Precision Medicine Care Coordination in the Veterans Health Administration

背景：精准医学是一种创新的方法，它考虑了个体基因 差异为个性化决策提供信息，可改善诊断、预后、风险评估和治疗 和疾病预防。基因服务，包括基因检测和基因咨询是基本的 敬精准医学。许多部门尚未系统地采用遗传服务 退伍军人事务部(VA)设施，因为它们的复杂性，有限的遗传学知识和专业知识 临床医生，以及使用的组织障碍。尽管如此，中国对精准医疗的需求 退伍军人管理局正在增加，并了解针对常见转诊原因的最佳护理安排 咨询对于为我们的退伍军人规划高质量和高价值的精准医学至关重要。 可获得的遗传咨询的类型有很大的变异性(例如，癌症、神经或 生殖遗传学)，遗传顾问的预期作用(即诊断、程序或护理 管理)和退伍军人事务部这些会诊的护理安排(即护理模式、模式 分娩和退伍军人护理或非退伍军人护理)。对精准医疗的护理安排具有不同的选择可以是 有益的，但只有在护理安排与患者的需求和偏好相匹配和 转介提供者，并导致安全、有效和高效的护理协调。然而，目前 VHA对精准医疗的护理安排的变化取决于当地可用的资源，如 作为现场或通过远程医疗服务协议提供的遗传学专业知识，而不是护理 灵活且符合患者和提供者的需求和偏好的安排。 目标：VA HSR&D IIR提案的目标是评估护理协调的精确度 医学，包括护理协调方法和活动及其影响，根据现有情况 在退伍军人管理局进行遗传咨询的常见原因的护理安排。我们将实现以下目标： 目标1.描述退伍军人管理局机构的精准医疗护理协调方法和活动 关于护理安排(即，模式、交付方式和环境)，包括： 促进或阻碍遗传咨询的转诊、转诊原因、转诊数量、预期作用 顾问，并使用从公司数据中提取的数据成功完成遗传咨询 仓库。目标2.描述护理协调方法和活动对以下患者的影响 根据护理安排完成了遗传咨询，包括：(A)基因检测吸收和(B) 卫生保健利用的程度(例如，采用程序、成像、治疗) 咨询临床医生。目标3.描述背景因素(患者、提供者、内外环境) 影响精确医疗保健协调方法和活动(目标1)；及其对 完成遗传咨询的患者(目标2)。目标4.制定精准医疗护理措施 利用专家小组方法协调遗传转介的共同原因的方法和活动。 方法：采用定量和定性相结合的方法进行回顾性观察研究。 方法：研究方法。我们将利用退伍军人管理局世界级的电子健康记录来识别患者的记录 他们被要求进行遗传咨询。我们将使用Natural从这些记录中提取数据 语言处理和手工图表审查(目标1和2)。我们将对KEY进行定性采访 举报人(目标3)，我们将使用专家小组方法制定护理协调措施(目标4)。 影响：项目调查结果的综合将指导医疗保健系统各级的决策，从 遗传保健服务的个人临床会诊到系统范围的政策决策 劳动力准备、基础设施需求以及精准医疗的最佳护理安排， 以确保我们退伍军人获得高质量、高价值的精准医疗为目标。

Background: Precision medicine is an innovative approach that takes into account individual genetic differences to inform personalized decisions that can improve diagnosis, prognosis, risk assessment, treatment and disease prevention. Genetic services, including genetic testing and genetic consultation are fundamental to precision medicine. Genetic services have not yet been systematically adopted in many Department of Veterans Affairs (VA) facilities because of their complexity, the limited genetics knowledge and expertise of clinicians, and organizational barriers to utilization. Nonetheless, the demand for precision medicine within the VA is increasing, and understanding optimal care arrangements for common referral reasons for genetic consultation will be crucial to planning for high-quality and high-value precision medicine for our Veterans. There is substantial variability in the type of genetic consultation available (e.g., cancer, neuro- or reproductive genetics), the expected role of the genetic consultant (i.e., diagnostic, procedural or care management) and in the care arrangements for these consultations in the VA (i.e., care model, mode of delivery and VA or non-VA care). Having different options for care arrangements for precision medicine can be beneficial, but only if the care arrangements are matched to the needs and preferences of both patients and the referring providers, and result in safe, effective and efficient care coordination. However, currently the variation in care arrangements for precision medicine in the VHA depends on available local resources, such as genetics expertise on-site or available through a telehealth service agreement, rather than care arrangements that are flexible and congruent with patient and provider needs and preferences. Objectives: The goal of this VA HSR&D IIR proposal is to evaluate care coordination for precision medicine, including the care coordination approaches and activities and their effects according to available care arrangements for common reasons for genetic consultation in the VA. We will conduct the following aims: Aim 1. Describe the precision medicine care coordination approaches and activities at VA facilities according to the care arrangement (i.e., model, mode of delivery, and setting), including: the structures of care that facilitate or hinder referral for genetic consultation, referral reasons, referral volume, expected role of the consultant, and successful completion of genetic consults using data extracted from the Corporate Data Warehouse. Aim 2. Describe the effects of care coordination approaches and activities for patients who have completed a genetic consult according to the care arrangement, including: (a) genetic testing uptake and (b) extent of health care utilization (e.g., uptake of procedures, imaging, treatment) as recommended by the consulting clinician. Aim 3. Characterize the contextual factors (patient, provider, and inner and outer setting) influencing precision medicine care coordination approaches and activities (Aim 1); and their effects for patients who have completed a genetic consult (Aim 2). Aim 4. Develop measures of precision medicine care coordination approaches and activities for common reasons for genetics referral using expert panel methods. Methods: We will conduct a retrospective, observational study using both quantitative and qualitative methods. We will leverage the VA’s world-class electronic health record to identify records from patients for whom a genetic consultation has been requested. We will extract data from these records using natural language processing and manual chart review (Aims 1 and 2). We will conduct qualitative interviews with key informants (Aim 3), and we will use expert panel methods to develop care coordination measures (Aim 4). Impact: Synthesis of the project findings will guide decisions at every level of the healthcare system, from the individual clinical encounter for genetic health care services to system-wide policy decisions regarding workforce preparedness, infrastructure needs, as well as optimal care arrangements for precision medicine, with the goal to ensure high-quality and high-value precision medicine for our Veterans.