Genomic Laboratory Stewardship in Texas
The rapid increase in clinical genomic testing has prompted the development of genomic laboratory stewardship programs at many hospitals, laboratories, and for-profit companies. Laboratory stewardship programs, historically referred to as utilization management programs, seek to help hospitals, reference laboratories, and providers improve patient care and safety by reducing lab-related errors and optimizing resources. Genomic stewardship programs in particular focus on best-practice ordering and return of genetic tests. There are many components to stewardship and genetic counselors have emerged as imperative assets to stewardship programs across the country. We interviewed several genetic counselors in Texas working in genomic stewardship to learn about their roles, responsibilities, and experiences in genomic stewardship.
Tell us how long your institution has been doing genomic stewardship and how many genetic counselors are involved.
University Health San Antonio, Megan Maxwell, MS, LCGC (UH): University Health first demonstrated the return on investment to justify a lab-based genetic counselor (GC) position in 2017, I believe, but didn’t fill the position until 2019 when I was hired. Since that time, we’ve opened two more lab-based GC positions (one of which is currently vacant) and have recently also branched out into somatic genetic test referrals operational oversight.
Texas Children’s Hospital, Lisa Saba, MS, CGC (TCH): Our genomic stewardship committee was officially formed in 2022 and our first stewardship intervention was launched in 2023. We have two genetic counselors working in stewardship (myself and Haley Streff).
Children’s Medical Center Dallas, Shirelle Barnes, MS, CGC (CMC): Genomic stewardship was started in 2014; however, there was a pause for a few years but are bringing it back on this year.
CHRISTUS Children’s Hospital, Rebecca Littlejohn, MS, CGC (CCH): CHRISTUS Children’s Hospital started the genomic stewardship program in June 2023. We have four genetic counselors filling part-time roles in the laboratory including: Rebecca Littlejohn, MS, CGC; Olivia Juarez, MMSc, CGC; Bailey Mitchell, MS, CGC; and Hailey Hein, MS, CGC.
What are the main responsibilities of the genetic counselors working on genomic stewardship at your institution?
UH: Since our institution lacks a dedicated clinical genetics presence, we’re very “hands on” and highly collaborative with our providers. Our main responsibilities include, but are not limited to: 1. on-demand pre-test clinician consultation (by request); 2. asynchronous chart review after order entry to stratify risk and assess appropriateness; 3. specimen coordination and logistics; 4. case management; and 5. post-test interpretative assistance. We also primarily drive test selection and referral laboratory relationships.
TCH: As of right now, our main responsibility is to review and manage inpatient exome and genome orders. In addition, we also answer any questions providers may have about ordering genetic testing in either the inpatient or outpatient setting.
CMC: Currently reviewing test orders in an outpatient/inpatient setting for certain departments here at CMC and then contacting the provider if there is a test change recommendation. This year, I will be leading a project to formalize/streamline the process and implement it across the institution.
CCH: At CHRISTUS Children’s, our primary roles include providing expertise and guidance to order appropriate genetic testing, resolving billing and logistics concerns, tracking orders, and helping with interpretation of results and next steps at provider request.
Can you tell us about an intervention or situation in which stewardship efforts made an important impact?
UH: Oh, we have so many examples of lab GC-mediated diagnoses that would not otherwise have been made, I’m actually hard-pressed to decide which would be the best to share…which is why I personally believe that more focus on the demonstrable benefit of genetic counselors in the laboratory space could significantly help our campaign for GC licensure in Texas!
TCH: While we do not have an official intervention in place to review all genetic testing orders, we have still come across situations where we have uncovered unnecessary, duplicate genetic testing orders that we were able to cancel. Additionally, we’ve seen many outpatient orders that were placed for institutional billing that we were able to work with providers to redirect to insurance billing, which prevented the patient from receiving a massive bill in the absence of prior-authorization.
CMC: The strongest impact I had was during my first year at CMC where the providers were ordering CMA, karyotypes, MECP2 testing, and Fragile X for males with autism. However, after educating the providers they stopped ordering all those tests together.
CCH: In some cases, choice of testing can determine whether a diagnosis is found by ensuring the proper test is ordered for a suspected condition, such as sending to a lab that uses appropriate testing methodologies with the fewest limitations.
Why do you like working in a laboratory genetic counseling role?
UH: Although I wasn’t such a train wreck that my clinical genetic counseling was a disservice to my patients, I definitely gravitated toward the “educator” paradigm and could never quite seem to capture the same agility in the psychosocial support and/or emotional intelligence domains. When I transitioned away from clinic, I realized that my personality really resonated with the lab-based role; that I could be more “myself” in my chosen profession, which was…liberating. As an ESTJ, I quickly recognized that I was a better fit for an “Oz behind the curtain”-type role in which my objectiveness was a welcomed counterbalance to the subjectiveness, stress, and sensitivities that conventionally characterize clinical care (particularly neonatal and pediatric critical care). The lab-based GC role allows me to live my intention—to help high-risk patients—in an environment that allows me to perform at my highest capacity.
TCH: I have always been interested in the healthcare system and specifically how insurance can be both a benefit and a barrier when it comes to genetic testing costs. With many different genetic testing laboratories available that offer similar tests, I like being able to help guide providers in choosing the best test for their patient that is not going to result in any surprise bills.
CMC: It allows me to help patients in a different way compared to directly counseling them about testing/diagnosis in a clinical setting. I can help advocate for them in situations where a provider orders a test that is expensive, unnecessary, or incorrect; most families don’t have the capacity to advocate for themselves regarding appropriate testing since they don’t have awareness of it.
CCH: We enjoy collaborating with different specialties and having the opportunity to make meaningful differences in the way non-genetics providers utilize genetic testing. Working clinically one-on-one with patients is a very special part of genetic counseling, and lab roles additionally offer the opportunity to impact broad scale improvements in patient care by encouraging and implementing best practices.
Why do you believe genetic counselors are uniquely qualified for and important to include in laboratory stewardship?
UH: You can take the GC out of patient care, but you can never really take patient care out of the GC. Besides our highly-specialized training and genetics subject matter expertise, we’re truly invested in positive patient experiences, continuity of care, and quality outcomes, and that doesn’t go away whether we’re in a clinic or a lab. We’re uniquely qualified because we’re patients’ best resource and most dedicated champions in the ever-evolving field of genomic medicine, and they need us to represent their best interests.
TCH: Ultimately, genetic counselors provide a crucial perspective when working in traditional stewardship teams that are comprised mostly of pathologists. We know the intricacies of test selection, sample collection, test billing, etc. and we are great collaborators and communicators.
CMC: Our training prepares us to have conversations with individuals of various educational backgrounds regarding testing whether it is in a clinical/non-clinical setting. This allows us to help on various levels, including being advocates for our patients, educate our providers, and help our institutions.
CCH: Genetic counselors have detailed working knowledge in the coordination and cost of genetic testing. We also are trained to consider downstream factors that other providers might not discern, for example the need for family cascade testing, ordering a rapid vs standard turnaround time test, or knowing which testing methodology will provide the most useful information.
If you are a genetic counselor in Texas working in genomic laboratory stewardship or are interested in learning more about these unique roles, please reach out to the Texas Transcript team at thetexastranscript@gmail.com so they can connect you with this unique network of Texas GCs!