The emerging role of primary care in genetics

Implementing Pharmacogenomics Testing: Single Center Experience at Arkansas Children's Hospital

Pharmacogenomics (PGx) is a growing field within precision medicine. Testing can help predict adverse events and sub-therapeutic response risks of certain medications. To date, the US FDA lists over 280 drugs which provide biomarker-based dosing guidance for adults and children. At Arkansas Children’s Hospital (ACH), a clinical PGx laboratory-based test was developed and implemented to provide guidance on 66 pediatric medications for genotype-guided dosing. This PGx test consists of 174 single nucleotide polymorphisms (SNPs) targeting 23 clinically actionable PGx genes or gene variants. Individual genotypes are processed to provide per-gene discrete results in star-allele and phenotype format. These results are then integrated into EPIC- EHR. Genomic indicators built into EPIC-EHR provide the source for clinical decision support (CDS) for clinicians, providing genotype-guided dosing.

First Responder to Genomic Information: A Guide for Primary Care Providers

With rapid advances in genetics and genomics, the commercialization and access to new applications has become more widespread and omnipresent throughout biomedical research. Thus, increasingly, more patients will have personal genomic information they may share with primary care providers (PCPs) to better understand the clinical significance of the data. To be able to respond to patient inquiries about genomic data, variant interpretation, disease risk, and other issues, PCPs will need to be able to increase or refresh their awareness about genetics and genomics, and identify reliable resources to use or refer patients. While provider educational efforts have increased, with the rapid advances in the field, ongoing efforts will be needed to prepare PCPs to manage patient needs, integrate results into care, and refer as indicated.

Genetic data and electronic health records: a discussion of ethical, logistical and technological considerations

Objective

The completion of sequencing the human genome in 2003 has spurred the production and collection of genetic data at ever increasing rates. Genetic data obtained for clinical purposes, as is true for all results of clinical tests, are expected to be included in patients’ medical records. With this explosion of information, questions of what, when, where and how to incorporate genetic data into electronic health records (EHRs) have reached a critical point. In order to answer these questions fully, this paper addresses the ethical, logistical and technological issues involved in incorporating these data into EHRs.

Materials and methods

This paper reviews journal articles, government documents and websites relevant to the ethics, genetics and informatics domains as they pertain to EHRs.

Results and discussion

The authors explore concerns and tasks facing health information technology (HIT) developers at the intersection of ethics, genetics, and technology as applied to EHR development.

Conclusions

By ensuring the efficient and effective incorporation of genetic data into EHRs, HIT developers will play a key role in facilitating the delivery of personalized medicine.

Technical report: Ethical and policy issues in genetic testing and screening of children

The genetic testing and genetic screening of children are commonplace. Decisions about whether to offer genetic testing and screening should be driven by the best interest of the child. The growing literature on the psychosocial and clinical effects of such testing and screening can help inform best practices. This technical report provides ethical justification and empirical data in support of the proposed policy recommendations regarding such practices in a myriad of settings.

Development of a Test of Residents' Ethics Knowledge for Pediatrics (TREK-P)

BACKGROUND

Professionalism is one of the Accreditation Council for Graduate Medical Education's core competencies. Residency programs must teach residents about ethical principles, which is an essential component of professionalism.

OBJECTIVES

We aimed to formally develop a valid and reliable test of ethics knowledge that effectively discriminated among learners in pediatric residency training and to improve methods for measuring outcomes of resident education in medical ethics.

METHODS

We created an instrument with 36 true/false questions that tested knowledge in several domains of pediatric ethics: professionalism, adolescent medicine, genetic testing and diagnosis, neonatology, end-of-life decisions, and decision making for minors. All questions and their correct answers were derived from published statements from the American Academy of Pediatrics Committee on Bioethics. We invited a range of participants from novices to experts to complete the test. We evaluated the instrument's reliability and explored item discrimination, omitting 13 items with the least discriminatory power. Score differences between the 3 categories of examinees were evaluated.

RESULTS

The 23-item test, completed by 54 participants, demonstrated good internal reliability (Kuder-Richardson 20 statistic  =  0.73). The test was moderately difficult and had a mean overall score of 17.3 (±3.3 standard deviation). Performance appropriately improved with degree of expertise: median scores for medical students, postgraduate year-3 residents, and ethicists were 15 (65%, range, 11-19), 19 (83%, range, 14-23), and 22 (96%, range, 20-23), respectively. Ethicists' scores were significantly higher than those of medical students (P < .001) and residents (P  =  .007). Moreover, residents performed significantly better than medical students (P  =  .001).

CONCLUSIONS

We developed a standardized instrument, entitled Test of Residents' Ethics Knowledge for Pediatrics (TREK-P), to evaluate residents' knowledge of pediatric ethics. The TREK-P is easy to administer, reliably discriminates among learners, and highlights content areas in which knowledge may be deficient.