This article has been updated to include a complete list of laboratories Frederick Health is integrating with.
CHICAGO – A year after introducing a genomics add-on to its core platform, electronic health records vendor Meditech is starting to bring customers up on this technology, called Expanse Genomics. At least one early adopter has big plans for Expanse, which is designed to deliver actionable results based on genetic tests to clinicians within standard clinical workflows.
Canton, Massachusetts-based Meditech went live with its first early adopter, Golden Valley Memorial Healthcare in Clinton, Missouri, during the first quarter of this year. Jennifer Ford, product manager for laboratory information systems and genomics at Meditech, said that Golden Valley is mainly using the technology for pharmacogenomics in oncology.
Frederick Health, a health system in Frederick, Maryland, is going live with Expanse Genomics this spring as the second organization to adopt the add-on. It expects Meditech to fully support an organization-wide precision medicine program within a year or two, though the rollout will happen in phases.
Frederick Chief Information Officer Jackie Rice noted that the switch to Expanse Genomics will be a "cultural change" for practitioners, so the health system's precision medicine program has a tall educational task ahead of it. To ease clinicians into the change, it will initially go live with a limited number of use cases.
"We have to take a baby-step approach so that we're not putting this genetic information in front of people and they're uncomfortable with receiving it," said Patricia Rice, Frederick's clinical director for precision medicine and genetics.
Marsha Fearing, a physician specialist at Meditech who is tasked with engaging and educating clinicians about Expanse Genomics, said that surgeons often claim they don't have to understand genetics. "Yes, you do," she insisted. "If your patient has an RYR-1 mutation, they're at risk for getting malignant hyperthermia if you give them succinylcholine for your anesthetic."
Frederick's precision medicine and genetics program includes hereditary genetics in oncology, neurology, and cardiology, and the health system is ramping up pharmacogenomics across numerous specialties. The program also covers precision medicine-focused clinical trials, according to Jackie Rice, a registered nurse.
Though Frederick Health is a community health system, it has a clinical trials program through partnerships with organizations, including Houston-based MD Anderson Cancer Center.
Through Expanse Genomics, Meditech will display genomic information in the front of the electronic chart for each patient. Patricia Rice said that any clinically significant items will be flagged in the system.
"We have to be really careful," she said. "There aren't many providers … that really understand genetics unless they recently graduated from medical school, so we have a big agenda ahead of us to educate them so that they feel comfortable using this genetic data."
Frederick Health wants to give clinicians what Patricia Rice called a "gene-informed approach" to each patient's care. "That's why we've taken such a broad stance with our precision medicine and genetics program."
She noted that the organization's pharmacy director has hired a PharmD to consult with prescribers on pharmacogenomic decisions, initially in behavioral health. She expects that this new employee, who will start in July, will save Frederick Health and its patients money by reducing drug failures as well as hospital readmissions by stepping in to explain why the EHR flagged a prescription due to a potential drug-gene interaction.
"We're stopping the physician before they're placing the order, giving them some education on what they should be doing," such as reaching out to a pharmacist, Ford said. "We want to make sure that we're getting that check done upfront."
It usually is up to each department within the health system to decide what kind of genetic test to order, Patricia Rice said, though she and others in the precision medicine program are available to offer guidance.
Frederick Health is also working to educate payors about the benefits of genomics for preventive services and patient safety. "Eventually, this has got to make better sense for the payors to pay for it for preventative health," Jackie Rice said. "The payors aren't there yet."
While Frederick Health has numerous molecular laboratory partners, the organization will be integrating Expanse Genomics initially with Caris Life Sciences, Ambry Genetics, Foundation Medicine, Pro-GeneX, and NeoGenomics Laboratories, according to Patricia Rice, largely because those companies are experienced in matching patients to clinical trials.
"We're going to allow Frederick to connect with these labs, streamline their workflows in order to connect with the laboratories, and then curate the data," Meditech's Ford said.
These lab connections are part of Meditech's plan to overcome some of the issues that EHR vendors have had in supporting clinical genomics in their systems. They do not, however, address the lack of clear industry standards for displaying genotypes in EHRs.
Ford said that Health Level Seven International (HL7) standards had "broken down historically" because EHRs could not tell the difference between germline and somatic mutations. Expanse Genomics promises to address this disparity.
"Being able to differentiate between a germline and a somatic mutation, do you know how much time I've spent of my life trying to read through the report and figure out where this [mutation] came from?" said Fearing, a pediatrician, biochemical geneticist, and clinical geneticist. "That alone, that simple, common-sense thing, will save oncologists a lot of time."
Ford said that Meditech has spent five years making sure structured genomic data gets into the EHR and creating individual connections with reference labs. Meditech relies on HL7 interfacing standards to move reports from lab to EHR, but the vendor also structures the data with ontology from Intelligent Medical Objects (IMO).
IMO, which is being acquired by private equity firm Thomas H. Lee Partners, has worked with Meditech to develop coding structures and harmonize ontology for pharmacogenomic genes and results, according to Ford. The partners have recently moved on to cancer genes.
EHR integration is still piecemeal across the industry. Last week, Guardant Health announced plans to integrate its cancer tests into Epic Systems EHRs. However, Meditech hopes to take the burden off its customers.
Meditech was the first EHR vendor to incorporate clinical decision support company First Databank's pharmacogenomic content. Frederick Health is working with FDB via Meditech for clinical decision support, making sure that pharmacogenomic information appears in front of prescribers when they order medications.
Jackie Rice noted that FDB updates its database every two weeks, and new information appears in the Meditech EHR as it comes in from the content supplier.
"This is where it's good to be [using] a cloud, because genomic medicine changes literally so fast," Fearing said.
Meditech was founded in 1969 by one of the developers of the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) — a programming language that still underpins some of the technology in modern EHRs — but the Meditech system has fully migrated to a cloud platform in the last few years.
Fearing recalled performing a pharmacogenomics demonstration for a psychiatry hospital when the Clinical Pharmacogenetics Implementation Consortium (CPIC) had just changed its guidelines for prescribing the antipsychotic drug Abilify (aripiprazole) minutes earlier.
"I went to go prescribe Abilify, and we were served with the notice that [the patient had] a cytochrome P450 mutation, and you have to dose this drug at half," Fearing said. "We didn't plan that at all. That happened real time in the background, and I hadn't even read [the new rule] yet."
Fearing said that Expanse Genomics will be standard for current and new Meditech customers going forward, if they choose to activate the feature. Meditech is offering the technology to its entire customer base, including integrated delivery networks, academic health systems, and community, rural, and safety-net care providers.
"I really believe that people should not only be receiving this type of cutting-edge care in the academic setting," Ford said. "They should be able to go to their hospitals wherever they may be and also be able to have access to the same clinical decision support, the same correct prescribing, the same analysis of the population that any academic center might be able to do."
Meditech has also built analytics into its platform, including population-level analysis. Ford said to expect news about new genomics-focused analytics later this year.
With genetic data being so sensitive — and so protected with laws like the Genetic Information Nondiscrimination Act in the US — Fearing said that she would love to automate as many processes as possible.
"If you've got an EHR that can essentially manage the information, manage the genotype and phenotype, handle the analysis inside of it, less hands touch that data," she said. "To me as a clinician, that's really important."
'Precision nutrition' and other challenges
Meditech still delivers PDF files of genetic test reports to the EHR through Expanse Genomics in case physicians want to refer to those reports, though all of the data in the PDF is stored as discrete data in the EHR when it comes from the lab, so it can drive clinical decision support, Ford said.
Fearing said that PDF reports have a lot of information to explain mutations, though some of it can be "overwhelming," to physicians, which is why Meditech wants to include both the PDF and the discrete data.
"The reasoning [for having] those discrete results is that, one, we can start to build a patient genetic history," Ford said. "We can then utilize it for clinical decision support, whether it be pharmacogenomic or oncology clinical decision support, or down the line, hereditary clinical decision support."
Patient genetic history in the EHR can classify mutations as either germline or somatic. "It's a quick glance to understand where that mutation lies for treatment purposes," she said.
Meditech and Frederick Health are still working out when genomic information — particularly somatic mutations — should be referred to the precision medicine program or to the oncology department, she added.
Frederick Health eventually wants all of its outside labs to integrate with Meditech, and all of its clinicians to have access to genomic services through the EHR. The organization did not provide a timetable for reaching that goal.
One priority within the next year is to incorporate nutrigenomics into clinical practice through the EHR at Frederick Health. Patricia Rice said that the precision medicine program will collaborate with the health system's weight management program on an effort tentatively dubbed "precision nutrition."
She added that Kristin Conley, medical director of the weight management program, already looks for nongenetic biomarkers in her patients that can cause inflammation.
"We also hope to incorporate a group that does genetic testing for our nutritional needs," Patricia Rice said. "I will say that nutrigenomics — precision nutrition — is in its infancy as a field. We will be developing and growing as it does."