1. PG X CDS PROCESS OUTCOMES Tim Herr Northwestern University

2. 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

3. Data Collection Data submission templates

4. Alert Scenarios

5. 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.”

6. 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.”

7. Provider Information

8. Alert Instances

9. Alert Response vs. Clinical Response Accept Override Ignore Followed Not Followed No Action Alert Response Clinical Response

10. Alerts Submitted OrganizationNumber of Alerts Boston Children’s0 (No production alerts fired) Cincinnati Children’s22 Marshfield Clinic12 Mayo Clinic5 Mt. Sinai2 Northwestern36 (5 active; 31 passive) Vanderbilt143 Total220

11. Alerts by Drug-Gene Interaction

12. Alert Responses

13. Clinical Responses

14. Responses by DGI DGI# AlertsAcceptFollow clopidogrel1713210 simvastatin191512 warfarin701

15. 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

16. 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

17. Questions? Acknowledgements: The PGx Process Outcomes Workgroup Especially Luke Rasmussen and Josh Peterson