 So, am I the only one here from the VA? Is that my understanding? Okay. And so, I thought, what was that? Because I really can't represent the whole VA. I can talk, I know what I'm doing, but I did want to introduce to you a little bit about the Veterans Health Administration for those who may not be familiar with it. It is the largest integrated delivery system in the U.S. I think these are numbers from 2009 or 2010, a $36 billion annual budget, most of that for patient care. But about almost $600 million for research. And we provide inpatient and outpatient care for veterans. And in multiple settings, there are 152 hospitals or medical centers. There are many community outpatient clinics that are affiliated with all of those medical centers, nursing homes, domiciliaries, home-based care, and rehab. With regards to research, we have an Office of Research and Development. And there are four main programs in that office, biomedical and laboratory, clinical science, and cooperative studies. These are clinical trials and large multi-site clinical studies. There's a whole research devoted to rehabilitation and there's health services, research and development, which is where I sit. And within that, there's a special initiative that's called Query or Quality Enhancement Research Initiative. And this is where most of the implementation, science implementation research is housed. So this is a slide from my colleague, Brian Mitman, who is our implementation scientist at my VA. And this is kind of the research implementation pipeline at the VA. This is like a unidirectional kind of thing, but there's feedback loops all the time. But on your far right, there's that initial basic discovery. And then there's trying to translate that into clinical guidelines with effectiveness studies and then in health services type research studies. And then eventually once those evidence-based guidelines are developed to then conduct implementation research to try and understand why there may be variability in the uptake of these guidelines and how they're practiced. And in the VA, it's kind of neat because we have all these medical centers and every single one of them is very different and yet we're trying to practice very standardized health care. So with respect to health services, genomics, this is a relatively new program. And I was introduced to it because while I was at the RAND Corporation, the VA asked RAND to develop a white paper, a systematic review, on the topic of delivery of genetic services for adults so that they could better understand what are some of the gaps to then inform priorities for research. And so this is what Pauline Severding, who is the project officer for the Health Services Genomics Program, she identified four main areas, capacity, informatics, education, and then implementation. So these are the four areas. And I think Dr. Severding is going to be revamping and revising her research priorities for the next five years pretty soon. And then so following that, coming up with what the research priorities are, then Dr. Severding put out a priority solicitation in 2008. And this was specifically two Centers of Excellence in Health Services Research that were already established within the VA system. And I believe at the time there were 15 or so. And so the idea was to have these Centers respond to do some health services genomics work, to encourage innovative research for evidence-based planning of veteran health services in genetics and genomics, and to begin development of tools and models for genomic translation within the VA. So seven Centers were funded. And so I'm at the bottom, Greater Los Angeles, but I wanted to share with you that there are other health services implementation researchers within the VA at these different sites. And they're doing all kinds of interesting work. This is what was proposed back in 2008 and many of them have expanded and gone beyond what's listed here. So for the rest of my talk, I wanted to just describe a little bit about what we're doing to give you an idea of perhaps what others are doing at the other sites. So we are within the Center of Excellence at the VA in Sepulveda. And that VA actually, its focus is the, that Center of Excellence, the focus is the study of healthcare provider behavior. And I thought that was a pretty good match because much of my interest is in trying to change healthcare provider behavior when it comes to genetics, genomics. And so we have lots of strength in provider behavior theory, quality improvement, implementation science. And then when I showed up, some experience with medical genetics. And so our mission to conduct health services and implementation research that will promote adoption and implementation of effective delivery of evidence-based genetic genomic medicine to improve the health and healthcare for veterans. And this is our team. This is kind of our core team. I don't wanna go over everybody's name and what their role is, but basically it was wonderful for me because I just kind of showed up and I was able to work with this group of people who have done health services and implementation research in other areas like HIV and women's health. And this was just one more thing for them to help tackle. So we have so far five funded projects. The first was that genomics pilot from the VA HSR&D office that kind of just got us started. There were several pilots that we did. We tried to understand what was being done at our facility in terms of genetic testing, family history. And we also had an expert panel help inform our research agenda. Education was a big thing that was mentioned over and over. And so I was lucky to apply for some funding from CDC. And the focus there was family history with regards to hereditary cancer syndromes. And I'll be talking more specifically about this project. The third project listed is actually a national survey. We're surveying chiefs of staff of all of the medical centers and chiefs of, if I can remember, pathology, oncology, neurology, and cardiology. And I think there's another one, but I can't recall. At the 152 medical centers, just trying to get a sense of what they're doing with respect to genetics, genomics, what kind of arrangements they may have to provide services and testing. The fourth project is another education project funded by CDC. And here we are developing strategies to improve, hopefully improve implementation of genetic tests requesting and also providing a consultative report back to providers for certain molecular genetic tests that are being ordered via our electronic health record. And then the last one is a relatively small project. Dr. Larry Meyer, who is the lead of the National Genomic Medicine Program, would like to roll out Lynch syndrome screening across the country and in my vision, which is Fetcher's Integrated Service Network 22. It's Southern California and Southern Nevada. We have five medical centers. And so I went and we're basically interviewing chiefs there to find out what are the potential barriers, what might help facilitate, and how should we develop an implementation plan to get this done. So for the remainder of my time, which I know I don't have much, I wanted to talk a little bit more about the Family History Project from CDC because this is the project that's most furthest along. So the goal, again, was to develop a multi-component education program to improve recognition and referral of patients at risk for hereditary cancer. And so essentially we wanted to try and implement guidelines or recommendations from USP, STF, NCCN and CDC regarding hereditary cancer with respect to family history. And this is our logic model. So have a population and try and have these educational strategies to improve family history documentation, referral for genetic consultation, utilization of preventive services, and then ultimately, hopefully morbidity and mortality. And with this particular project, the first year was devoted mostly to just developing our implementation strategies, our education program. And so the outcomes that we proposed to assess were really the family history documentation and the referral for genetic consultation. And so I said multi-component because if all we did was give didactic lectures, that wouldn't do anything. So, but we did, we gave didactic lectures, but also developed other informational interventions and clinical interventions, mostly tools in our electronic health record and behavioral interventions where we gave feedback to clinicians about their performance. And this is just a picture to show you. So we did a seven part CME approved lecture series. We have a website that we call GCAT that has a bunch of information on it. We had patient information sheets about family history and what to expect from a genetic consultation. We had in the clinic a paper administered family history questionnaire that the front office staff were supposed to give to patients to fill out before they saw the provider, and then their provider would go through a clinical reminder to capture family history information. In that reminder, there's a document that's kind of the red flags to remind them about indication for referral. And then right over here, that's basically our quarterly report back to the providers to let them know, well, this is how often you're completing the reminder compared to your peers. This is how often you're referring a patient for genetics compared to your peers. So we first set out trying to maybe develop a tool in the electronic health record that would help identify red flags. We talked about that yesterday. And what we heard in focus group feedback from our primary care clinicians is this is totally not useful. We need to document complete family history and then once the family history is documented, we'll be able to figure out who we should refer. Well, I already knew that that was unlikely because they hadn't made any referrals. They hadn't ordered any genetic tests in five years. So it was like, okay, whatever. But I had to listen to them because the one that we created wasn't gonna work. And they wanted a tool that would be very quick that most of the time, the answer would be no. So we did, we built that tool, I think. And I'm sorry for these screenshots. This is what our electronic health record looks like right now. It's not very pretty. It's kind of gray on gray, but the providers are very usey. So this is a reminder. It sits in a reminder drawer and primary care clinicians are very accustomed to going in there and completing reminders when they're due. It's non-mandatory. But basically it just explains on the front sheet what this reminder is all about to help them document family history and make referral. The patient can decline to provide family history at that visit or if the patient has limited life expectancy then they can opt out. So it's about eight questions. And the first one, well, first you have to decide if it's a female or a male. And then are you adopted? If yes, they're supposed to try to provide information about biological family members. And then two questions, have you ever been diagnosed with any kind of cancer and have you ever had 10 or more colon polyps? So yes, no, don't know. Were any first degree relatives ever affected with cancer? Any second degree maternal relatives? Any second degree paternal relatives? Any other relatives? And then this window is if you had clicked yes, then it would open up and say, okay, which first degree relative, for example, mother, father, brother, sister? If you click on here at sister, then which cancer? And then if you click on which cancer, what's the age on set? And we just use 50 as a threshold. And then to get out of this reminder, they have to make a decision about whether or not they wanna refer this patient for a genetic consult. And so they can request the consult or they can say, well, the consult's indicated but the patient is declining or they can say it's not indicated. And at the bottom there are some links to the NCCN guidelines and USPSTF, et cetera. And again, there's that indications for cancer genetic consultation. They can click into that if they've forgotten. Okay, so we are just finished now with implementation. We finished in September. So basically we had some pre-implementation data. We're probably gonna have to go back a little bit more in time on that. And we've been monitoring these health factors that are generated by this tool. So every click of the tool generates data that we can query in Vista, which is the backbone to our EHR. And then we've also been abstracting information from 10% of randomly selected charts each month. And we did a pre-post knowledge and attitude survey and also some interviews with the clinicians involved. Oh, and I should have said this was implemented in our women's clinics only. So there were only nine providers in those clinics and seven were actively involved in this project. So it's a relatively small project pilot. So in the 18 months of implementation, there were just over 4,700 family history reminders due, so 4,700 patients. And it was completed for 27% of them. And then by looking at those health factors, I assigned a strong moderate or weak familial risk for cancer based on kind of standard guidelines. And you'll see 13% had a strong familial risk, 27% moderate, et cetera. And about two thirds of the strong were referred, almost 20% of moderate familial risk and a few of the weak familial risk were referred for consult. And so in that chart abstraction, we saw that before we implemented our tool, 30% of the charts had some family history in it, although it wasn't that great. And I'll show you that on the next slide. And then post implementation in orange, you'll see that with the template, we increased documentation of family history, but still some providers were using just documenting in text, that's in green. And then over time, you'll see that documentation kind of almost decreased over time from that progress note, but in looking back, the family history had been completed previously. So about half of the charts overall, and this is data through June, so we still need to keep looking at this. And the type of family history that was recorded, so before implementation, there was some mention of family history in first degree relatives, of course, 76% of the charts, second degree relatives, 48%, as you can see. But so what we saw was an increase in that in the post implementation phase. And then the lineage of the relatives, so were they second degree, and if they were maternal or paternal, that increased substantially. The age of cancer onset increased substantially and Jewish ancestry. So these were all things that allowed the clinicians, I believe, to do a better job of risk assessment. And then the knowledge and attitudes, and I'll finish up quickly. We looked pre and post at the knowledge, which is kind of in the middle, those two, and I just did this slide last night, so I apologize if it's not too clear. And then we asked a bunch of questions about their attitudes of how relevant genetics was to their practice. And we had about 42 questions on this survey and we've broken them out into domains. And basically, you can see at the bottom of the slide, they had 59% correct score pre-implementation and that went up to 73%. So they did learn and they learned actually, you look at genetic testing topics, they went from knowledge of correct percent of 33 up to 71. So they actually learned quite a bit over this whole process about management and referral and ethical issues, et cetera. But the relevance to their practice didn't change at all, if anything, it was even less. So I think it's because, well, I can tell you in a bit, but maybe this next quote might summarize it. So this is one provider and this is similar to the interviews we have with the others. So she said, I've gained in so many ways by participating, I've refreshed and expanded my knowledge about genetics, I've gained substantial new knowledge about hereditary cancers. As a result, I now feel quite confident in recognizing red flag patterns. I don't necessarily identify which syndrome a patient may have, but I can ascertain whether further evaluation is needed, can understand what the results of tests mean, and understand my obligation to follow through. So I think because I was there and our anthropologists interviewing these providers learned that they just were happy that I was there to make a referral when they saw these patients, but they didn't wanna take on the job of testing, et cetera, for themselves. So basically, now that we're done, our anthropologists asked, well, do you want this reminder? What aspects of the program do you want to continue? They want the reminder, they think it was most influential in improving their performance around family history, and they wanted to stay in our electronic record, but they don't want it mandatory, and they all value the consult service. If it wasn't there, they probably wouldn't wanna be asking these questions because they wouldn't necessarily know what to do or have the time to deal with it. And they all wanted me to continue to review those reminder, the health factors generated to help them identify patients who would be appropriate for referral in case they didn't pick those up. They wanted more lectures. Some wanted to continue with the family history questionnaire in the clinic, and very few use the website. And so just next steps, I mentioned that we were only, with this project, able to look at family history documentation and consultation. So we are now planning with VA funding to look at utilization of preventive services by women for whom the reminder was completed. Those who were referred, and that referred to genetics. So we're pretty excited about that, and that's it. Thanks. Sorry, I went over a little bit. Any questions? I think we have time for just a question or two. Yeah, so can you comment on genetic services across the VA because, and actually it's a problem when they do identify somebody who has hereditary disease because referring them out of the VA and then trying to deal with it becomes pretty complicated. So are they planning to increase genetic services? Yeah, so right now, so our national survey is gonna tell us a lot more about what arrangements exist and which facilities actually have genetics providers because I've even learned myself, Boston, San Antonio, Houston, Seattle, Los Angeles. There are sites that have geneticists and counselors. But yeah, you're right, that's just a handful of 152. So the national program is doing something interesting. That program started about a year ago and they're hiring counselors to provide telemedicine consultation to sites. So that's one model that should increase accessibility. The other is there are arrangements and so really any veteran who needs genetic services, they just have to do fee basis care and make a request and it has to be reviewed and hopefully the people reviewing it understand the request and most importantly, the request needs to indicate how it's gonna help make diagnosis, change management, et cetera. So it's not like you can't get it, it's just people have to go the fee basis route to get this arranged for their patients. So Marin, hi Gail Jarvik. Hi. So just an update on Seattle which is that the VA doesn't plan on replacing Tom Bird when he retires this year. So we'll have no geneticists. We're going in the wrong direction. But I mean, what you're finding is you have to drum up the genetics consults, the docs aren't finding them on their own. And that's the real concern about just waiting for referrals because they are not appropriately referring patients. Well, I would say, we conducted a bunch of interviews with chiefs to inform our web-based survey and the neurologists, the oncologists. So the specialists, they know, half of my referrals are coming from specialists to help make a diagnosis of a genetic disorder. These referrals from primary care are mostly patients at risk with family history, et cetera. But I think that it's just a combination of both. Frankly, I don't think our providers are any different from people out in the community. And so, yeah, the neurologists know when they think they have a case and they need genetic testing and whether or not they need the counseling, et cetera, to go along with it. So at my facility, the minute they knew I was there, I started getting a lot of consults. Right, but before you were there, you said you had five years with no consults. Well, I think that's what I worry about that without that presence, without thinking about it. But that was from primary care. So I honestly don't know what oncology and neurology was doing before I arrived. I would have to go and look into that. Right, I think my own opinion is that I would really like to see the VA continue that service because I believe having someone embedded increases education and increases referrals, but there's something you can study. Well, hopefully. And I think this type of research is, the VA loves health services research. It thrives on it. And if we can provide good feedback to the powers that be, then things can happen. Okay, I think we need to move on. We're gonna try to squeeze in Bill and Les for five minutes here. Talk about the NIH Clinical Center.