How a Nashville-area clinic teamed up with Allscripts on precision medicine

Primary care doctor Nicholas Cote, D.O., has worked with patients for months—sometimes years—as they try one prescription medication after another to try to find the best therapy with the fewest side effects, for behavioral health conditions.

With psychiatric medications and cardiovascular treatments, such as statins, it’s traditionally a trial-and-error approach, Cote told FierceHealthcare. It’s a frustrating process for patients and their doctors.

“I had a 39-year-old patient who had issues with anxiety and depression for years. We had gone back and forth with some medications to try to find the most appropriate dose; she was on one for a while but was not feeling enough effect,” said Cote, the chief medical information officer and president of the Murfreesboro Medical Clinic and SurgiCenter.

Cote ordered pharmacogenomic testing which evaluates how well patients will metabolize specific medications based on their genetic profile. As a result of those tests, Cote switched the patient to a new medication that her body would process more effectively.

“Within a month, she sent me a message saying, ‘Thank you, you’ve really changed my life.’ She said she was able to do the things that she needed to do throughout the day and was not debilitated by her problems," he said. “We see that kind of feedback from patients pretty consistently.”

Murfreesboro Medical Clinic & SurgiCenter is a 70-physician, multispecialty clinic located in Rutherford County in Tennessee, about 30 miles southeast of Nashville. For several years, the clinic has used molecular test results for select patients to support diagnostic and treatment decisions. The organization is stepping up its precision medicine efforts in a partnership with technology company 2bPrecise, a subsidiary of health IT company Allscripts, to integrate pharmacogenomic test results at the point of care.

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The use of genomic data at the point of care helps physicians to prescribe the most effective and safest medications for patients, Cote said. And genomic testing is a good fit for family practice as primary care often serves as the epicenter of care.

"I think in the next 10 years this is going to be baseline what we do in primary care," he said. "Those organizations that wait another 10 years to start doing precision medicine are going to be way behind where medicine actually is."

Finding the right medication for the patient the first time is a win for patients—and it can be a win for physicians too, Cote said.

“So much of what we do in different aspects of medicine is formulaic and it’s algorithmic. The result is, if all you do is use algorithms all day, you start to feel like an AI and not a physician practicing the art of medicine,” he said.

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“This helps make us feel like doctors again. We can go in and use our brain and think about the pharmacology of the medication, and make sure we are tailoring the pharmacology to that person’s genetic makeup. And that’s just cool,” he said.

Scaling precision medicine across the organization

Next-generation technologies like genomics and precision medicine are often touted at academic medical systems and some of the top health systems in the country. In Murfreesboro, the clinic's precision medicine strategy helps to differentiate the organization in its service area, Cote said.

"We know this is the future of medicine. We want to invest in it because it’s the right thing to do for patients. It's also an area of distinction. One of the advantages of being an organization our size—we’re not so big that we have to go through 17 levels of bureaucracy and we’re not so small that we don’t have resources—is that we can leverage our position and move to the bleeding edge with some of these technologies,” Cote said.

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Initially, the clinic’s precision medicine efforts centered on psychiatric and behavioral health medications (e.g., antidepressants and anti-anxiety drugs) and common cardiovascular treatments (such as statins and clopidogrel). Recognizing the value of using genomic information, clinic leadership decided they want to expand the precision medicine program.

There were several major barriers to scaling precision medicine, Cote said, with the cost of testing being one big obstacle. Patients would opt out of the testing if it was a significant out-of-pocket expense.

To address this, clinic leaders negotiated with a laboratory vendor on a pricing model for the testing. "If the testing is around $99, patients will do it every time," Cote said.

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Also, initially doctors found it difficult to apply genomic insights to medical decisions during patient visits. Accessing the pharmacogenomic test results was a clunky process for doctors involving paper documents or scanned attachments not integrated into the patients’ medical records and not easily available within the EHR workflow.

The 2bPrecise software integrates into the clinical workflow so physicians can access the results more easily from the electronic health record and within their clinical workflow. The technology tool not only indicates whether a medication is a good match based on a patient's genome but if it isn't a good match, it will provide alternative medications, Cote said.

MMC anticipates expanding to areas of precision medicine beyond pharmacogenomics to eventually identify patients at risk for heritable diseases across specialties.