Implementing universal Lynch Syndrome screening in a large healthcare system

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

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

Laboratory and IT Services Clinical Departments and Physician Groups Health System Administration
Clinical lab services Informatics/IT Oncology Genetics Pathology Surgery Gastroenterology Gynecology Dermatology Primary care Institution leadership Business Services
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• What are the roles of stakeholders?

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• 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

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• 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

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• 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

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

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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?

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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.

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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.

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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

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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

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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

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• 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

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• 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

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• 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.

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• 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.

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• 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.

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• 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.