Implementing universal Lynch Syndrome screening in a large healthcare system

1. Implementing universal Lynch Syndrome screening in a large healthcare system

3. 1. Getting Started • The goal of universal Lynch Syndrome screening is to provide a population based approach to identify individuals at increased cancer risk resulting in: • Enhanced surveillance • Early cancer detection • Decreased disease-specific mortality • Overall cost savings due to earlier detection and prevention of cancer.

4. Getting Started • Identify who will play a role in moving universal screening forward.

5. Getting Started • What are the roles of stakeholders?

6. Getting Started • Consider what information is relevant to each stakeholder group and foster communication around the benefits to the healthcare system, clinicians, and patients. • Administrators • Clinical providers (e.g., oncologist, surgeon, pathologist, and geneticist) • Laboratory and IT Services

7. Getting Started • Administrators (business services, institutions) • Goal of universal screening • Clinical overview of Lynch Syndrome • Community standard for MSI/IHC testing • Cost benefit, both short term and long term perspectives for institutions

8. Getting Started • Clinical providers (oncologist, surgeon, pathologist, and geneticist) • Evolving national and international standards • Evidence based data showing improved patient outcomes from universal Lynch syndrome screening testing • Examples of clinical management algorithms

9. Getting Started • Laboratory and IT Services • Lynch Syndrome diagnostic and tumor testing criteria recommendations • Evolving standards for universal testing

10. Getting Started

11. 2.Challenges with infrastructure Identifying and understand challenges in a large healthcare system from communication with stakeholders • System culture - how new program decisions are made? • Evidence based review- does the science support the decision? • Financial impact (Prevention vs. Treatment) • New technology required?

12. Challenges with infrastructure • What resources are needed during: • Development • Implementation • Ongoing • From lab order through results management, what departments will be most impacted? • Pathology: Accommodating increased specimen management for testing • Laboratory/ IT: Increased resources for developing and implementing universal screening • Genetics: Increased resources during development as well as an potential change in volume of referrals.

13. Challenges with infrastructure • How does a new process get integrated into complex, well established workflows? • What is the existing workflow for Lynch Syndrome screening? • Who are the owners of the current workflow? • Anticipate resistance to change! • Training requirements when new system is established.

14. Challenges with infrastructure Laboratory, pathology, and IT services require high level of commitment for process development. • Engage identified leaders who will manage the development for the laboratory flow • Determine pathology specimen flow from surgery to pathology laboratory • Specimen management by Inpatient pathologist and tech staff • Specimen management by Regional Lab pathologist and tech staff

15. Challenges with infrastructure Laboratory/Pathology • Design detailed work flow • Engage IT for programing of automated orders in computerized pathology system • Flow design of Lynch syndrome screening to complete with IT, lab, and genetics stakeholders • Identify training needs to ensure implementation processes are followed • Test the processes – QC from start to finish

16. Challenges with infrastructure Genetics – Lynch screening test results • Development of appropriate work flow for results and patient education • Consistency in receiving results from testing lab • Incorporation of results into medical record • Appropriate providers informed of results • Disclosure of results to patient • Coordination of appropriate reflex testing • Lynch syndrome screening billing processes • Genetic counseling for patient as indicated • Workflow should maximize patient compliance

17. Frequent communication before, during, and after implementation • Identify and address problems as they arise • Pathologist work load impact- delay in specimen review, and sending to central laboratory causes delay for patient receiving results • Identifying need for training with lab staff • Communicate with stakeholders after implementation has begun to: • Provide opportunity for feedback • Assess need for changes • Inform and keep engaged

18. Elements for successful Lynch screening implementation: • Identify decision makers • Engage stakeholders • Provide information to inform and facilitate buy-in • Meet with key personnel to develop the implementation plan • Keep channels of communication going during the process to ensure implementation plan is progressing • When hurdles arise- look to stakeholders and key personnel to assist with resolution of the problem • Ongoing communication is a must with: • Pathology • Laboratory, IT • Genetics • Surgery • Oncology

19. Overcoming barriers Genetics – Lynch screening test results • Development of appropriate work flow for results and patient education • Consistency in receiving results from testing lab • Will they be mailed/faxed/incorporated into electronic medical record? • A point person or department is essential as is a consistent method of sending/receiving results. • Incorporation of results into medical record • Where in the chart will the results go? • Will they be incorporated into the original pathology report? • They should be in the same place for each patient to ensure consistency and ease of locating results.

20. Overcoming barriers Genetics – Lynch screening test results • Development of appropriate work flow for results and patient education • Appropriate providers informed of results • How do providers involved in care typically receive lab results? • Consider routing results directly to relevant stakeholders, holding a case conference with stakeholders for all screen positive cases, etc. • Disclosure of results to patient • How will results be disclosed to patient? • Letter or phone call with appropriate stakeholder; determine if all results or only abnormal results will be provided to patients etc.

21. Overcoming barriers Genetics – Lynch screening test results • Development of appropriate work flow for results and patient education • Coordination of appropriate reflex testing • Who will be involved? What consenting may be indicated? • Consider how current workflows could be modified. • Consider which stakeholders should be closely involved with this task. • Lynch syndrome screening billing processes • What are the current billing processes/barriers? • Is an order in the EMR necessary for billing purposes? • Determine how will this impact workflow for a screening program.

22. Overcoming barriers Genetics – Lynch screening test results • Development of appropriate work flow for results and patient education • Genetic counseling for patient as indicated • Consider patient education handouts for screen positive cases (prior to reflex testing if available). • Comprehensive Lynch syndrome screening program should consider genetic counseling of high risk cases if resources are available. • What will the patient population be in a more formal Genetics clinic setting once screening is in place? How will this impact clinic workflow? • Workflow should maximize patient compliance • EGAPP cost-effective analyses are based on appropriate at risk family members receiving cancer surveillance. • Strive to obtain patient compliance data to track screening implementation process successes.