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Processes for Providing Genetic Services in the Veterans Health Administration (VHA)

McIntosh NM, Lerner BN, Clark JA, Frank NY, Meterko MM. Processes for Providing Genetic Services in the Veterans Health Administration (VHA). Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando FL.


Research Objective: The goal of this project was to describe the processes for providing genetic services in the VHA and to identify issues regarding the provision of quality genetics services. Study Design: Semi-structured telephone interviews with genetic service providers were conducted, transcribed and analyzed qualitatively. Participants were asked to describe the steps involved in the provision of genetic services, from identifying appropriate patients to disclosing and documenting genetic results. Barriers and facilitators of the process were also elicited. Population Studied: VHA providers nationwide who had ordered at least one genetic test in the past year. Principal Findings: Eight of 69 invited providers participated in interviews. Respondents were from cardiology, hematology-oncology, nephrology, neurology and surgical departments. All respondents used clinical evaluations and personal/family histories to identify patients for genetic testing. The amount of genetic counseling offered varied widely. In some facilities patients were referred to non-VHA providers for genetic counseling and/or genetic testing services. Outside referrals made it difficult for VHA providers to get patient results or incorporate them in the patient's VHA record. Approval for genetic tests was generally required, but the approval process varied. Approvals were most often based on test cost and whether results would change medical management. Nearly all genetic tests were send-outs. Most facilities had a process for requesting commonly ordered genetic tests but relied on ad-hoc procedures for unusual tests. Close relationships between the VHA ordering department and the VHA send-out lab facilitated this process for both types of tests. Test results disclosures to patients were done in person or by telephone. Letters to patients summarizing genetic visits or genetic test results were not routinely sent. Test results were recorded in the electronic medical record but many were located under "other tests," making them difficult to find. Test result interpretation was facilitated by relationships with outside genetic experts and testing laboratories. There was confusion as to what VHA services could be provided to non-veteran family members; many providers had affiliations with outside facilities to which they referred non-veteran family members. Conclusions: There is variation in the processes for providing Genetics Services in the VHA. Factors affecting access to and the quality of genetic services include: the need for approval for genetic testing; the ease with which results in the patient records can be found; how to provide genetic counseling and testing to non-veteran family members; and how to incorporate genetic visit/test results from non-VHA facilities. Genetic services in the VHA were facilitated by: having close relationships with the Director of the VHA laboratory; having an affiliation with a non-VHA genetic service to refer VHA patients and their non-veteran relatives for genetic counseling/testing; and having access to genetic expertise outside of the VHA. A formal survey, based on these findings, will be conducted to determine the prevalence of these facilitators and barriers in order to prioritize solutions. Implications for Policy, Delivery or Practice: Genetic services within the VHA could benefit from having genetic experts and/or genetic counselors within the VHA, a standardized genetic testing approval and ordering process, and clarification regarding what services can be provided to non-veteran family members.

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