according to Ford.

Ford said that Frederick's strategy of providing the service to its employees before making it universal for all its patients is a smart one. "That's how you get an organization involved," she said.

The health system's pharmacy director hired a Pharm.D. last year to consult with prescribers on decisions based on pharmacogenetic results. This position is intended to save Frederick Health and its patients money by reducing drug failures as well as hospital readmissions by stepping in to explain why the EHR flagged a prescription due to a potential drug-gene interaction.

Rice said that her goal as CIO is to put contextualized genomic data in front of clinicians at the point of care, just like any other type of patient data such as vital signs or lab results.

"I look at it as my job to give the best information I can to the providers to make the best clinical [decisions] to support their patients," Rice said. "Along with that, we need to educate our patients" about why they are getting genetic tests.

Rice said that Frederick Health still delivers genetic test reports as PDF files that are not machine-readable. While those are easy to refer to, clinicians might not take the time to do so, particularly during short primary care visits. Having discrete data allows the EHR to deliver actionable clinical decision support.

Rice noted that pharmacogenomics is changing so fast that the health system needs weekly updates to its database. In the case of Frederick Health, pharmacogenomics knowledge — including new drug approvals — comes from Meditech partner First Databank, which is integrated into the EHR through an application programming interface.

It is up to the IT department to decide which clinical decision support alerts to show to each department. "My [emergency department] docs are not going to be interested in the same kind of alerts as the oncologist or even the primary care doctor," Rice said.

Frederick Health is Meditech's de facto flagship customer for Expanse Genomics. With the exception of Golden Valley Memorial Healthcare in Clinton, Missouri, which went live on Expanse Genomics for oncology pharmacogenomics in early 2022, Meditech has not named other users of its genomics module.

Reimbursement rules

Frederick Health started its pharmacogenomics program in behavioral health, expanded it to oncology, and recently opened up testing to all of its affiliated primary care physicians. Genetic counselors and nutritionists need to be involved as well, according to Rice.

Rice said that Frederick Health decided to put precision medicine under a single umbrella, rather than separate it into categories like oncology and pharmacogenomics.

"Our one goal here from my side in IT is to get the discrete data in," Rice said. Genetic testing labs are continuously telling Rice that they have their own portals for providers to log into, but Rice said that clinicians are not going to do that for multiple labs, especially in primary care, where time is of the essence.

At the HIMSS conference, an audience member asked why pharmacogenomics testing has not yet become a standard of care in routine physicals.

"It seems like it should be super simple, and I think it is," Ford said in a subsequent interview, noting the simplicity of placing orders and checking medication interactions within the EHR. But primary care physicians have so much else to squeeze into a 20-minute patient encounter that things like genetic testing tend to get pushed aside.

Criteria for eligibility for pharmacogenomics include being on multiple medications, having multiple hospital admissions, and even having insurance that will cover PGx testing, Ford added.

Indeed, lack of reimbursement is a perpetual issue, which is why Frederick Health is focusing on its employees first — and on ambulatory care.

Maryland is a certificate-of-need state, heavily regulating expansion of healthcare facilities.

"We do our pharmacogenomics testing [for] outpatients because there's no reimbursement for inpatients at all," Rice explained. Within that framework, the health system has developed registries to help identify candidates for pharmacogenomics, including those on specific classes of medications and those who have been to the emergency department at least twice in the past year.

"I do think that it's going to take a few more major disrupters, a few more Fredericks out there saying this can be done in a community system" before payors take notice, Ford said. It would also help to have integrated delivery systems and academic medical centers adopting universal pharmacogenomic testing.

Rice said that Frederick Health is working with Meditech and other technology vendors to create dashboards for tracking the progress of patients who go through its tumor board, in an effort to prove return on investment in the pharmacogenomics program.

"It's hard to prove an ROI on … decisions to change people's medication or to change their chemotherapy," Rice noted. "I think our challenge is to make sure that we are showing what we're doing, the number of tests, [and whether we] are getting reimbursed."

Rice predicted that 10 years from now, people will look back and wonder why patients were ever treated without genetic information on drug interactions. "Your genetic information is going to be used as a major data point for your treatments," she said.

Rice said that clinical decision support is "absolutely needed" for pharmacogenetic test results.

Budgetary constraints will necessitate showing the value of PGx testing in the next five years, according to Rice. She said that Frederick Health has a CEO who sees the importance of genomics, but not every community health system does. "I believe if we didn't have that from the top down, we would not be where we are," Rice said.