PGX CDSPROCESS OUTCOMESTim Herr

Northwestern University

Goals

•Primary:• Determine how PGx CDS alerts affect clinical action

• Intermediate:• Inventory of alert scenarios across sites• Understand rates at which alerts are firing• Determine how physicians interact with alerts

Data Collection• Data submission templates

Alert Scenarios

Example Alert Scenarios: Warfarin• Marshfield: WARFARIN_2_2_AA

• “Genetic testing for this individual (CYP2C9*2/*2 and VKORC1: AA) indicates an initial Warfarin dose of 0.5 mg - 2 mg may be considered.”

• Mayo: warfarin/CYP2C9/VKORC1_dose_calculator• “An alert/calculator is generated for new warfarin orders if patient has

CYP2C9 and VKORC1 results in the EMR. The alert/calculator displays the variables used and the calculated dose.”

• Northwestern: Warfarin (Not on Medication, Prescribing) • “Dosing calculator should be used to determine initial warfarin dose.

Enter clinical data into dosing calculator for all patients. Addition of genetic information (see lab results) suggested for non-African Americans.”

Example Alert Scenarios: Clopidogrel• Mt. Sinai: Clopidogrel-CYP2C19 IM

• “Change to either Prasugrel or Ticagrelor”

• Marshfield: CLOPIDOGREL_2_17• “Consider alternative antiplatelet therapy.”

• Northwestern: Clopidogrel Intermediate Metabolizer (Prescribing)• “Consider alternative - medication may be ineffective if prescribed.”

Provider Information

Alert Instances

Alert Response vs. Clinical Response

Accept

Override

Ignore

Followed

Not Followed

No Action

Alert Response Clinical Response

Alerts Submitted

Organization Number of Alerts

Boston Children’s 0 (No production alerts fired)

Cincinnati Children’s 22

Marshfield Clinic 12

Mayo Clinic 5

Mt. Sinai 2

Northwestern 36 (5 active; 31 passive)

Vanderbilt 143

Total 220

Alerts by Drug-Gene Interaction

Alert Responses

Clinical Responses

Responses by DGI

DGI # Alerts Accept Followclopidogrel 171 32 10simvastatin 19 15 12warfarin 7 0 1

An Interesting Story…

• Alert: 12294605• SIMVASTATIN METABOLISM-INTERMEDIATE ACTIVITY (NOT ON MED)

• Patient had been on simvastatin 40mg for several years but Rx was expired or discontinued

• Physician sees alert at order entry• Physician opens SmartSet (informational materials)

• Physician orders simvastatin 40 mg, anyway

An Interesting Story…

• Approx. three weeks later...• Alert: 12501097• SIMVASTATIN METABOLISM-INTERMEDIATE ACTIVITY

• Physician #2 sees alert in General BPAs section

• Physician #2 opens SmartSet (informational materials)

• Physician #2 orders atorvastatin 20mg

Questions?

• Acknowledgements:• The PGx Process Outcomes Workgroup• Especially Luke Rasmussen and Josh Peterson