The practice of genomic medicine: A delineation of the process and its governing principles

Genomic medicine, an emerging medical discipline, applies the principles of evolution, developmental biology, functional genomics, and structural genomics within clinical care. Enabling widespread adoption and integration of genomic medicine into clinical practice is key to achieving precision medicine. We delineate a biological framework defining diagnostic utility of genomic testing and map the process of genomic medicine to inform integration into clinical practice. This process leverages collaboration and collective cognition of patients, principal care providers, clinical genomic specialists, laboratory geneticists, and payers. We detail considerations for referral, triage, patient intake, phenotyping, testing eligibility, variant analysis and interpretation, counseling, and management within the utilitarian limitations of health care systems. To reduce barriers for clinician engagement in genomic medicine, we provide several decision-making frameworks and tools and describe the implementation of the proposed workflow in a prototyped electronic platform that facilitates genomic care. Finally, we discuss a vision for the future of genomic medicine and comment on areas for continued efforts.

The Clinical Variant Analysis Tool: Analyzing the evidence supporting reported genomic variation in clinical practice

PURPOSE

Genomic test results, regardless of laboratory variant classification, require clinical practitioners to judge the applicability of a variant for medical decisions. Teaching and standardizing clinical interpretation of genomic variation calls for a methodology or tool.

METHODS

To generate such a tool, we distilled the Clinical Genome Resource framework of causality and the American College of Medical Genetics/Association of Molecular Pathology and Quest Diagnostic Laboratory scoring of variant deleteriousness into the Clinical Variant Analysis Tool (CVAT). Applying this to 289 clinical exome reports, we compared the performance of junior practitioners with that of experienced medical geneticists and assessed the utility of reported variants.

RESULTS

CVAT enabled performance comparable to that of experienced medical geneticists. In total, 124 of 289 (42.9%) exome reports and 146 of 382 (38.2%) reported variants supported a diagnosis. Overall, 10.5% (1 pathogenic [P] or likely pathogenic [LP] variant and 39 variants of uncertain significance [VUS]) of variants were reported in genes without established disease association; 20.2% (23 P/LP and 54 VUS) were in genes without sufficient phenotypic concordance; 7.3% (15 P/LP and 13 VUS) conflicted with the known molecular disease mechanism; and 24% (91 VUS) had insufficient evidence for deleteriousness.

CONCLUSION

Implementation of CVAT standardized clinical interpretation of genomic variation and emphasized the need for collaborative and transparent reporting of genomic variation.

Impact of a nurse led multidisciplinary team on an acute medical admissions unit

OBJECTIVE

To determine the impact of a nurse-led multi-disciplinary team on management of elderly patients with functional problems admitted to an acute medical admission unit.

DESIGN

Data collection from the first 16 months of the team's operation.

SETTING

A district general hospital, Scotland.

SUBJECTS

All elderly patients with functional problems who were considered fit for immediate multi-disciplinary assessment.

RESULTS

Over 1000 patients were assessed during the first 16 months. Twenty four per cent of these frail individuals were discharged directly home, of whom, almost half had some form of ongoing support. The remaining 76% were transferred for ongoing care to other wards in the Medical Directorate. Of this group, 49% moved to general medicine, 43% to geriatric assessment and 8% to the Stroke Unit. The team were perceived to improve the appropriateness of these transfers by enabling staff to review both the medical and functional needs of elderly patients when deciding on the best setting for ongoing care.

CONCLUSIONS

Immediate multi-disciplinary assessment of elderly patients admitted to a medical admissions unit enables the early supported discharge of a proportion of elderly and enhances the ability of the hospital to place appropriately those patients requiring a longer stay.