Table 2.

Clinician attitudes regarding notification and responsibility for acting on a pharmacogenomics result

Clinical scenario: A 65 year old patient with diabetes and hypertension experiences angina with brisk walking. Nuclear stress testing reveals evidence of cardiac ischemia. Upon referral to an interventional cardiologist, he is scheduled for elective angiography the following day and receives pharmacogenomic testing. He is prescribed aspirin and clopidogrel after successful placement of a drug-eluting stent and is discharged. One week later, the result of the pharmacogenomic test is returned and indicates that the patient is homozygous for the CYP2C19 *2 variant and thus is a poor metabolizer of clopidogrel.
	Cardiology N (%)	Non- cardiology N (%)
In addition to including the results in the electronic medical record (EMR), who should be individually notified of the new pharmacogenomics result? (check all that apply)
Not necessary to notify any provider directly	0 (0)	0 (0)
Primary care provider	22 (54)	27 (69)
Specialist treating medical condition affected by test result	37 (90)	35 (90)
Provider who ordered pharmacogenomic test	31 (76)	27 (69)
Provider who prescribed drug therapy affected by test	33 (80)	37 (95)
Patient should be notified directly	18(44)	19 (49)
Which of the patient’s providers is responsible for acting on a pharmacogenomic result if a prescription change is indicated? (check all that apply)
Primary care provider	3(7)	7 (18)
Specialist treating medical condition affected by test result	33 (80)	29 (74)
Provider who ordered pharmacogenomic test	23(56)	20 (51)
Provider who previously prescribed drug therapy affected by test	20 (49)	23 (59)
When should providers be actively notified (e.g. with a reminder or prompt) if a prescription change based on the pharmacogenomic result is indicated?
As soon as results are available in the EMR	37 (92)	36 (92)
During the next appointment at Vanderbilt	1 (2)	1 (3)
Only when selecting antiplatelet medication using e-script	2 (5)	1 (3)
No reminder or prompt necessary	0 (0)	1 (3)

Continued scenario: Six months following the patient’s stent placement, the program begins reporting genetic results to guide warfarin therapy. Based on genetic and clinical variables, the patient is expected to have a stable therapeutic INR1 on a low dose of warfarin (<21mg/week) and increased risk of bleeding on standard or high doses of warfarin. Since his stent, the patient has resumed care with his primary care provider and cardiologist in his home town.
Who should be notified of the pharmacogenomic result? (check all that apply)	Cardiology N (%)	Non- cardiology N (%)
Vanderbilt provider who has seen the patient most recently	11 (27)	8 (21)
Primary care provider	27 (66)	30 (77)
Specialist treating medical condition affected by test result	31 (76)	28 (72)
Provider who ordered the pharmacogenomic test	24 (59)	22 (56)
Provider who will prescribe drug therapy affected by test	35 (85)	30 (77)
Patient should be notified directly	19 (46)	21 (54)
Who, within Vanderbilt, should take responsibility for following up with the patient or outside providers? (check all that apply)
Vanderbilt provider who has seen the patient most recently	9 (22)	4 (10)
Vanderbilt provider who ordered the pharmacogenomic test	21 (51)	24 (62)
PREDICT2 staff should contact the providers	28 (68)	28 (72)
PREDICT staff should contact the patient directly	11 (27)	12 (31)
What are your preferred methods of receiving notification of a pharmacogenomic result that may require you to take clinical action?
Standard laboratory reporting in EMR3	15 (37)	19 (49)
Phone call from PREDICT staff	4 (10)	3 (8)
Electronic clinical message from PREDICT staff	33 (80)	27 (69)
Clinical decision support via e-prescribing and computerized physician order entry	15 (37)	16 (41)
Message to nursing staff or pharmacy directly	1 (2)	0 (0)

¹INR = International Normalized Ratio

²PREDICT is the name of the institutional pharmacogenomics program

³EMR = Electronic Medical Records