Before the COVID-19 pandemic, Clinical Pharmacogenomics Specialist D. Max Smith was a trusted resource for clinician colleagues at MedStar Health with questions about pharmacogenomics.
Nowadays, Smith’s pharmacogenomics expertise is also available to some patients through a telehealth pilot project that’s part of MedStar Health’s growing portfolio of remote care options.
“It wasn’t by design that I was going to be talking to patients directly. This service was initially designed to be a peer-to-peer consult service for providers,” Smith noted. “But ... clinicians were reaching out and saying, ‘Hey, I need some help talking with my patients about pharmacogenomics and how this affects their care.’”
MedStar Health operates 10 hospitals and more than 300 care sites in Maryland, Washington, D.C., and Virginia. Smith is cochair of the health system's Pharmacogenomics Steering Committee and Pharmacy and Therapeutics Pharmacogenomics Subcommittee.
Smith completed a postgraduate year 2 residency program and postdoctoral fellowship in pharmacogenomics at the University of Florida before joining MedStar Health in 2018.
Because his pharmacogenomics expertise is a rare resource for the health system, his services span the whole organization.
“You really need a systems approach to tackle pharmacogenomics,” Smith explained. “Genes don’t know the boundaries of medical specialties. And ... there aren’t very many people trained to do pharmacogenomics.”
Smith said clinicians use the health system’s electronic medical record system to request a pharmacogenomics consultation.
“It’s a way for them to just raise their hand and say, ‘I need some assistance,’” Smith said.
He said the consultations serve two purposes — improving the quality of patient care by helping clinicians interpret pharmacogenomic test results and helping clinicians decide when it’s appropriate to order the tests.
Smith described himself as a very strong advocate for pharmacogenomic testing. But he evaluates each patient’s medical circumstances and the strength of supporting data to determine if testing is warranted.
“And then you have to take into account patient-specific factors like what their insurance is, if they’re able to pay, if they want to do testing,” he added.
He noted that patients increasingly arrive with genetic test results in hand after being tested during a previous medical encounter or using a direct-to-consumer testing service.
“This is really starting to create more and more of a need to help providers interpret these results and kind of bypassing the decision of whether or not to test. And so that’s where I think a pharmacist can really step in, utilizing evidence-based guidelines,” Smith said.
The telehealth consultations with patients, which got underway this year, usually follow an initial conversation between a patient and a healthcare provider.
“The provider describes my role and asks if they would like me to call them,” Smith said. “Then I reach out to the patient and ... ask if they want to continue the conversation via phone or if they want to switch over to telehealth.”
If the patient opts for the telehealth consultation, Smith provides a secure link, and they switch to that format.
He said that compared with phone conversations, telehealth visits allow him to read the patient’s facial cues and better gauge whether the person understands what’s being discussed. And he can share his computer screen as he reviews and interprets patients’ data and helps them make informed decisions about their care.
Smith said he became attuned to the benefits of telehealth early during the COVID-19 pandemic, when he was deployed to the MedStar Telehealth Innovation Center to help establish inpatient telehealth services in the organization’s hospitals.
“I was able to see it work, and not only work but really excel across the health system in a variety of medical specialties,” he said.
The innovation center was launched in 2017 to provide infrastructure, best practices, subject matter expertise, and other telehealth assistance across the health system. Telehealth services for patients include urgent and primary care and postoperative video visits. Services for clinicians include emergency department triage and consultation services, such as vascular neurology consultation for acute stroke and multidisciplinary transplantation consultations.
MedStar Health reported that it delivered more than 772,750 telehealth sessions during the first 12 months of the COVID-19 pandemic.
Smith said federal regulatory flexibilities around telehealth during the pandemic haven’t affected the pharmacogenomics service, because patients aren’t billed for the consultations.
“This is really an initiative to help improve the quality of care, support our providers and ... figure out how to best build this service,” he said. Billing options could be explored later, if MedStar Health expands the service.
“This is a very complex topic, especially with pharmacist provider status in the situation that it is,” Smith added. “You’ve got to start somewhere, and you’ve got to explore what the providers and what the patients need.”
For access to guidelines, educational materials, and other information about pharmacogenomics, visit ASHP’s Pharmacogenomics Resource Center.
[This news story will appear in an upcoming issue of AJHP.]