Precision Medicine Care Coordination in the Veterans Health Administration

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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.