Bridging the Rural Precision Medicine Gap: An Infrastructure-Adaptive Framework for Pharmacogenomics Implementation

Pharmacogenomics (PGx) enables genotype-guided prescribing to improve medication safety and efficacy, yet its clinical adoption remains uneven and concentrated in well-resourced academic centers. Rural and underserved populations, which experience a disproportionate burden of adverse drug reactions and limited access to specialist care, have been largely excluded from these advances. This review employs a structured narrative synthesis to examine current evidence on PGx implementation and to identify structural barriers limiting uptake across heterogeneous healthcare settings, including workforce limitations, infrastructure variability, geographic access constraints, patient engagement challenges, and inconsistent reimbursement. Existing implementation models are typically designed for specific institutional contexts and often assume a uniform level of infrastructure, restricting their scalability and applicability across diverse settings. To address this gap, we propose a novel infrastructure-adaptive framework that explicitly aligns PGx delivery strategies with institutional capacity. The framework comprises three tiers: (1) centralized testing with telepharmacist support for low-resource settings, (2) point-of-care testing integrated with clinical decision support for moderate-resource systems, and (3) mobile outreach models for communities without fixed healthcare access. By matching implementation strategies to system capacity, this approach offers a scalable and context-sensitive pathway for integrating pharmacogenomics into routine care and advancing equity in precision medicine.