Effect of incorporating NGS ordering into computerized patient records system (CPRS) on VA precision oncology care.
Authors: Poland Sarah G , Maynard Hannah , Stoeckle James Hart , Roman Stefanie D. , Sherman Scott , Mettman Daniel , Makarov Danil V. , Becker Daniel Jacob 
Published: June 2022

e18617

Background: Precision oncology, targeting therapy to the molecular specifics of one patient’s cancer, improves outcomes and decreases toxicity. Previous studies have documented underuse of next generation sequencing (NGS) in both the Veterans Health Administration (VHA) and private sector cancer care. Our group’s work has found that requiring providers to order and review tests in multiple electronic medical record systems for a single patient is a significant barrier to precision oncology. Following the incorporation of electronic medical record (EMR) NGS ordering into the VA EMR (CPRS) at a New York VA Medical Center, we examined the effect of the ordering change on precision oncology care for veterans. Methods: We identified patients eligible for NGS testing who had medical oncology clinic visits at the Manhattan VA in 2021, and divided patients into those whose NGS required external ordering (EO) (i.e. direct to Foundation Medicine (FM)) and those whose NGS used internal ordering (IO) (i.e. integrated CPRS ordering). We collected demographic and clinical information, including intention to order NGS, date of NGS order, specimen receipt, and testing results, on all patients from CPRS and FM web-based portal. Descriptive statistics were calculated and variables were compared with chi-square, T-tests, and Mood’s median test. Results: A total of 138 patients were identified, 99 in the EO group and 38 in the IO group. The groups were vastly male, (100% EO vs 95% IO), had similar ages (average age 69 and 75, respectively, p = 0.24), approximately half were self-reported Black race (48% EO vs 46% IO; p = 0.89), and the preponderance of prostate cancer was higher in the EO group vs the IO group (81% EO vs 62% IO, p = 0.02). For the 99 EO patients, 74 (75%) had a documented intention to order, and 47 (64%) of those had a specimen received by FM. Of the 38 patients in the IO group, 38 (100%) had intention to order and 25 had results received by FM (66% vs 64% IO vs EO p = 0.91). Compared to the EO group, the IO group had shorter time from intention to order to sample received (among those with positive values): mean 172 days (d) vs 18 d and median 40 d vs 6 d (p = 0.04). Among those with metastatic disease and documented intention to order NGS (EO n = 72, IO n = 32), the time from diagnosis of metastatic disease to intention to order NGS was significantly shorter after implementation of internal ordering: mean 764 d vs 698 d, median 226 d vs 15 d, (p = 0.004). The time from diagnosis of metastatic disease to NGS result in FM was also significantly shorter for IO patients (mean 980 d vs 251 d; median 46 d vs 428 d, p = 0.0003). Conclusions: We found that incorporating NGS testing into CPRS decreased delay from diagnosis of metastatic disease to intention to order NGS testing, and from intention to order NGS testing to results received, ultimately enabling faster precision oncology care for patients.