Converting a Genetic Screening Program to Virtual Visits

May 5, 2020
To minimize disruption caused by the pandemic, the Adventist Health Early All-Around Detection (AHEAD) program now screens, counsels, and tests patients in their homes

The American Society of Clinical Oncology (ASCO) has reported that COVID-19 is disrupting cancer treatments, screenings and clinical trials.  Screening centers will be challenged to catch up with the backlog once things open up again. The pandemic also has had an impact on genetic counseling and testing. To address the issue, Adventist Health in California is shifting its Adventist Health Early All-Around Detection (AHEAD) program to virtual visits.

Candace Westgate, D.O., is board certified in obstetrics and gynecology, along with additional certification in Women’s Genomics Counseling from the American College of Obstetrics and Gynecology. She is the medical director of Women and Infant Services and Adventist Health St. Helena, and the founder of the AHEAD program. She notes that the whole point of the AHEAD program is to help physicians and patients stay ahead of cancer.

After working on the program for three or four years, Westgate said, “we had a beautiful, well-oiled machine that included an electronic tablet where the patient filled out a family history questionnaire as they were sitting in the waiting room for their appointment with a physician, and an automatically generated report came to the physician that explained whether patients met certain criteria to offer genetic testing.” The AHEAD program deploys a software platform called CancerIQ, which analyzes family history and runs predictive risk models to identify candidates for genetic testing.  Westgate said the platform enables office staff and physicians to function more efficiently and provide better care for patients, without requiring extra time from them.

“The problem was that it was all based on in-person visits,” she explained. “When COVID 19 hit, the focus was on getting hospitals and clinics ready for an influx of very sick patients. Because of the quarantine and shelter at home in California, our state did a good job of flattening that curve, and because we work in more rural communities, we haven’t seen that big surge that some big cities have.”

Instead they found themselves in a place where their offices were almost empty and patient volumes fell by 50 percent. “We have had to — on the fly — within a week, think of a totally different approach,” Westgate said. “My biggest concern was about those patients, especially high-risk patients, who need those preventative services, and our ability to pick up breast cancer at an early stage because of prevention. Now we are not doing those anymore and pushing those screening modalities out, and we are going to find ourselves later this year with a higher volume of later-stage cancer diagnoses, which is going to be devastating to both the individual patient as well as the whole community.”

Because CancerIQ already had the foundation of an electronic platform, she said, the AHEAD team did some brainstorming with a development team, and within a week they had switched the entire program to something virtual. Instead of the patients coming to the office  to do the cancer screening, they get an e-mail request from their primary care physician to fill out the family history online.

If patients meet certain criteria, the next steps include a virtual genetic counseling session, virtual test ordering and then virtual results disclosure and care management. “We have incorporated a virtual component into every one of those buckets,” Westgate said, “so the patient doesn’t have to leave their home.”

For example, those that meet the criteria for being at high risk are set up for a virtual visit with a genetic specialist. They complete the counseling session using Microsoft Teams. “If the patient meets the criteria and needs to have genetic testing, I order the genetic testing for them and have the test kit shipped to their house.” They return saliva samples to Adventist's genetics testing partner. 

The patient is then set up  with a follow-up visit a few weeks later, when they receive results disclosure and complete care management planning. Those who at high risk for cancer go through increased screening guidelines, and for instance a woman might be put at the top of a list sent to breast imaging centers for priority scheduling when they open up next month.

 “As a result of this program, we are not letting anyone slip through the cracks,” she said. “We are still able to connect with our patients virtually.”

I asked Westgate if a few months ago she could have pictured doing all this work virtually. “No. Not at all. It has been amazing,” she said. “Here’s why: Over the last eight months, I have diligently been working with our organization to try to get telemedicine privileges. A lot of our clinics are in rural areas, and I wanted to provide these genetic counseling services for our entire Northern California region. Our organization has seven telemedicine locations set up. It had taken eight months and I was still no closer to seeing my first telemedicine patient. Yet once COVID-19 hit, within two weeks, we have been able to turn this whole thing around, and I am doing virtual consulting and testing. It has been amazing to see how quickly healthcare overall has been able to adjust and change and do what is right for our patients in the middle of a crisis.”

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