Implementation of Cancer Genetic Surveillance in Rural Primary Care Clinics: The Role of the Nurse Informaticist

Purpose: This project explored the impact of genetic risk testing services and surveillance within the electronic health record (EHR) on rural and urban primary care clinics’ operational workflow and patient outcomes. The roles of the nurse informaticist (NI) and interprofessional team are discussed to leverage a scaled, phased implementation approach to optimize the EHR infrastructure and support the early identification of patient cancer risk, genetic surveillance, and primary care support.
Background/significance: Genetic testing is instrumental in identifying individuals with cancer risk and guiding them through treatment and surveillance strategies. Yet, few health systems have developed the EHR infrastructure necessary to support the effective adoption of genomic healthcare within primary care clinics. Furthermore, primary care providers (PCPs) are often ill-equipped to address genetic risk, testing, and counseling and lack necessary EHR support for successful implementation within clinic workflow. Additionally, implementation of genetic testing services in primary care clinics requires interprofessional collaboration, genetic knowledge, and coordination of care—a mission nurse informaticists are well-positioned to lead.
Method: Implementation of EHR infrastructure and genetic testing services in primary care clinics occurred over three phases between April 2021 and December 2022 as part of the Early Detection of GEnetic Risk (EDGE) study. The interprofessional study team, led by the NI, met weekly to refine EHR formats and clinical workflow within three urban and three rural primary care clinics from a fully integrated healthcare organization in the rural Northwest.

Result: Since study launch, numerous new features over three phases have been deployed and optimized within the EHR. In phase 1, the NI led an interprofessional team (i.e., health information management, genetic counselors, chief medical information officers, pathologists, and PCPs) to improve EHR infrastructure to store genetic testing results and the surveillance plan for positive results. In phase 2, the advent of a folder naming convention required electronic authentication by PCPs, resulting in the automatic entry of genetic test results to both the EHR genetic folder and the patient’s healthcare portal. An electronic message script was implemented within the EHR for individualized genetic mutation result notifications to PCPs. Notifications included ICD-10 diagnosis codes, information to guide PCPs with patient follow-up, National Comprehensive Cancer Network (NCCN) guidelines, and the procedure to request genetic counselor referral within the healthcare system. In phase 3, the study team created personalized previvor reports containing known genetic mutation information, personal and family history information, frequently asked questions for patients and families, and cancer resources. The genetic counselor mailed these reports to the patient.

Conclusions/implications: NIs are well-equipped to facilitate implementation of genetic cancer risk test results and surveillance across the care continuum from patient testing to genetic counseling. Tangible steps were identified and implemented to improve electronic and patient communication for genetic testing results, resulting in timely and comprehensible genetic information for PCPs, genetic counselors, and patients. The next step is evaluating the process with the NI and key stakeholders in primary care and genetic counseling for implementation of genetic cancer risk surveillance and testing as the standard of care.