Physician perspectives of CYP2C19 and clopidogrel drug-gene interaction active clinical decision support alerts

Abstract

Objective: To determine if physicians find clinical decision support alerts for pharmacogenomic drug-gene interactions useful and assess their perceptions of usability aspects that impact usefulness.

Materials and methods: 52 physicians participated in an online simulation and questionnaire involving a prototype alert for the clopidogrel and CYP2C19 drug-gene interaction.

Results: Only 4% of participants stated they would override the alert. 92% agreed that the alerts were useful. 87% found the visual interface appropriate, 91% felt the timing of the alert was appropriate and 75% were unfamiliar with the specific drug-gene interaction. 80% of providers preferred the ability to order the recommended medication within the alert. Qualitative responses suggested that supplementary information is important, but should be provided as external links, and that the utility of pharmacogenomic alerts depends on the broader ecosystem of alerts.

Principal conclusions: Pharmacogenomic alerts would be welcomed by many physicians, can be built with minimalist design principles, and are appropriately placed at the end of the prescribing process. Since many physicians lack familiarity with pharmacogenomics but have limited time, information and educational resources within the alert should be carefully selected and presented in concise ways.

Keywords: Clinical decision support; Clinical informatics; Electronic medical records; Genomic medicine; Pharmacogenomics.

Figure 1. Screenshot of prototype clopidogrel and CYP2C19 alert

The prototype variant-drug alert was created in Cerner^® with the Discern^® rules engine. Concise information is provided explaining the variant-drug interaction and several possible actions. The “Guidelines” button loads the CYP2C19 and clopidogrel Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines in a browser window.

Figure 2. Results of Likert Scale Questionnaire Assessing Physician Perspectives

Block A shows that most participants felt the alerts were helpful and applicable to the simulation patient. Block B shows most participants approve of interface design features and Block C shows they approved of the alerts place in the prescribing workflow. Block D shows that the majority were unfamiliar with the drug-gene interaction presented and were unsure about the evidence backing it.

Figure 3. Responses Regarding Potential Alert Modifications

The top half of figure 3 shows the original alert (B) as well as a proposed modification (A), in which providers can change their drug/dose of choice within the alert itself. 80% of respondents preferred this option. The lower half shows another potential modification (C), in which additional CPIC guidelines are included in the text portion of the alert. A less strong majority of 67% preferred this option to the original alert.