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Johnson D, Del Fiol G, Kawamoto K, Romagnoli KM, Sanders N, Isaacson G, Jenkins E, Williams MS. Genetically guided precision medicine clinical decision support tools: a systematic review. J Am Med Inform Assoc 2024; 31:1183-1194. [PMID: 38558013 PMCID: PMC11031215 DOI: 10.1093/jamia/ocae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES Patient care using genetics presents complex challenges. Clinical decision support (CDS) tools are a potential solution because they provide patient-specific risk assessments and/or recommendations at the point of care. This systematic review evaluated the literature on CDS systems which have been implemented to support genetically guided precision medicine (GPM). MATERIALS AND METHODS A comprehensive search was conducted in MEDLINE and Embase, encompassing January 1, 2011-March 14, 2023. The review included primary English peer-reviewed research articles studying humans, focused on the use of computers to guide clinical decision-making and delivering genetically guided, patient-specific assessments, and/or recommendations to healthcare providers and/or patients. RESULTS The search yielded 3832 unique articles. After screening, 41 articles were identified that met the inclusion criteria. Alerts and reminders were the most common form of CDS used. About 27 systems were integrated with the electronic health record; 2 of those used standards-based approaches for genomic data transfer. Three studies used a framework to analyze the implementation strategy. DISCUSSION Findings include limited use of standards-based approaches for genomic data transfer, system evaluations that do not employ formal frameworks, and inconsistencies in the methodologies used to assess genetic CDS systems and their impact on patient outcomes. CONCLUSION We recommend that future research on CDS system implementation for genetically GPM should focus on implementing more CDS systems, utilization of standards-based approaches, user-centered design, exploration of alternative forms of CDS interventions, and use of formal frameworks to systematically evaluate genetic CDS systems and their effects on patient care.
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Affiliation(s)
- Darren Johnson
- Department of Genomic Health, Geisinger Health Systems, Danville, PA 17822, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84108, United States
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84108, United States
| | - Katrina M Romagnoli
- Department of Genomic Health, Geisinger Health Systems, Danville, PA 17822, United States
| | - Nathan Sanders
- School of Medicine, Geisinger Health Systems, Danville, PA 17822, United States
| | - Grace Isaacson
- Family Medicine, Penn Highlands Healthcare, DuBois, PA 16830, United States
| | - Elden Jenkins
- School of Medicine, Noorda College of Osteopathic Medicine, Provo, UT 84606, United States
| | - Marc S Williams
- Department of Genomic Health, Geisinger Health Systems, Danville, PA 17822, United States
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Ackerhans S, Huynh T, Kaiser C, Schultz C. Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review. Implement Sci 2024; 19:11. [PMID: 38347525 PMCID: PMC10860285 DOI: 10.1186/s13012-024-01339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity. METHODS We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists). RESULTS One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation. CONCLUSION This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.
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Affiliation(s)
- Sophia Ackerhans
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany.
| | - Thomas Huynh
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Kaiser
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
| | - Carsten Schultz
- Kiel Institute for Responsible Innovation, University of Kiel, Westring 425, 24118, Kiel, Germany
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A Theory-Informed Systematic Review of Barriers and Enablers to Implementing Multi-Drug Pharmacogenomic Testing. J Pers Med 2022; 12:jpm12111821. [PMID: 36579514 PMCID: PMC9696651 DOI: 10.3390/jpm12111821] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
PGx testing requires a complex set of activities undertaken by practitioners and patients, resulting in varying implementation success. This systematic review aimed (PROSPERO: CRD42019150940) to identify barriers and enablers to practitioners and patients implementing pharmacogenomic testing. We followed PRISMA guidelines to conduct and report this review. Medline, EMBASE, CINAHL, PsycINFO, and PubMed Central were systematically searched from inception to June 2022. The theoretical domain framework (TDF) guided the organisation and reporting of barriers or enablers relating to pharmacogenomic testing activities. From the twenty-five eligible reports, eleven activities were described relating to four implementation stages: ordering, facilitating, interpreting, and applying pharmacogenomic testing. Four themes were identified across the implementation stages: IT infrastructure, effort, rewards, and unknown territory. Barriers were most consistently mapped to TDF domains: memory, attention and decision-making processes, environmental context and resources, and belief about consequences.
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Haga SB. Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:273-285. [PMID: 31686893 PMCID: PMC6800463 DOI: 10.2147/pgpm.s179172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/12/2019] [Indexed: 12/17/2022]
Abstract
For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.
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Affiliation(s)
- Susanne B Haga
- Department of Medicine, Division of General Internal Medicine, Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, 27708, USA
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Prokosch HU, Acker T, Bernarding J, Binder H, Boeker M, Boerries M, Daumke P, Ganslandt T, Hesser J, Höning G, Neumaier M, Marquardt K, Renz H, Rothkötter HJ, Schade-Brittinger C, Schmücker P, Schüttler J, Sedlmayr M, Serve H, Sohrabi K, Storf H. MIRACUM: Medical Informatics in Research and Care in University Medicine. Methods Inf Med 2018; 57:e82-e91. [PMID: 30016814 PMCID: PMC6178200 DOI: 10.3414/me17-02-0025] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Abstract
INTRODUCTION This article is part of the Focus Theme of Methods of Information in Medicine on the German Medical Informatics Initiative. Similar to other large international data sharing networks (e.g. OHDSI, PCORnet, eMerge, RD-Connect) MIRACUM is a consortium of academic and hospital partners as well as one industrial partner in eight German cities which have joined forces to create interoperable data integration centres (DIC) and make data within those DIC available for innovative new IT solutions in patient care and medical research. OBJECTIVES Sharing data shall be supported by common interoperable tools and services, in order to leverage the power of such data for biomedical discovery and moving towards a learning health system. This paper aims at illustrating the major building blocks and concepts which MIRACUM will apply to achieve this goal. GOVERNANCE AND POLICIES Besides establishing an efficient governance structure within the MIRACUM consortium (based on the steering board, a central administrative office, the general MIRACUM assembly, six working groups and the international scientific advisory board), defining DIC governance rules and data sharing policies, as well as establishing (at each MIRACUM DIC site, but also for MIRACUM in total) use and access committees are major building blocks for the success of such an endeavor. ARCHITECTURAL FRAMEWORK AND METHODOLOGY The MIRACUM DIC architecture builds on a comprehensive ecosystem of reusable open source tools (MIRACOLIX), which are linkable and interoperable amongst each other, but also with the existing software environment of the MIRACUM hospitals. Efficient data protection measures, considering patient consent, data harmonization and a MIRACUM metadata repository as well as a common data model are major pillars of this framework. The methodological approach for shared data usage relies on a federated querying and analysis concept. USE CASES MIRACUM aims at proving the value of their DIC with three use cases: IT support for patient recruitment into clinical trials, the development and routine care implementation of a clinico-molecular predictive knowledge tool, and molecular-guided therapy recommendations in molecular tumor boards. RESULTS Based on the MIRACUM DIC release in the nine months conceptual phase first large scale analysis for stroke and colorectal cancer cohorts have been pursued. DISCUSSION Beyond all technological challenges successfully applying the MIRACUM tools for the enrichment of our knowledge about diagnostic and therapeutic concepts, thus supporting the concept of a Learning Health System will be crucial for the acceptance and sustainability in the medical community and the MIRACUM university hospitals.
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Affiliation(s)
- Hans-Ulrich Prokosch
- Chair of Medical Informatics, Department of Medical Informatics, Biometrics and Epidemiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Till Acker
- Institute of Neuropathology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Johannes Bernarding
- Chair of Medical Informatics, Institute for Biometry and Medical Informatics, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Harald Binder
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Medical Faculty and Medical Center – University of Freiburg, Freiburg, Germany
| | - Martin Boeker
- Institute of Medical Biometry and Statistics, Medical Faculty and Medical Center – University of Freiburg, Freiburg, Germany
| | - Melanie Boerries
- Institute of Molecular Medicine and Cell Research and Comprehensive Cancer Center Freiburg (CCCF), University Medical Center, Faculty of Medicine, University of Freiburg; German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) partner site Freiburg, Freiburg, Germany
| | | | - Thomas Ganslandt
- Chair of Medical Informatics, Department of Medical Informatics, Biometrics and Epidemiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Department of Biomedical Informatics, University Medicine Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Jürgen Hesser
- Experimental Radiation Oncology Department, University Medical Center Mannheim, Central Institute for Scientific Computing (IWR), Central Institute for Computer Engineering (ZITI), Heidelberg University, Mannheim, Germany
| | - Gunther Höning
- Department of Information Technology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael Neumaier
- Chair for Clinical Chemistry, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Kurt Marquardt
- University Hospital of Giessen and Marburg, Giessen, Germany
| | - Harald Renz
- Chair for Clinical Chemistry, Philipps University Marburg, Medical Director of the University Clinic Marburg, Marburg, Germany
| | - Hermann-Josef Rothkötter
- Institute of Anatomy, Otto-von-Guericke-University Magdeburg, Dean of the Medical Faculty, Magdeburg, Germany
| | - Carmen Schade-Brittinger
- Chair of the Coordinating Centre for Clinical Trials, Philipps University Marburg, Marburg, Germany
| | - Paul Schmücker
- University of Applied Sciences Mannheim, Institute for Medical Informatics, Mannheim, Germany
| | - Jürgen Schüttler
- Department of Anesthesiology, University of Erlangen-Nürnberg, Dean of the Medical Faculty, Erlangen, Germany
| | - Martin Sedlmayr
- Chair of Medical Informatics, Department of Medical Informatics, Biometrics and Epidemiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Institute of Medical Informatics and Biometrics, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Hubert Serve
- Department of Hematology and Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Keywan Sohrabi
- Faculty of Health Sciences, University of Applied Sciences – THM, Giessen, Germany
| | - Holger Storf
- Medical Informatics Group, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Bank PCD, Swen JJ, Guchelaar HJ. Implementation of Pharmacogenomics in Everyday Clinical Settings. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:219-246. [PMID: 29801576 DOI: 10.1016/bs.apha.2018.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Currently, germline pharmacogenomics (PGx) is successfully implemented within certain specialties in clinical care. With the integration of PGx in pharmacotherapy multiple stakeholders are involved, which are identified in this chapter. Clinically relevant pharmacogenes with their related PGx test are discussed, along with diagnostic test criteria to guide clinicians and policy makers in PGx test selection. The chapter further reviews the similarities and the differences between the guidelines of the Dutch Pharmacogenetics Working Group and the Clinical Pharmacogenetics Implementation Consortium which both support healthcare professionals in understanding PGx test results and help guiding pharmacotherapy by providing evidence-based dosing recommendations. Finally, clinical studies which provide scientific evidence and information on cost-effectiveness supporting clinical implementation of PGx in clinical care are discussed along with the remaining barriers for adoption of PGx testing by healthcare professionals.
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Affiliation(s)
- Paul C D Bank
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands.
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