Laurence Meyer: So thank you.
This is my first genomic meeting here so -- just to back up, there's been a lot of references
to the VA.
I think it is the best example to the NHS or anything that's -- it's a wonderful system.
There are about 23 million veterans alive, with 7 million who are expected to receive
care this year, so it's a very large healthcare system, over 60 million yearly visits.
There are 153 medical centers, and then there are a lot of outpatient clinics.
So over 1,400 total sites of care.
All systems do use the same electronic medical record system, but actually, they're not integrated
across.
We can finally get remote access to other ones, but there are about 180 separate servers
involved, so that's a different issue.
From my point of view as a clinical geneticist, the VA kind of lagged in delivery of genetic
care behind a lot of other health provider organizations because we didn't have pediatrics.
And I did a pediatric genetic fellowship, and, you know, 20, 30 years ago, dysmorphology
was a very big piece of genetic care.
And then it evolved into something very different.
And so in academic centers now, it obviously evolved oncology/neurology, but the VA kind
of lagged.
And back in 2006, then Secretary Peake really established the first Genetic Medicine Program
Advisory Committee with the goal of using genetic information to optimize clinic care,
but also recommending processes and goals for the development of VA genetic medicine
program.
So two years later, the committee was formed.
There was genetic care in the VA.
There are 120, in round numbers, of the VAs have academic affiliates.
Obviously, they're high-class providers in all of these places, and they were providing
care one-off in a neurology clinic, in a cardiology clinic, in an oncology clinic.
There were four actual board-certified clinic molecular -- clinical geneticists delivering
care, and the Los Angeles developed a center.
But really, we only started capturing genetic workload; the VA didn't even use workload
capture systems.
Genetics was integrated into research very quickly within the VA after this was announced.
Sara Knight will be talking, as soon as I finish as fast as I can here, will, I think,
describe a lot of the HSRND programs as well as the MVP.
And they are -- those are incredibly large research programs, but the clinical program
really lagged.
And so I was hired in, I think, 2009, as the national director, and I quickly realized
there was no service.
So, you know, it's a little -- it sounds great until you realize that you have nothing to
do.
We -- I hired the first actual clinical provider as a clinical geneticist in 2010 -- excuse
me, in 2011, and the -- one of the key points in providing a centralized, integrated genomic
service within the VA was an agreement between the VA and, well, an understanding with the
joint commission that we could cross-credential people across all of the 153 medical centers.
So that's at least possible; getting it done through the bureaucratic web was interesting.
So we hired our first counselor in 2011, and in March 2011, we got the first memorandum
of understanding between two facilities.
And then there was -- there are now 29 stop points that we've identified in the process
of delivering care.
Telehealth has really made this possible.
The VA bought into telehealth in a very big way.
The goal is to have 50 percent of all patient encounters done by telehealth.
A lot of these are between the local VA medical center and what are called the community-based
outpatient clinics or CBOCs; there are about a thousand of those.
And so the images of the mothership and then the little outpatient clinics, it keeps the
veterans from driving 150 miles; they only have to drive 20 miles.
Great place, they can get specialty care there.
A lot of it is telemental health.
But I think the idea of genetic counseling, where you're using a specialist as the primary
care physician and then a genetic counselor, and a backup medical geneticist, really works
well and is integrated well into that potential model.
Another program, I mean, I'm really surprised, there's a big ICU program, with tele ICU,
where rural hospitals have an ICU, but they can get support from, with a little robotic
interface, from an intensivist at a much higher acuity hospital.
So we really built a centralized service in Salt Lake City.
This is where we were one year ago, and here is where we are now.
So we're delivering care in, actively, I think, in 47 or 48 places.
We have over 60 memoranda of understanding signed to deliver care, but the IT infrastructure
lags, you have to get permission from each hospital, and get integrated into their system.
My counselors have to log on to each medical center every 30 days to maintain their passwords.
We have an encrypted log.
So if you can imagine trying to keep track of a 153 user IDs and log-ins just to be able
to deliver care.
There's got to be a better way.
We're going to work on that.
Here's the set up, these are actually two counselors talking to each other, but it's
just on through a nice set up.
And here's the way the workload has increased through the first quarter of this year.
So we're just -- we're exponentially increasing, which is really fun.
And here's the agreements with TSAs.
A lot of this has been through the telemedicine capacity, over a third of it; about a third
of it is e-consults.
And a lot of the driver of that is from pathology.
We get consults from -- I think well over the half of the e-consults are from pathology
saying, "Is this test appropriate?
How do we handle this?"
The pathologists in question, a lot of times, are not certified molecular pathologists.
There are more than a handful of excellent certified molecular pathologists within the
VA., but a lot of these go to the regional lab.
There's a saying in the VA, "If you've seen one VA, you've seen one VA."
They're kind of entrenched, and so the test lands at a local VA medical center that may
not have anybody skilled in molecular pathology, so we handle those.
We also just do a lot by telephone.
As soon as we have the memorandum understanding signed, we can get in there and legitimately
contact the veteran, and then we're emailing encrypted notes.
It's -- but it does work.
We've gotten referrals from every department and division within the VA, with the sole
exception of the emergency room.
So -- and I imagine that's going to happen one of these days.
So we're -- we've really made inroads in every place.
Usually, when we get into a site, we give an in-service.
The big users are our oncology women's clinic, which also includes breast cancer obviously,
GI.
So you know, the needs and gaps, I'm trying to close here, you know, everything that we've
heard today, I think that there's a tremendous consensus in the room about what the needs
are.
Clearly, integration with EMR is a big one.
The one thing that hasn't been mentioned yet is the structured family history.
And if you're looking at Amsterdam or Bethesda Criteria, you're looking at Bracha Pro [spelled
phonetically].
You want to -- if you're going to computerize that for decision support for some busy primary
care physician at the point of care, you really need to have a structured family history.
I know there's a conference a little later this week that might address some of that.
I'm going to the conference in San Francisco, and disparities of care.
So -- but building computerized decision support all the way through and making this seamless
has got to happen.
There's no way that any of us who are -- you know, no matter how good we are and how long
we've been doing this can keep track of all the polymorphisms.
I think the processes, as just alluded, you know that the idea that there should not be
a genetic exceptionalism, either in the ways we order the test or anything.
It's just another test, and it's just more medical information.
How can we use that?
How are we going to run this into -- how are we going to build this into large scale?
There are 3,000, I think, or very close to 3,000 individual genetic tests performed commercially
in the United States right now.
And then if -- as we approach whole genome sequencing, or exome sequencing, or regularome
[spelled phonetically], or whatever it is, how are we going to divide that?
There are also -- so these are sort of the more external issues.
I think the internal issues, building a service within the VA -- I was at a meeting in D.C.
a little less than a year ago, and they were suggesting words that describe the VA as "flexible"
and "responsive" --
[laughter]
-- and those of us in the field were saying you know, "glacial, monolithic, bureaucratic."
And working this through so that we can get access to the high-quality molecular labs
and centralizing those, so that we can work with IT, which is a local issue, work between
all the medical centers; all of those are issues.
But I think -- you know, I can just go back to that trajectory slide.
So I also work in research, and so I'll turn over now to my colleague from ORD.
But thank you.