Assessing multilevel determinants of adoption and implementation of genomic medicine: an organizational mixed-methods approach

PurposeAdoption and implementation of evidence-based genetic and genomic medicine have been slow. We describe a methodology for identifying the influence of organizational factors on adoption and implementation of these services in health-care organizations.MethodsWe illustrate a three-component, mixed-methods health services research approach, including expert panels, qualitative interviews with key informants, and quantitative surveys completed by key informants.ResultsThis research approach yielded a baseline assessment of existing genetic health-care models in the Veterans Health Administration and identified organizational barriers to and facilitators of adoption. In aggregate, the panel and key informant strategies created a communication network of relevant organizational stakeholders and a detailed foundation of organizational knowledge from which to design tools and models for implementation-level genetic/genomic translation.ConclusionExpert panel and key informant strategies can be used to create a backdrop of stakeholder involvement and baseline organizational knowledge within which to plan translation research and to inform strategic planning and policies for adoption and implementation of genetic services in health-care organizations.Genet Med17 11, 919–926.     

Factors influencing organizational adoption and implementation of clinical genetic services

PurposeWe sought to identify characteristics of genetic services that facilitate or hinder adoption.MethodsWe conducted semi-structured key informant interviews in five clinical specialties (primary care, medical oncology, neurology, cardiology, pathology/laboratory medicine) within 13 Veterans Administration facilities.ResultsGenetic services (defined as genetic testing and consultation) were not typically characterized by informants (n = 64) as advantageous for their facilities or their patients; compatible with organizational norms of low cost and high clinical impact; or applicable to patient populations or norms of clinical care. Furthermore, genetic services had not been systematically adopted in most facilities because of their complexity: knowledge of and expertise on genetic testing was limited, and organizational barriers to utilization of genetic services were formidable. The few facilities that had some success with implementation of genetic services had knowledgeable clinicians interested in developing services and organizational-level facilitators such as accessible genetic test–ordering processes.ConclusionAdoption and implementation of genetic services will require a multilevel effort that includes education of providers and administrators, opportunities for observing the benefits of genetic medicine, strategies for reducing the complexity of genomic medicine, expanded strategies for accessing genetics expertise and streamlining utilization, and resources dedicated to assessing the value of genetic information for the outcomes that matter to health-care organizations.Genet Med 2014:16(3):238–245.     

The value of genetic testing: beyond clinical utility

ObjectiveTo assess the value of genetic testing from the perspective of the Department of Veterans Affairs (VA) clinical leadership.MethodsWe administered an Internet-based survey to VA clinical leaders nationwide. Respondents rated the value (on a 5-point scale) of each of six possible reasons for genetic testing. Bivariate and linear regressions identified associations between value ratings and environmental, organizational, provider, patient, and encounter characteristics.ResultsRespondents (n = 353; 63% response rate) represented 92% of VA medical centers. Tests that inform clinical management had the highest value rating (58.6%), followed by tests that inform disease prevention (56.4%), reproductive options (50.1%), life planning (43.9%), and a suspected (39.9%) or established (32.3%) diagnosis. Factors positively associated with high value included a culture that fosters adoption of genomics, specialist versus primary care provider, genetic tests available on laboratory menus, availability of genetic testing guidelines, clinicians knowing when to request genetics referrals, and availability of genetics professionals.ConclusionOur results demonstrate the varied value of genetic testing from the perspective of clinical leadership within a health-care system. Engaging organizational leadership in understanding the various reasons for genetic testing and its value beyond clinical utility may increase adoption of genetic tests to support patient-centered care.Genet Med advance online publication 15 December 2016     

Challenging the patient and therapist during evolving phases of a veteran's treatment within a strong public–private partnership

Veterans Health Administration (VA) Medical Centers provide excellent care for many veterans. However, there are a number of veterans who are ineligible or choose not to access mental health treatment at the VA. To meet the needs of those veterans and of military family members, private centers have emerged to fill in gaps where care is unavailable or scarce. This paper describes how one such center, the Steven A. Cohen Military Family Center at NYU Langone Health, partnered with the local VA hospital to give one veteran ineligible for free mental health services the care he desperately needed. The case demonstrates the transformative work that can take place when public–private partnerships are forged and evidence-based treatments can be provided in a flexible way. It also illustrates the complexity of many veterans' presentations, which in this case required the therapist to continually challenge her conceptualization as she and the patient navigated different phases of his treatment.     

Status report on ambulatory care and education in the VA Western Region and western medical schools

Since the initial 1988 Ambulatory Care and Education (ACE) conference, reported in the October 1989 supplement to Academic Medicine, the Western Region Veterans Health Administration and its 11 affiliated western medical schools have established several programs and related activities that implement strategic ACE recommendations. This report gives an update on the ACE Advisory Group; the Pilot Ambulatory Care and Education (PACE) Center at the VA Medical Center, Sepulveda, California; other innovative ambulatory care and education projects; the second ACE Development Conference; and future activities in the expanded Western Region of the Department of Veterans Affairs.     

Creation of a national resource with linked genealogy and phenotypic data: the Veterans Genealogy Project

PurposeCreation of a genealogy of the United States and its ancestral populations is under way. When complete, this US genealogy will be record linked to the National Veteran’s Health Administration medical data representing more than 8 million US veterans.MethodsGenealogical data are gathered from public sources, primarily the Internet. Record linking using data from relatives is accomplished to integrate multiple data sources and then to link genealogical data to the veteran’s demographic data.ResultsThis resource currently includes genealogy for more than 22 million individuals representing the Intermountain West and the East Coast. The demographic data for more than 40,000 veteran patients using Veterans Hospital Administration services in Utah and Massachusetts have already been record linked.ConclusionThe resource is only in its second year of creation and already represents the largest such combination of genealogy and medical data in the world. The data sources, the creation of the genealogy, record-linking methods and results, proposed genetic analyses, and future directions are discussed.Genet Med 2013:15(7):541–547     

A cancer genetics toolkit improves access to genetic services through documentation and use of the family history by primary-care clinicians

PurposeWe developed, implemented, and evaluated a multicomponent cancer genetics toolkit designed to improve recognition and appropriate referral of individuals at risk for hereditary cancer syndromes.MethodsWe evaluated toolkit implementation in the women’s clinics at a large Veterans Administration medical center using mixed methods, including pre–post semistructured interviews, clinician surveys, and chart reviews, and during implementation, monthly tracking of genetic consultation requests and use of a reminder in the electronic health record. We randomly sampled 10% of progress notes 6 months before (n = 139) and 18 months during implementation (n = 677).ResultsThe toolkit increased cancer family history documentation by almost 10% (26.6% pre- and 36.3% postimplementation). The reminder was a key component of the toolkit; when used, it was associated with a twofold increase in cancer family history documentation (odds ratio = 2.09; 95% confidence interval: 1.39–3.15), and the history was more complete. Patients whose clinicians completed the reminder were twice as likely to be referred for genetic consultation (4.1–9.6%, P < 0.0001).ConclusionA multicomponent approach to the systematic collection and use of family history by primary-care clinicians increased access to genetic services.Genet Med16 1, 60–69.     

Saudi Arabian-American differences in antimicrobial resistance of Escherichia, Klebsiella, and Pseudomonas

Increasing microbial resistance to newly developed antibiotics has been a limiting factor in the therapeutic use of these agents. To determine the extent of the problem, in vitro antimicrobial susceptibility of 7,140 clinical isolates of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa to seven commonly used antibiotics was established at the 1,700-bed Riyadh Central Hospital in Saudi Arabia and compared with 5,513 isolates at the Oklahoma Memorial Hospital and Veterans Administration Medical Center, Oklahoma City, Oklahoma. Escherichia coli and Pseudomonas aeruginosa at Riyadh Central Hospital were generally more resistant to ampicillin, carbenicillin, gentamicin, and trimethoprim-sulfamethoxazole than those at Oklahoma Memorial Hospital and the Veterans Administration Medical Center. All 1,022 isolates of Klebsiella pneumoniae at Oklahoma Memorial Hospital were more sensitive to the antibiotics than those at Riyadh Central Hospital or the Veterans Administration Medical Center. The sensitivity pattern of Klebsiella pneumoniae at Riyadh Central Hospital and the Veterans Administration Medical Centers was similar.     

Prevalence of the Clostridium difficile BI/NAP1/027 strain across the United States Veterans Health Administration

ObjectivesThe increased incidence and severity of Clostridium difficile infection (CDI) are thought to result partly from the emergence of the hypervirulent BI/NAP1/027 strain. Limited recent data are available on the prevalence of BI/NAP1/027 in the United States (US). The objective of this study was to assess the recent prevalence of BI/NAP1/027 within the US Veterans Health Administration (VHA).MethodsPatients with CDI at any Veterans Affairs Medical Center found to routinely test for the presence of BI/NAP1/027 during the study period were included between 1 June 2011 and 30 June 2016 in this retrospective, observational, nationwide study.ResultsIn total, 7571 patients had 8224 positive C. difficile tests that had a corresponding BI/NAP1/027 test. Of those, there were 1810 (22.0%) presumptive positive for BI/NAP1/027. The overall prevalence of BI/NAP1/027 decreased from a high of 26.2% in 2013 to 16.9% in 2016. Statistically significant reductions in rates from 2012 to 2016 occurred in seven of nine US Census Bureau regions.ConclusionsThe prevalence of C. difficile with the BI/NAP1/027 strain was 22.0% across the VHA between 2012 and 2016. Further studies are needed to confirm these results and for continued monitoring of the trends in BI/NAP1/027 prevalence.     

Cost minimization analysis of telepathology.

Telepathology is gaining acceptance as a mode of providing pathology services to remote sites, but its economic feasibility is unknown. A dynamic robotic telepathology service between the Veterans Affairs Medical Center, Iron Mountain, MI, and the Veterans Affairs Medical Center, Milwaukee, WI, provides diagnostic services for routine and frozen section surgical pathology cases at Iron Mountain. We conducted a cost minimization analysis of this service by building a model to compare telepathology and on-site pathology in Iron Mountain and a courier method of transporting specimens from Iron Mountain to Milwaukee for diagnosis. Base case analysis showed the courier method to be the most economic; telepathology was less costly than on-site pathology. If the costs of telepathology equipment and telecommunication are lowered to reflect current cost, then telepathology becomes the favored option. Telepathology can be an economic mode of providing pathology services to a remote site.     

Prescribers' interactions with medication alerts at the point of prescribing: A multi-method, in situ investigation of the human-computer interaction

PurposeFew studies have examined prescribers’ interactions with medication alerts at the point of prescribing. We conducted an in situ, human factors investigation of outpatient prescribing to uncover factors that influence the prescriber–alert interaction and identify strategies to improve alert design.MethodsField observations and interviews were conducted with outpatient prescribers at a major Veterans Affairs Medical Center. Physicians, clinical pharmacists, and nurse practitioners were recruited across five primary care clinics and eight specialty clinics. Prescribers were observed in situ as they ordered medications for patients and resolved alerts. Researchers collected 351 pages of typed notes across 102 hours of observations and interviews. An interdisciplinary team identified emergent themes via inductive qualitative analysis.ResultsAltogether, 320 alerts were observed among 30 prescribers and their interactions with 146 patients. Qualitative analysis uncovered 44 emergent themes and 9 overarching factors, which were organized into a framework that describes the prescriber–alert interaction. Prescribers’ ability to act on alerts was impeded by the alert interface, which did not adequately support all prescriber types.ConclusionsThis empiric study produced a novel framework for understanding the prescriber–alert interaction. Results revealed key components of the alert interface that influence prescribers and indicate a need for more universal design. Actionable design recommendations are presented and may be used to enhance alert design and patient safety.     

Genetics professionals are key to the integration of genetic testing within the practice of frontline clinicians

PurposeGenetic tests have become widely available. We sought to understand the use of genetic tests in the practice of frontline clinicians within the United States Department of Veterans Affairs (VA).MethodsWe administered a web-based survey to clinicians at 20 VA facilities. Physicians, nurse practitioners, physician assistants, and pharmacists were eligible. We excluded genetics providers and clinicians not seeing patients. We used multiple logistic regression to evaluate the associations between clinician characteristics and experience with genetics.ResultsThe response rate was 11.3% (1207/10,680) and of these, 909 respondents were eligible. Only 20.8% of the respondents reported feeling prepared to use genetic tests and 13.0% of the respondents were currently ordering genetic tests; although, it was usually only 1 or 2 a year. Delivery of genetic tests without involving genetics providers was preferred by only 7.9% of the respondents. Characteristics positively associated with currently ordering genetic tests included practice in clinical and research settings, believing improving genetics knowledge could alter their practice, feeling prepared to use genetic tests, and referral of at least 1 patient to genetics in the past year.ConclusionMost VA clinicians don’t feel prepared to use genetic tests. Those with genetic testing experience are more likely to consult genetics providers. The demand for genetics providers should increase as frontline clinicians use genetic tests in their practice.     

Prevalence of gentamicin- and amikacin-resistant bacteria in sink drains.

Sink drains from the Veterans Administration Medical Center, University of Oklahoma Health Sciences Center, and the Oklahoma City community were selectively cultured for gentamicin- and amikacin-resistant bacteria. Aminoglycoside-resistant organisms were found in 86% (Veterans Administration Medical Center, 88%; University of Oklahoma Health Sciences Center, 88%; and Oklahoma City community, 77%) of all 233 sink drains sampled. Of 207 sink drains harboring aminoglycoside-resistent organisms, 99% of the organisms were gentamicin resistant and 82% were amikacin resistant. These data suggest that aminoglycoside-resistent organisms are commonly present in the environment.     

Psychotherapy in mental health clinics of the Department of Veterans Affairs

In this study, Department of Veterans Affairs Fiscal Year 2006 national workload data are analyzed to determine use and intensity of outpatient individual and group psychotherapy and, using multivariate analysis, to identify sociodemographic and diagnostic correlates. Results show that among veterans receiving specialty mental health services (n=934,832), average visits numbered 7.9, 64.7% received at least one psychotherapy visit, 94% received individual therapy, and 24.1% received group. Veterans with the most mental health specialty visits of any kind were most likely to receive psychotherapy. Veterans with affective disorders and post-traumatic stress disorder diagnosis were more likely to receive psychotherapy than others. Veterans who are older, male, Black, or psychiatrically hospitalized were less likely to receive psychotherapy. Correlates of receipt of group therapy (i.e., older, Black, male, substance abuse diagnosis, urban residence) tend to be inversely related to receiving individual therapy. We conclude that psychotherapy is widely available at modest levels of intensity in Veterans Affairs.     

The University of Texas Medical Branch--Texas Department of Criminal Justice Telemedicine Project: findings from the first year of operation.

BACKGROUND: The University of Texas Medical Branch (UTMB) and Texas Tech Health Science Center (TTHSC) are responsible for providing health care for approximately 130,000 inmates of the Texas Department of Criminal Justice through a health maintenance organization (HMO). Telemedicine was considered a way to solve some of the problems presented. OBJECTIVES: To develop approaches to patient care, technology, support systems, evaluation, and uses of the system for applications other than patient care as part of the first stage of implementation. METHODS: Four prison delivery unit models were utilized. After a pilot study, the first patients were seen from October 1994 to November 1995, when 1715 consults were conducted in 18 scheduled specialty telemedicine clinics. Patients and providers were surveyed by interviews and questionnaires for their views on this form of providing care. RESULTS: Ninety-five per cent of the telemedicine consults saved one or more trips to UTMB for outpatient specialty appointments. User surveys indicated a high degree of satisfaction on the part of patients, presenters, and specialty consultants. CONCLUSIONS: Preliminary review of the data indicated favorable care outcomes, and initial economic analyses suggested that telemedicine is likely to be cost-effective in this environment. The project will be continued.     

Genetics in clinical practice: general practitioners' educational priorities in European countries

PurposeTo assess how general practitioners (GPs) from European countries prioritized their genetic educational needs according to their geographic, sociodemographic, and educational characteristics.MethodsCross-sectional survey, random and total samples of GPs in five European countries (France, Germany, the Netherlands, Sweden, and United Kingdom), mailed questionnaires; Outcome: Genetic Educational Priority Scale (30 items; six subscores).ResultsA total 1168 GPs answered. Priorities differed (P < 0.001) but were consistently ranked across the countries. Previous education had a marginal effect on priorities. Women gave higher priorities than men to Genetics of Common Disorders (adjusted odds ratio [OR_adj], 2.5; 95% confidence interval [CI], 1.6–3.8), Psychosocial and Counseling Issues (OR_adj, 1.6; 95% CI, 1.1–2.5), and Ethical, Legal, and Public Health Issues (OR_adj, 1.3; 95% CI, 1.1–1.8), but lower than men to Techniques and Innovation in Genetics (OR_adj, 0.7; 95% CI, 0.5–0.9). Older physicians gave higher priorities to Basic Genetics and Congenital Malformations (OR_adj, 1.5; 95% CI, 1.1–1.9), and to Techniques and Innovation in Genetics (OR_adj: 1.3; 95% CI, 1.0–1.7), compared with their younger colleagues.ConclusionsExpressed genetic educational needs vary according to the countries and sociodemographics. In accordance, training could be more focused on genetics of common disorders and on how to approach genetic risk in clinical practice rather than on ethics, new technologies, or basic concepts.     

Do service innovations influence the adoption of electronic health records in long-term care organizations? Results from the U.S. National Survey of Residential Care Facilities

ObjectiveHealthcare organizations including residential care facilities (RCFs) are diversifying their services to meet market demands. Service innovations have been linked to the changes in the way that healthcare organizations organize their work. The objective of this study is to explore the relationship between organizational service innovations and Electronic Health Record (EHR) adoption in the RCFs.MethodsWe used the data from the 2010 National Survey of Residential Care Facilities conducted by the Centers for Disease Control and Prevention. The outcome was whether an RCF adopted EHR or not, and the predictors were the organizational service innovations including provision of skilled nursing care and medication review. We also added facility characteristics as control variables. Weighted multivariate logistic regressions were used to estimate the relationship between service innovation factors and EHR adoption in the RCFs.ResultsIn 2010, about 17.4% of the RCFs were estimated to use EHR. Multivariate analysis showed that RCFs employing service innovations were more likely to adopt EHR. The residential care facilities that provide skilled nursing services to their residents are more likely (OR: 1.42; 95% CI: 1.09–1.87) to adopt EHR. Similarly, RCFs with a provision of medication review were also more likely to adopt EHR (OR: 1.40; 95% CI: 1.00–1.95). Among the control variables, facility size, chain affiliation, ownership type, and Medicaid certification were significantly associated with EHR adoption.ConclusionsOur findings suggest that service innovations may drive EHR adoption in the RCFs in the United States. This can be viewed as a strategic attempt by RCFs to engage in a new business arrangement with hospitals and other health care organizations, where quality of care and interoperability of patients’ records might play a vital role under the current healthcare reform. Future research could examine the relationship between service innovations and use of different EHR functionality in RCFs.     

Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

ObjectivesDrawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.MethodsWe interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.ResultsParticipants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.ConclusionOur findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.Practice ImplicationsWe discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers’ burnout.