What would you say if you had to make an “elevator pitch” in just three to five minutes to the President of the United States about what to focus on in terms of the nation’s healthcare system? That was the question put to panelists at a Sept. 26 meeting of the National Academy of Medicine (NAM). Jonathan Perlin, M.D., chief medical officer of Hospital Corporation of America (HCA), responded: “It’s all about the data.”
To inform debate and decision-making, NAM has launched a program called Vital Directions for Health and Health Care. It commissioned expert papers on 19 priority focus areas for U.S. health policy, including health IT. Together, these papers represent the guidance of more than 100 leading researchers, scientists, and policy makers from across the United States. Perlin co-authored a paper with a cast of well-known health IT experts, including Dixie B. Baker, David J. Brailer, Douglas B. Fridsma, Mark E. Frisse, John D. Halamka, Jeffrey Levi, Kenneth D. Mandl, Janet M. Marchibroda, Richard Platt, and Paul C. Tang.
Representing these authors at the Sept. 26 meeting, Perlin said that knowing that data is central to every strategy for research and discovery and point-to-point healthcare, there is an opportunity that is ripe for the taking. “With meaningful use, the president, if you will, has bought the car and now it is time to drive it,” said Perlin, who before joining HCA in 2006 was CEO of the Veterans Health Administration. “The president's opportunity is not to drive on a slow toll road but to realize the vision of a fast superhighway.”
In his elevator pitch, Perlin focused on three themes: development of a learning health system, end-to-end interoperability and cybersecurity initiatives.
Data strategy for learning health system. The notion of a learning health system is defined as a system that commits to the continuous use of data as a byproduct of care for continuous learning and a virtuous cycle. Perlin pointed out that 98 percent of hospitals and 95 percent of physician practices are computerized. “We are clicking, but we're not yet learning,” he said. “By virtue of all that clicking, a ‘data exhaust’ is created, and in the data are answers to numerous questions,” he said. That data exhaust in the form of structured data could be fed back into the system to spur discovery, knowledge and better population health management. As an example, Perlin noted that he grew up as a physician lumping diabetics into a few categories, when actually there are 14 or more forms of diabetes. “I need the decision support tools so I can best treat the patient in a personalized and precise way.”
He gave as an example of a learning health system project the recently completed landmark REDUCE MRSA study, which demonstrated a 44 percent improvement on known best practices for reducing bloodstream infections.
Interoperability. Perlin said end-to-end interoperability must extend from formal settings of care to medical devices and importantly enfranchise patients as consumers of healthcare and their health data, encompassing patient-reported outcomes as well as patient-generated data.
“We are not talking about a single structured monolithic system,” he said, “but rather a set of architectures that take advantage of technologies we use today in things like web services that would allow for the development of an ecosystem of utilities that can support plug-and-play and clinical decision support for formal caregivers but also the opportunity for the patient to reach in and access of information.”
Referring to FHIR (Fast Health Interoperabilty Resources), Perlin said there are new standards that have very much in common with the infrastructure we take for granted in applications we use on our smartphones or when we use web services on the Internet. “We can also get data that are extremely granular so they are available to research and discovery. And the patient can be enfranchised as part of that data equation in that virtuous loop.”
In their recently published Vital Signs paper, Perlin and his co-authors note that “a generation of legacy EHRs that lack the design and features needed for interoperation is widely in place, so it will be challenging and potentially expensive to reach this goal.
“Progress toward interoperability could be accelerated initially by focusing on high-value use cases, such as transitions of care, outcomes measurement, and public-health reporting. Achieving interoperability is like building the interstate highway system: we need to construct on ramps and off ramps one at a time, but we also need a master plan.
“In the absence of an authoritative private source, the federal government should be highly specific about standards for end-to-end interoperability. Interoperability needs to extend from medical devices to EHR systems. In the absence of interoperability, end-user costs are higher because users are compelled to cobble together inherently non-interoperable systems. In addition to all the risks posed by imperfect interoperation, there is a loss of the value that could be gained through research, care, and public health when these systems interoperate.”
Cybersecurity. Finally, Perlin said he would tell the president that we have an obligation as well as an opportunity to aggressively address cybersecurity vulnerabilities and create protections in that regard. “We are in an era where the penetration and threats are significant, not only in terms of frequency but in terms of sophistication, even with state actors.” He stressed the importance of sharing threat information and strategies to mitigate the threat. He said policies might need to protect those organizations that meet all of the requirements but still may be subject to the action of a state actor.