August 13, 2014 Reduced Risk & Improved Efficacy through ... · Reduced Risk & Improved Efficacy through Integrated . 8/15/2014 4:16:52 PM

Share with us #ACE14 Copyright © 2014 Allscripts Healthcare Solutions, Inc.

1

Allscripts Client Experience 2014

Reduced Risk & Improved Efficacy through Integrated Pharmacogenetics

August 13, 2014


2

Share with us #ACE14

Stone Run Family Medicine: Joseph Weidner, Jr. – MD, FAAFP

Genelex Corp:

Kristine Ashcraft, COO

Reduced Risk & Improved Efficacy through Integrated Pharmacogenetic Analysis


3

Agenda • Adverse Drug Event Risk

• Stone Run Family Medicine - Present Integration and Workflow

– Case Presentation of Usefulness of Improved Efficacy

• Future Integration Plans


4

Learning Objectives: • Identify patients at highest risk for drug to gene interactions.

• Incorporate genetic testing and analysis into the clinical decision making

process and workflow of Allscripts ProEHR.

• Capture pharmacogenetic analysis & lab results as structured data to reduce

the risk from drug to gene interactions.

Copyright © 2013 Allscripts Healthcare Solutions, Inc. 5


Adverse Drug Event Risk & YouScript

Kristine Ashcraft, COO, Genelex



6

Prescribing in the United States • 3.7 billion drug prescriptions written in 2011

• 48% of the population on at least one prescription medication in 2008

All medication use carries risks of unforeseen consequences


7

2.2 MILLION severe adverse drug events per year

Adverse Drug Events: Avoidable medical problem

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000 H

ea

rt D

ise

as

e

Ca

nc

er

Str

ok

e

Ca

r C

ras

he

s

Rx Sources: U.S. Center for Disease Control and Prevention and Journal of the American Medical Association (JAMA)

FOURTH leading cause of death in the U.S.

Drugs and Genes play a

significant role in causing ADEs


8

Drug Interactions and Patient Genetics

• Pharmacogenetics (PGx) is the

understanding of how genetic variability

changes drug response

• Cytochromes (CYPs) are the metabolic

factories in the liver and intestine

• Genes, OTCs, herbals and other drugs

change CYP levels

• 75% of patients have variations in at least

one CYP and do not metabolize

medications normally

Medication management can help avoid these interactions


9

Personalized Prescribing

BLOCKBUSTER

One size fits all approach to drug

development and prescribing

PERSONALIZED PRESCRIBING

Enables selection of the right drug and dose


10

YouScript Personalized Prescribing Software • Sophisticated CDS tool

• Can be used with or without Genetic

information for Medication Management

• Population Risk Analysis

• Ranked Alternate Selector

• Incorporates herbals, over-the-counter and

recreational drugs

• Genotype-based drug and dosage

recommendations

• Only solution to factor multi-drug and

cumulative effects

• Evidence-based, thousands of links to clinical

literature


11

Bringing Real-Time Analytics to Prescribing


12

Personalized Prescribing Meets the Triple Aim

• Roughly half of all prescribers are using software applications which allow for

clinical decision support (CDS) tools, a meaningful use requirement.

• Utilizing pharmacogenetics and advanced medication management tools

strongly align with the Institute for Healthcare Improvement’s Triple Aim:


13

Predict Risks • Alerts help caregivers avoid potential Adverse Drug Events and treatment

failures by:

– Devoting extra vigilance to side effects

– Changing the medication’s dose

– Choosing a new therapeutic route

• Analyzing entire population also helps reveal wider trends

– Highlights high-risk patients

– Predict who may have significant unknown risks


14

Frequency of Drug and Gene Interactions

• DGIs and DDGIs accounted for 33.9%

of major or significant interactions

• Increase of 51.3% when compared to

DDIs alone

• May represent a large portion of

interactions that go undetected

– E.g. clopidogrel (Plavix®)and

CYP2C19

© 2014

Genelex

Corporation. All

DGI, 14.70%

DDGI, 19.20%

DDI, 66.10%

Major or Significant Interaction Predicted


15

Clinical Study Preliminary Data

Study background:

• 2 arms dividing a 700,000

patient, ~ 2000 physician

plan, 1000 patient genetic

testing subarm

• Patients stratified into

“Warned” or “Unwarned”

• Physician response to warnings

was voluntary

• Patients 65+ on 5+ meds

compared in 2 arms to assess

healthcare resource utilization

• MDs changed prescribing habits in 40% of

accessed warnings

• $530 USD per patient savings seen although

only 15% of MDs accessed warnings

• In high healthcare resource consuming

patients, savings was $2400 USD

Hospitalizations -2.9%

Imaging Procedures (MRI, CT, U/S, X-ray) -3.0%

Total number of drugs used* -2.0%

vs. Control Arm

* 1st 6 months



Reducing Risk at Stone Run Family Medicine (Present Integration)



17

About Stone Run Family Medicine • Family medicine practice located in Rising Sun, MD

• 2MD/1.5 PA-C; 9 FTE staff; NCQA Level 3

• 4500 active patients (past two years)

• 14000 office encounters/year

• Visits:13.7% Medical Assistance; 22% Medicare; 5% Self Pay

• Patients: 18% >age 65; 14% <age 18


18

Allscripts Professional Environment • Hosted at Union Hospital of Cecil County Since 2007

– 53 providers (46% of outpatient providers in catchment area of 120,000)

Community: 56% of primary care and 38% of specialists use Allscripts

Professional EHR

• Professional EHR Clinical Module Version 13.0 Service Pack 2 Hot Fix 1

• Build 13.2.0.98

• Allscripts PM 10.5.3.17


19

Objectives • Identify if integrating pharmacogenetic analysis provides better patient

outcomes & reduced adverse drug events

• Reduce time required to incorporate pharmacogenetic analysis in patient care

• Improved workflow determining pharmacogenetic analysis at the point of care

• Determine if proactive identification of high-risk patients improves patient

care


20

Testing & Review Workflow Overview • Comprehensive identification of high risk patients through the Allscripts

Professional EHR Reporting Module

• Patient schedule notations within Allscripts Practice Management

• Clinical & nonclinical staff collaboration for patient notification of testing

• Customized requisition form/consent form printed out

• Chart attachment & provider notifications of YouScript pharmacogenetic

analysis

• Provider review of pharmacogenetic analysis & medication changes


21

Integration Features Used • Active Medication Sync

• Daily Testing Recommendations for Scheduled Appointments

• Custom Lab Order Template

• Provider Results Messaging

• Lab Report Document sent to Patient Chart

• Genetic Problem List Entry

• YouScript Single-Sign-On


22

• Active Medication Sync

• Daily Testing Recommendations for

Scheduled Appointments






• Comprehensive identification of high risk

patients through the Allscripts Professional

EHR Reporting Module

• Patient schedule notations within Allscripts

Practice Management

• Clinical & nonclinical staff collaboration for

patient notification of testing

• Customized requisition form/consent form

printed out

• Chart attachment & provider notifications of

YouScript pharmacogenetic analysis

• Provider review of pharmacogenetic analysis

& medication changes

Integration Features Used Testing & Review Workflow


23













Practice Management



• Customized requisition form/Consent form

printed out







24

Active Medication Sync • Active or Current Medications in patient EHR charts sync to YouScript in real-

time.

Professional EHR Image © Allscripts Healthcare, LLC.


25













Practice Management




printed out







26

Daily Testing Recommendations Each night YouScript looks at scheduled patient appointments for the next day,

and indicates high-risk patients with an appointment who would benefit from

genetic testing by sending a message to a staff person.



27

Office Protocol / Workflow • “YouScript testing” entered into comments section of patient schedule of

Allscripts Practice Management


28

Office Protocol / Workflow • “YouScript testing” entered into comments section of patient schedule of

Allscripts Professional EHR


29













Practice Management




printed out







30













Practice Management




printed out







31

Custom Lab Order Template • Patient Consent Form for patient to sign

• YouScript patient and insurance billing policies (give to patient)

• Lab requisition form

• Active medications

• Allergies

• Problem list and other

past medical history



32













Practice Management




printed out







33













Practice Management




printed out







34

Provider Results Messaging

John Doe


John Doe

Billy Rubin

Walter Melon

Jane Plain

Gene U Lux

Ray Dium


35

Provider Results Messaging



36

Provider Results Messaging Open Encounters


37













Practice Management




printed out







38













Practice Management




printed out







39

Lab Report Document - Patient Chart Attachments


40

Lab Report Document sent to Patient Chart


41

Lab Report Document sent to Patient Chart Lab reports with medication analysis send to the patient chart after genetic

testing and pharmacist recommendations are complete.



42



43



44

Stone Run's Top 20 Drugs Impacted by Genes


45

Stone Run Prescribing Suggestion Actions

547 Count of Prescribing Suggestions

38% 18% 44%

Nov 16, 2013 - Aug 1, 2014


46


239 Drug-Gene / Drug-Drug-Gene Prescribing Suggestions

Nov 16, 2013 - Aug 1, 2014


47


DGI, 15%

DDGI, 19%

DDI, 66%

Major or Significant Interaction Predicted

DGI, 24%

DDGI, 22%

DDI, 53%

Major or Significant Interaction at Stone Run Family Medicine


48

NOT


49

NOT


50

Case Presentation - Utilization in the workflow of the office

• 75 year old white female

• Hypertension, Asthma, CHF, Hypothyroidism, GERD


51













Practice Management




printed out







52













Practice Management




printed out







53

Genetic Problem List Entry A problem list entry is made for each tested patient, listing their genetic

results, which are constant for the rest of their life. These diagnosis codes are

searchable in the EHR reporting module and an associated encounter is

created.



54

Genetic Problem List Entry


55













Practice Management




printed out







56













Practice Management




printed out



• Provider review of pharmacogenetic

analysis & medication changes



57

YouScript Single Sign-On


58



59



60

Outcomes • Reduced time to determine drug to gene interactions, compared with previous

available tools.

• Improved identification of high risk patients who would benefit from

pharmacogenetic screening.

• Streamlined office processes to apply pharmacogenetic testing and analysis.

• Optimizing prescription writing decision making process utilizing drug to gene

interaction analytics.


61

Lessons Learned • Using pharmacogenetic to deliver individualized care creates a shift in how we

think about adverse drug events. Side effects previously ignored because they

are expected now become solvable problems.

• Updated current Medication and Problem Lists are important in order to

generate the best pharmacogenetic analysis, and determine best who to test.

• Improve workflow during the testing process. Identify how to capture the most

appropriate testing.

• Retrospective vs Time of Prescribing Decision Making.

• Corroboration with other specialists – pitfalls and mental gymnastics

• More pointed Drug/Drug/Gene interaction checker than present Drug/Drug

Interaction Checker



Future Integration Plans



63

Next Steps • Weekly reports of highest risk recommendations

• Have other providers at Stone Run Family Medicine utilize YouScript

• Recruit other practitioners from local Allscripts user network to integrate

• Truly reduce Adverse Drug events and deaths in this group

• Realize savings in reduced health care expenditures

• Ideal scenario: Helix or other alert beside meds at time of prescribing


64

Next Steps


65

Next Steps – The good green double helix



Questions


Documents

August 13, 2014 Reduced Risk & Improved Efficacy through ... · Reduced Risk & Improved Efficacy through Integrated . 8/15/2014 4:16:52 PM