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For providers Challenges to implementation in practice were reported by participants, including both to themselves as well as to their patients. One of the main hurdles for providers was difficulty in understanding the pharmacogenomics test report. A desire for content clarification on the results report was mentioned and some preferred certain formats for results display as well as a paper copy of the results. A delay (beyond typical 3 weeks) in receiving results was also described as a barrier in providing timely patient feedback. Difficulty with accessing the results report within the EMR was also mentioned. One physician (P02) articulated his challenges: “So, I've been having problems. I really have not received anybody's clinical results, as far as a notification goes, that it's ready. I get the results of their phenotyping only and then later on I'll find that the clinical [result] has been sitting there and it's back, and it never comes at the same time. It comes later and it doesn't alert us to when those results are populated”. Many of the participants described having a lack of understanding of how to interpret the pharmacogenomics results and that they were not adequately prepared to communicate complex results. One physician (P05) shared that he felt: “Less comfortable. You know, looking at some of the results that were returned, that just kind of says ‘drugs to avoid’, but doesn't give a lot of science behind it or explanation. I think I would like some guidance with that”. One of the perceived barriers to uptake of PGx testing in their practices was high cost and lack of reimbursement. A participant (P12) stated: “…maybe the cost for some patients. If it's not covered by insurance, it might be a bit much and patients may not have so much buy in to it if they don't think it is really going to be a benefit”. Another practitioner (P15) commented about test benefit and justification for insurance coverage: “Then of course that becomes a challenge of what you have to prove to them [insurance companies] in order to show them that a patient would benefit in order for them to cover. Are there any instances where insurance companies cover, can you answer that, or no?” Although most primary care physicians mentioned that the workflow process utilizing direct access PGx testing worked well in their practices, they brought up time constraints as a challenge and the need for an in-office follow-up appointment to discuss results. One physician (P08) noted: “A lot of times when people think genetic testing, they think this is going to show them that they're going to get cancer or whatever. We have limited time to be explaining this along with everything else that we talk about in our exams”. For patient The barrier to PGx testing that was most often discussed by participants was the cost to their patients. An interviewed provider (P11) said: “I don't think that any patients are really going to pay for that unless there's really, truly a concern. You know, if someone's tried multiple statins or multiple antidepressants and even then it's hard for them, it's going to be hard to convince someone to do this test that's not covered. I think it's different from paying out of pocket for a heart scan because it's such a visual thing and people totally get it. I mean, we'll see with time how it goes”. Another primary care physician (P10) related a patient's reaction to not receiving significant clinical results from pharmacogenomic testing in regards to cost; he recalled: “I know one person felt shortchanged that they did this test and they didn't get any information from it”. A number of physicians described how concern with data and privacy could be a challenge for patient uptake of PGx testing. One provider (P11) commented on concerns patients may have about protection of their genetic information from the government: “I think people get concerned when they're sending their cheek cells off that their DNA is getting sent in the mail and they don't know what's actually truly happening to it, and people think that maybe they're getting cloned or finding out genetic information that's going to come back and hurt them in the future in some ‘Brave New World’ situation where the government is tracking our genetic codes and that can harm them in some way. I
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