Table 3.
Overview of barriers and facilitators to adoption of genomic services for colorectal cancer care in the Veterans Health Administration.
| Domain | Genomic Service | Implication | ||
|---|---|---|---|---|
| Family Health History (FHH) Documentation | Clinical Testing (Molecular and Genetic) | Genetic Counseling | ||
| Structural | +/− FHH routinely collected; however, lack of policy to standardize collection according to guidelines (incentives and mandates 1) |
− Limited use and, for some, unclear referral process due to perceived low disease burden (innovation-system fit 1) |
+/− GMS has facilitated referral process for genetic counseling; however, limited access presently (inter-organizational networks 1) |
Structural barriers are lack of mandates for guideline adherent FHH documentation, perceived low need for testing in VHA patient population, and limited availability of in-house genetic counseling service; national VHA LS policy could improve adherence to guidelines via mandates for systematic FHH documentation, clinical testing protocol, and genetic counseling access. |
| Individual | +/− Gastroenterologists and oncologists likely to consider FHH documentation for CRC; however, when documented, completed with limited detail (attitudes 2) |
+/− Across specialties, clinician use of testing facilitated by individual awareness/interest and local champion, and negatively impacted by lack thereof (attitudes 2; resources 2,3) |
+ Resources facilitative because variability in individual expertise (attitudes 2; resources 2,3) |
Individual-level barriers for FHH and clinical testing are low knowledge of or interest in LS, particularly by non-specialists; development of clinician education, local clinical champions, and genetic counseling resources could increase knowledge of evidence-based processes and ways to access services. |
| Innovational | − Lack of template/tool to facilitate guideline-informed use of FHH (augmentation/support 1) |
+ Perceived advantage of molecular testing as more reliable 1st step than FHH (relative advantage 1) |
+ “Expert” genomics support appreciated, such as provided by academic affiliate or within VA by local navigators, other VA facilities, or centralized GMS (augmentation/Support 1) |
Availability of a tool (or template) could facilitate adherence to guidelines for documenting FHH. Clinical testing regarded as advantageous, indicating potential for wider uptake. Access to expert support is essential. |