Publications by authors named "Barbara Lerner"

14 Publications

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The End-to-End Provenance Project.

Patterns (N Y) 2020 May 8;1(2):100016. Epub 2020 May 8.

Department of Computer Science, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.

Data provenance is a machine-readable summary of the collection and computational history of a dataset. Data provenance confers or adds value to a dataset, helps reproduce computational analyses, or validates scientific conclusions. The people of the End-to-End Provenance Project are a community of professionals who have developed software tools to collect and use data provenance.
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May 2020

Facilitators and barriers to the Lean Enterprise Transformation program at the Veterans Health Administration.

Health Care Manage Rev 2020 Jan 28. Epub 2020 Jan 28.

Kathryn J. Azevedo, PhD, is Medical Anthropologist, National Center for PTSD, VA Palo Alto Health Care System, California. Caroline P. Gray, PhD, is Research Sociologist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Randall C. Gale (deceased), DrPH, is Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Tracy H. Urech, MPH, is Research Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Jeremy C. Ramirez, MPH, is Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Emily P. Wong, MPH, is Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Barbara Lerner, PhD, is Investigator, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Massachusetts. Martin P. Charns, DBA, is Investigator, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, and Professor of Health Policy and Management, Boston University School of Public Health, Massachusetts. Anita A. Vashi, MD, is Physician Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto; and Department of Emergency Medicine, University of California, San Francisco; and Department of Emergency Medicine (Affiliated), Stanford University, Stanford, California.

Background: The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care.

Purpose: Barriers and facilitators to Lean implementation were evaluated.

Methods: Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers. Interview transcripts were analyzed using thematic analysis techniques.

Results: Supporting the utility of the model, facilitators and barriers to Lean implementation were found in each of the Lean Enterprise Transformation evaluation model domains: (a) impetus to transform, (b) leadership commitment to quality, (c) improvement initiatives, (d) alignment across the organization, (e) integration across internal boundaries, (f) communication, (g) capability development, (h) informed decision making, (i) patient engagement, and (j) organization culture. In addition, three emergent themes were identified: staff engagement, sufficient staffing, and use of Lean experts (senseis).

Conclusions: Effective implementation required staff engagement, strategic planning, proper scoping and pacing, deliberate coaching, and accountability structures. Visible, stable leadership drove Lean when leaders articulated a clear impetus to change, aligned goals within the facility, and supported middle management. Reliable data and metrics provided support for and evidence of successful change. Strategic early planning with continual reassessment translated into focused and sustained Lean implementation.

Practice Implications: Prominent best practices identified include (a) reward participants by broadcasting Lean successes; (b) provide time and resources for participation in Lean activities; (c) avoid overscoping projects; (d) select metrics that closely align with improvement processes; and (e) invest in coaches, informal champions, process improvement staff, and senior leadership to promote staff engagement and minimize turnover.
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January 2020

Lean Enterprise Transformation in VA: a national evaluation framework and study protocol.

BMC Health Serv Res 2019 Feb 4;19(1):98. Epub 2019 Feb 4.

Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, 150 S Huntington Ave, Boston, MA, 02130, USA.

Background: The goal of Lean Enterprise Transformation (LET) is to go beyond simply using Lean tools and instead embed Lean principles and practices in the system so that it becomes a fundamental, collective mindset of the entire enterprise. The Veterans Engineering Resource Center (VERC) launched the Veterans Affairs (VA) LET pilot program to improve quality, safety, and the Veteran's experience. A national evaluation will examine the pilot program sites' implementation processes, outcomes and impacts, and abilities to improve LET adoption and sustainment. This paper describes the evaluation design for the VA LET national evaluation and describes development of a conceptual framework to evaluate LET specifically in healthcare settings.

Methods: A targeted literature review of Lean evaluation frameworks was performed to inform the development of the conceptual framework. Key domains were identified by a multidisciplinary expert group and then validated with key stakeholders. The national evaluation design will examine LET implementation using qualitative, survey, and quantitative methods at ten VA facilities. Qualitative data include site visits, interviews, and field observation notes. Survey data include an employee engagement survey to be administered to front-line staff at all pilot sites. Quantitative data include site-level quality improvement metrics collected by the Veterans Services Support Center. Qualitative, quantitative, and mixed-methods analyses will be conducted to examine implementation of LET strategic initiatives and variations in implementation success across sites.

Discussion: This national evaluation of a large-scale LET implementation effort will provide insights helpful to other systems interested in embarking on a Lean journey. Additionally, we created a multi-faceted conceptual framework to capture the specific features of a Lean healthcare organization. This framework will guide this evaluation and may be useful as an assessment tool for other organizations interested in implementing Lean principles at an enterprise level.
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February 2019

Stakeholders' views on the value of outcomes from clinical genetic and genomic interventions.

Genet Med 2019 06 31;21(6):1371-1380. Epub 2018 Oct 31.

William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.

Purpose: Robust evidence about the value of clinical genomic interventions (CGIs), such as genetic/genomic testing or clinical genetic evaluation, is limited. We obtained stakeholders' perspectives on outcomes from CGIs to help inform their value.

Methods: We used an adapted Delphi expert panel process. Two anonymous survey rounds assessed the value of 44 CGI outcomes and whether a third party should pay for them, with discussion in between rounds.

Results: Sixty-six panelists responded to the first-round survey and 60 to the second. Policy-makers/payers gave the lowest ratings for value and researchers gave the highest. Patients/consumers had the most uncertainty about value and payment by a third party. Uncertainty about value was observed when evidence of proven health benefit was lacking, potential harms outweighed benefits for reproductive outcomes, and outcomes had only personal utility for individuals or family members. Agreement about outcomes for which a third party should not pay included prevention through surgery with unproven health benefits, establishing ancestry, parental consanguinity, and paternity.

Conclusion: Research is needed to understand factors contributing to uncertainty and stakeholder differences about the value of CGI outcomes. Reaching consensus will accelerate the creation of metrics to generate the evidence needed to inform value and guide policies that promote availability, uptake, and coverage of CGIs.
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June 2019

A logic model for precision medicine implementation informed by stakeholder views and implementation science.

Genet Med 2019 05 23;21(5):1139-1154. Epub 2018 Oct 23.

VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.

Purpose: Precision medicine promises to improve patient outcomes, but much is unknown about its adoption within health-care systems. A comprehensive implementation plan is needed to realize its benefits.

Methods: We convened 80 stakeholders for agenda setting to inform precision medicine policy, delivery, and research. Conference proceedings were audio-recorded, transcribed, and thematically analyzed. We mapped themes representing opportunities, challenges, and implementation strategies to a logic model, and two implementation science frameworks provided context.

Results: The logic model components included inputs: precision medicine infrastructure (clinical, research, and information technology), big data (from data sources to analytics), and resources (e.g., workforce and funding); activities: precision medicine research, practice, and education; outputs: precision medicine diagnosis; outcomes: personal utility, clinical utility, and health-care utilization; and impacts: precision medicine value, equity and access, and economic indicators. Precision medicine implementation challenges include evidence gaps demonstrating precision medicine utility, an unprepared workforce, the need to improve precision medicine access and reduce variation, and uncertain impacts on health-care utilization. Opportunities include integrated health-care systems, partnerships, and data analytics to support clinical decisions. Examples of implementation strategies to promote precision medicine are: changing record systems, data warehousing techniques, centralized technical assistance, and engaging consumers.

Conclusion: We developed a theory-based, context-specific logic model that can be used by health-care organizations to facilitate precision medicine implementation.
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May 2019

A Rapid Systematic Review of Outcomes Studies in Genetic Counseling.

J Genet Couns 2017 Jun 6;26(3):361-378. Epub 2017 Feb 6.

Department of Genetics, Cell Biology, and Development, University of Minnesota - Twin Cities, Minneapolis, MN, USA.

As healthcare reimbursement is increasingly tied to value-of-service, it is critical for the genetic counselor (GC) profession to demonstrate the value added by GCs through outcomes research. We conducted a rapid systematic literature review to identify outcomes of genetic counseling. Web of Science (including PubMed) and CINAHL databases were systematically searched to identify articles meeting the following criteria: 1) measures were assessed before and after genetic counseling (pre-post design) or comparisons were made between a GC group vs. a non-GC group (comparative cohort design); 2) genetic counseling outcomes could be assessed independently of genetic testing outcomes, and 3) genetic counseling was conducted by masters-level genetic counselors, or non-physician providers. Twenty-three papers met the inclusion criteria. The majority of studies were in the cancer genetic setting and the most commonly measured outcomes included knowledge, anxiety or distress, satisfaction, perceived risk, genetic testing (intentions or receipt), health behaviors, and decisional conflict. Results suggest that genetic counseling can lead to increased knowledge, perceived personal control, positive health behaviors, and improved risk perception accuracy as well as decreases in anxiety, cancer-related worry, and decisional conflict. However, further studies are needed to evaluate a wider array of outcomes in more diverse genetic counseling settings.
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June 2017

The value of genetic testing: beyond clinical utility.

Genet Med 2017 07 15;19(7):763-771. Epub 2016 Dec 15.

VA HSR&D Center for the Study of Healthcare Innovation, Implementation &Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.

Objective: To assess the value of genetic testing from the perspective of the Department of Veterans Affairs (VA) clinical leadership.

Methods: We administered an Internet-based survey to VA clinical leaders nationwide. Respondents rated the value (on a 5-point scale) of each of six possible reasons for genetic testing. Bivariate and linear regressions identified associations between value ratings and environmental, organizational, provider, patient, and encounter characteristics.

Results: Respondents (n = 353; 63% response rate) represented 92% of VA medical centers. Tests that inform clinical management had the highest value rating (58.6%), followed by tests that inform disease prevention (56.4%), reproductive options (50.1%), life planning (43.9%), and a suspected (39.9%) or established (32.3%) diagnosis. Factors positively associated with high value included a culture that fosters adoption of genomics, specialist versus primary care provider, genetic tests available on laboratory menus, availability of genetic testing guidelines, clinicians knowing when to request genetics referrals, and availability of genetics professionals.

Conclusion: Our results demonstrate the varied value of genetic testing from the perspective of clinical leadership within a health-care system. Engaging organizational leadership in understanding the various reasons for genetic testing and its value beyond clinical utility may increase adoption of genetic tests to support patient-centered care.Genet Med advance online publication 15 December 2016.
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July 2017

Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter?

Qual Manag Health Care 2016 Apr-Jun;25(2):92-101

Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts (Drs Babich, Charns, McIntosh, Lerner, Burgess, and VanDeusen Lukas and Ms Stolzmann); and Departments of Family Medicine (Dr Babich) and Health Law, Policy, and Management (Drs Charns, Burgess, and VanDeusen Lukas), Boston University, Boston, Massachusetts.

Objectives: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning.

Methods: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results.

Results: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success.

Conclusions: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.
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February 2017

Developing a Model of Advanced Training to Promote Career Advancement for Certified Genetic Counselors: An Investigation of Expanded Skills, Advanced Training Paths, and Professional Opportunities.

J Genet Couns 2016 08 7;25(4):625-34. Epub 2016 Jan 7.

Departments of Pediatrics and of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health, Houston, TX, USA.

There are currently multiple paths through which genetic counselors can acquire advanced knowledge and skills. However, outside of continuing education opportunities, there are few formal training programs designed specifically for the advanced training of genetic counselors. In the genetic counseling profession, there is currently considerable debate about the paths that should be available to attain advanced skills, as well as the skills that might be needed for practice in the future. The Association of Genetic Counseling Program Directors (AGCPD) convened a national committee, the Committee on Advanced Training for Certified Genetic Counselors (CATCGC), to investigate varied paths to post-master's training and career development. The committee began its work by developing three related grids that view career advancement from the viewpoints of the skills needed to advance (skills), ways to obtain these skills (paths), and existing genetic counselor positions that offer career change or advancement (positions). Here we describe previous work related to genetic counselor career advancement, the charge of the CATCGC, our preliminary work in developing a model through which to view genetic counselor advanced training and career advancement opportunities, and our next steps in further developing and disseminating the model.
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August 2016

Assessing multilevel determinants of adoption and implementation of genomic medicine: an organizational mixed-methods approach.

Genet Med 2015 Nov 5;17(11):919-26. Epub 2015 Mar 5.

Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.

Purpose: Adoption and implementation of evidence-based genetic and genomic medicine have been slow. We describe a methodology for identifying the influence of organizational factors on adoption and implementation of these services in health-care organizations.

Methods: We illustrate a three-component, mixed-methods health services research approach, including expert panels, qualitative interviews with key informants, and quantitative surveys completed by key informants.

Results: This research approach yielded a baseline assessment of existing genetic health-care models in the Veterans Health Administration and identified organizational barriers to and facilitators of adoption. In aggregate, the panel and key informant strategies created a communication network of relevant organizational stakeholders and a detailed foundation of organizational knowledge from which to design tools and models for implementation-level genetic/genomic translation.

Conclusion: Expert panel and key informant strategies can be used to create a backdrop of stakeholder involvement and baseline organizational knowledge within which to plan translation research and to inform strategic planning and policies for adoption and implementation of genetic services in health-care organizations.
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November 2015

Delivery of clinical genetic consultative services in the Veterans Health Administration.

Genet Med 2014 Aug 6;16(8):609-19. Epub 2014 Feb 6.

1] Department of Research, VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California, USA [2] Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA.

Objective: To characterize the delivery of genetic consultative services for adults, we examined the prevalence and organizational determinants of genetic consult availability and the organization of these services in the Veterans Health Administration.

Methods: We conducted a Web-based survey of Veterans Health Administration clinical leaders. We summarized facility characteristics using descriptive statistics. Multivariate logistic regression assessed associations between organizational characteristics and consult availability.

Results: We received 353 survey responses from key informants representing 141 Veterans Affairs Medical Centers. Clinicians could obtain genetic consults at 110 (78%) Veterans Affairs Medical Centers. Cancer genetic and neurogenetic consults were most common. Academic affiliation (odds ratio = 3.0; 95% confidence interval: 1.1-8.6) and provider education about genetics (odds ratio = 2.9; 95% confidence interval: 1.1-7.8) were significantly associated with consult availability. The traditional model of multidisciplinary specialty clinics or coordinated services between geneticists and other providers was most prevalent, although variability in the organization of these services was described, with consults available on-site, at another Veterans Affairs Medical Center, via telegenetics, or at non-Veterans Health Administration facilities. The emerging model of nongeneticists integrating genetics into their practices was also reported, with considerable variability by specialty.

Conclusion: Both traditional and emerging models for genetic consultation are available in the Veterans Health Administration; however, there is variability in service organization that could influence quality of care.
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August 2014

Distinct communication patterns during genetic counseling for late-onset Alzheimer's risk assessment.

Patient Educ Couns 2014 Feb 5;94(2):170-9. Epub 2013 Nov 5.

Edith Nourse Rogers Memorial Veterans Hospital, Bedford, USA.

Objective: To identify and characterize patient-provider communication patterns during disclosure of Alzheimer's disease genetic susceptibility test results and to assess whether these patterns reflect differing models of genetic counseling.

Methods: 262 genetic counseling session audio-recordings were coded using the Roter Interactional Analysis System. Cluster analysis was used to distinguish communication patterns. Bivariate analyses were used to identify characteristics associated with the patterns.

Results: Three patterns were identified: Biomedical-Provider-Teaching (40%), Biomedical-Patient-Driven (34.4%), and Psychosocial-Patient-Centered (26%). Psychosocial-Patient-Centered and Biomedical-Provider-Teaching sessions included more female participants while the Biomedical-Patient-Driven sessions included more male participants (p=0.04).

Conclusion: Communication patterns observed reflected the teaching model primarily, with genetic counseling models less frequently used. The emphasis on biomedical communication may potentially be at the expense of more patient-centered approaches.

Practice Implications: To deliver more patient-centered care, providers may need to better balance the ratio of verbal exchange with their patients, as well as their educational and psychosocial discussions. The delineation of these patterns provides insights into the genetic counseling process that can be used to improve the delivery of genetic counseling care. These results can also be used in future research designed to study the association between patient-centered genetic counseling communication and improved patient outcomes.
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February 2014

Genetic library: genetics and public health.

J Genet Couns 2004 Jun;13(3):259-66

Genetic Counseling Program, Biology Department, Brandeis University, Waltham, Massachusetts 02454, USA.

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June 2004