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to other family members In addition to the concepts of clinical utility of PGx testing described by the study physicians, they also mentioned testing as beneficial to specific populations, such as patients being seen for psychiatry, cardiology, oncology and for pain management, as well as for patients highly engaged in their healthcare. Providers also described a medication ‘odyssey,’ referring to time required for a trial-and-error approach to medication management until finding an effective and safe medication. All of these factors described as aspects of clinical utility, value and benefit are important to consider in informing effective clinical PGx delivery. The ability of the primary care practitioners to have personal experience going through the direct access PGx testing process was described as beneficial through experiencing the process of using the kit and receiving and reviewing their own results. In order for PGx testing methods to be most effective, stakeholders, such as physicians, will need to better understand the process themselves in order to provide recommendations of such testing to their patients [20,35]. Other studies conducted with medical, graduate and pharmacy students who underwent personal genomic testing, which included PGx-related data, also revealed that this testing provided insight into the patient experience and increased understanding of genetic concepts [37–40]. Another study of physician assistant students who were specifically offered CYP2D6 testing reported similar results and noted that further exposure to PGx testing during rotations influenced perceptions of clinical utility as well [41]. Physicians in our study similarly commented on the benefit of undergoing personal PGx direct access testing to better appreciate the patient experience; however, many participants remarked that they need further education to increase understanding of PGx-related concepts. In addition to positive aspects of PGx testing, participants relayed challenged they encountered. Physicians described the need for more understandable result reports for both themselves and their patients and less delay in receiving results. Previous studies have reported physicians’ views on their lack of preparedness in interpreting and providing recommendations based on PGx results to their patients [9,20]. Modifications have been made in response to these concerns; result reports were revised to be more clear, concise and patient-centered. A new summary chart was added to the report that includes every medication with a well-established PGx interaction for the patient. An example report and instructions are now available on a website along with answers to frequently asked questions and links to informational resources and educational materials. The delay in physicians receiving results was a result of unfamiliarity; therefore, methods for finding results were clarified within the electronic medical record. Time constraints for providing medications in an emergent scenario make it difficult for patients to utilize PGx testing, which is due to the length of time it requires for the sample to be analyzed and resulted [35]. However, some argue that pre-emptive PGx testing may be a way to mitigate this concern [42]. Physicians also described test cost incurred by the patient (as many insurance companies will cover testing) as one of the most significant barriers to PGx testing. Several other studies have highlighted cost as a barrier as well]. Following this feedback, this health system implemented cost strategies that make pricing more accessible to patients. Further research will need to be done to determine acceptability of the reduced cost. Many of the aforementioned challenges have begun to be addressed within this healthcare system; in addition, physicians expressed several areas of future need. Assistance with addressing cost and insurance coverage with patients was requested. Additionally, education for providers and materials to assist both the provider and the patient through the testing process, and receiving results, were identified as other areas to address. Previous studies have identified a similar need and various educational resources have been made available online [42,43]. Although this

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