Implementing a Pharmacogenomics Program in a Large-Scale Rural Based Healthcare System


Most PGx programs operate in large academic medical centers within densely populated urban areas. These communities are often already rich in healthcare resources. But what about more rural populations?

The value of healthcare innovations in these underserved populations is immense. But rural areas pose unique challenges for PGx implementation. Sanford Health’s Imagenetics initiative offers useful insights for overcoming barriers and successfully implementing a PGx program in a large-scale rural healthcare system.

Sanford Health: Serving Rural Populations Across the Midwest

Sanford Health is a non-profit, integrated healthcare delivery network. With more than 2 million patients, 1,350 physicians, and 48,000 employees, Sanford operates 44 medical centers and 482 clinics.

When it comes to PGx implementation, Sanford is unique. That’s because Sanford’s patients and employees are spread out over a geographic footprint of more than 250,000 square miles. With its headquarters in Sioux Falls, South Dakota, Sanford’s healthcare system spans 26 states mostly concentrated in the upper Midwest.

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The Imagenetics Program: Bringing Precision Medicine to Rural Populations

In 2014, Sanford launched its Imagenetics program. Imagenetics combines Sanford’s strength in internal medicine with emerging genetic technologies. The program aims to improve health outcomes for Sanford’s patients by fully integrating genetic medicine into primary care.

The hallmark of Sanford Imagenetics is the Sanford Chip—a platform designed to detect genomic variants across an individual’s genome. There are two parts to the platform.


PGx testing identifies genetic variants that impact a patient’s ability to metabolize certain medications. Every patient that chooses to use the Sanford Chip receives PGx test results.

Sanford currently offers an eight-gene PGx panel for pre-emptive testing, and a 10-gene panel is in undergoing a validation process, with future plans for a 17-gene panel. Providers can also order single-gene tests if a patient has an unexpected response to a medication. 

Medically Actionable Predisposition (MAP)

Imagenetics also has an optional genetic screening tool for healthy individuals. MAP tests for genetic variations that may increase an individual’s chance of developing a specific set of health conditions, including some types of cancer and heart problems. 

To date, Sanford has run and reviewed more than 4,900 PGx panels. And about 14 percent contained an actionable drug-gene interaction, according to CPIC guidelines.

Implementing PGx in a Rural Footprint

Like many PGx programs, Sanford’s Imagenetics experienced quite a few implementation challenges. But it also faced some unique barriers due to its largely rural patient population. Let’s take a look at some of the hurdles Sanford overcame while implementing Imagenetics.


In a rural area, distance becomes a real barrier to PGx implementation. A geographic footprint of more than 250,000 square miles can complicate relatively simple operational considerations like sample delivery. And some patients may have to travel upward of two to three hours to access clinical genetics services.

On the patient side, Sanford has solved the distance issue in part with its developed telemedicine network. Even smaller clinics in Sanford’s healthcare network have telemedicine stations. This means patients can get more frequent access to their doctors, as well as specialists such as genetic counselors.

Startup Costs

Startup costs for new PGx programs are significant. There is also a need for broad institutional support. A generous gift from Denny Sanford, Sanford’s namesake, who wanted to see Sanford’s PGx program succeed, made Imagenetics possible.


Without education and outreach, patients are unlikely to participate in a PGx program. Successful implementation also requires informed doctors, nurses, pharmacists, and other medical staff to help champion a fledgling PGx program.

Sanford has gone to great lengths to make sure that everyone in its network is educated. The program’s successful approach involves consistent and varied educational content with flexible delivery options

For providers, Sanford uses compensation incentives. They also embed reference materials in easy-to-access places like its patient’s electronic health records. 

Technology Integration

Building a functional platform for patients and providers can be a major roadblock for institutions looking to start a new PGx program. Sanford made IT a priority for its Imagenetics program. It maintains a well-trained and well-staffed IT team. Sanford’s IT team is a key player for Imagenetics, keeping all of its testing platforms running smoothly. 

Maintenance and Upkeep

Maintaining a PGx program can be just as expensive and time-consuming as the program’s startup process. Sanford puts a great deal of its resources toward keeping its program continually updated, and is always looking ahead.

The ongoing support of PGx champions are also key, especially given Sanford’s wide geographic footprint. Both provider and pharmacist PGx champions help support the Imagenetics initiative, and maintain enthusiasm for the program across Sanford’s healthcare network.


Not all PGx programs are located at urban academic institutions. Sanford Health’s Imagenetics program shows that PGx implementation can thrive even in sparsely populated rural areas. Listen to our webinar with Sanford Health to learn more about how it successfully implemented a large-scale clinical PGx program for a rural population.

PGx in Rural Healthcare Systems Webinar