Announcer (00:05):

Welcome to Hospitals In Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:15):

I believe that it is now over a year since COVID cases were first reported in the United States. By March 2020, the pandemic’s full impact was manifesting in a combination of overwhelmed hospitals in COVID hotspots, and shut downs everywhere else, as health systems worked to preserve PPE and prepare for the worst.

Chip Kahn (00:37):

Amid these challenges, Dr. Jon Perlin, CMO and President Clinical Services at HCA Healthcare joined me on Hospitals In Focus to discuss the impact of COVID on the front lines, and to explore what policy makers should do to enable hospitals and health systems to defeat COVID.

Chip Kahn (00:55):

Today, 11 months later, I am talking with Jon again. This time with an apparent downturn and COVID hospitalizations, and the diffusion of vaccines picking up, we may be seeing the light at the end of the tunnel. Jon is here to discuss what he has learned about treating COVID patients, how HCA Healthcare has used its size and scale to disseminate treatment protocols throughout its system of hospitals, and how they plan to use big data to improve the treatment of COVID and other conditions.

Chip Kahn (01:26):

Thank you for joining me today, Jon.

Jon Perlin (01:29):

Well, Chip, thanks for the invitation back. It’s good to be with you.

Chip Kahn (01:32):

Jon, this is our third time with you as a guest on our podcast. But for our audience, who may not have heard you previously, will you tell us a bit about yourself, your career and your responsibilities as CMO of HCA Healthcare?

Jon Perlin (01:48):

Well thanks, Chip.

Jon Perlin (01:49):

Well, I’m an internist by background. That’s pretty broadly known. What may not be known is that I was actually an English and philosophy major, which has come into great utility over the course of my career and, certainly, during COVID.

Jon Perlin (02:03):

I sort of retread from an MD-PhD and molecular neuropharmacology, not the obvious course to health administration, to health services, research, and quality improvement. That path took me to a number of positions at the US Department of Veterans Affairs, culminating with serving as the CEO of the Veterans Health Administration, as undersecretary for health. And after serving in that role, a number of roles at VA for the better part of a decade, I was recruited to a HCA Healthcare. And I can’t believe that I’m going to be coming up on my 15th anniversary in August of this year.

Jon Perlin (02:41):

There, I serve as the chief medical officer, and the president of Clinical Operations, have the privilege of really leading a team of nearly 400, who are comprised of data scientists and clinicians. Really, I’m proud to say, world caliber in both areas, could be department chairs and deans, who really work to support the system’s care excellence. And their work has really come to the fore over the past year, as we’ve really needed to fire on all cylinders in terms of safety, and quality, and decision support for being able to not only care for COVID patients but also, to the extent possible, care for all of the other needs that are part of being a large health system.

Chip Kahn (03:30):

Jon, COVID has been so impactful on the United States, as well as the world over the last year. In your view, what is the prognosis for the pandemic? How do you see our progress? And how quickly can the vaccines get us back to some kind of in quotes “normal life”?

Jon Perlin (03:52):

Well, I think it’s important to have the quotes around normal because pre-COVID is not going to be the post COVID world. And I hate to be a Debbie Downer on this topic. I think there’s every reason to be excited about the vaccines. The vaccines, I think not only confer optimism for COVID, but for vaccine technology.

Jon Perlin (04:12):

But what gives me some pause is not the vaccines because they really set a benchmark for effectiveness, both the mRNA vaccines, like the Moderna and the Pfizer, as well as the viral vectors, like the Johnson & Johnson. But what gives us pause is what’s really coming to the fore in the news, which are all these mutations of COVID, particularly in South Africa and Brazil. And these mutations are potentially conferring upon the virus the ability to evade the immunity conferred by the vaccine.

Jon Perlin (04:47):

So, when we look to the end of the sort of peak of activity worldwide that we’ve seen, we’re likely to see sort of assault on humans from a number of mutant strains that are likely to require additional vaccines, booster shots that are tuned to the new mutations.

Jon Perlin (05:08):

Now, you may have heard Dr. Fauci talking about this transformation from really a pandemic and episodic type of disease to one that is endemic and sort of in the background like influenza. So, the good news is, is I think we’re going to see a conference of immunity either through the broad distribution of vaccines, and probably we should talk about how many people have likely actually been affected, infected beyond the public numbers. But I think we’re going to be living with this in the same way that we live with seasonal influenza and seasonality yet to be determined.

Jon Perlin (05:48):

So, I think the watch words for the future are optimism about what we’ve learned to do in terms of vaccines and providing a degree of safety. But also really cautious optimism in terms of observing what may be a transformation from pandemic to endemic.

Chip Kahn (06:09):

So, just like the flu, treatment is going to continually probably be an issue.

Chip Kahn (06:14):

What did HCA Healthcare learn about treating COVID patients over the course of the year, and how is that treatment evolving for those diagnosed today?

Jon Perlin (06:25):

Well, any success we’ve had in treatment over the last year is really based on a decade long history of building a learning health system. And we learned to learn faster. And I think I mentioned before that the privilege of scale is in size. The privilege of scale is accelerated in learning, and that we did. Patients today are roughly a third more likely to survive COVID. And the patients who end up in the hospital are much sicker on average because we can, now, care for patients with more mild COVID as outpatients, particularly with the use of monoclonal antibodies. But we’ve learned not only how to cure better for COVID patients, I think we’ve learned how to care better for our staff and for all patients. We’ve learned how to do better in terms of infection prevention. We’ve learned how to do better in terms of storing precious resources, both medications and protective equipment.

Jon Perlin (07:17):

And while I’ve always been proud of the sort of virtuous cycle of data coming from the patient to our collective memory, the data warehouse, and then processing it to feedback to the bedside to improve care. We’ve learned to accelerate that learning loop. And our CEO, Sam Hazen likes to refer to this as COVID speed. And it’s really taught us how to focus on a problem, and move with an unprecedented alacrity. And really put a lot of the issues that are less relevant to the back. So, whether it’s been in the arena of care itself, in the arena of systems operation and improvement. Or in terms of formal research, where we literally have hundreds of research studies in progress, over 50 publications, either already published, or in press or submitted, or under review, we’ve really learned how to learn better, and that’s improving care efficiency and safety.

Chip Kahn (08:18):

So, in terms of this COVID speed, how did you disseminate what you learned? And how quickly were changes incorporated in the course of treatment at HCA Healthcare hospitals? And do you expect some of these… you started off with this a minute ago, to some of these treatments and approaches to stick post pandemic?

Jon Perlin (08:40):

Well, disseminating information is really a challenge. And I’m sure you and I have read the same literature about what’s called the 17 year translation gap where Balas and Bohen published that historically it’s taken 17 years for new findings to be accepted daily practice.

Jon Perlin (08:56):

We didn’t have 17 years in the last year, simple math, but we learned within a month. In fact, within the first 1% of the patients we cared for things like what didn’t work, we learned within the first 1500 patients of the roughly 111,000 we took care of in 2020 with COVID that not only did hydroxychloroquine not work, but that it conferred additional risk for mortality.

Jon Perlin (09:23):

So, I think we’ve worked on only have a learned faster, as I mentioned, but helped to disseminate the findings. And the modes of dissemination have ranged from involving our clinicians in the research, meaning the uptake is faster to reusing our closed loop, sort of virtuous cycle learning health system to feed information back to the teams, to operations, to the bedside. And we’ve also created, I believe, a much tighter community. We’ve had some really terrific conversations, and this is really pretty hard to believe, across not only the 5,000 or so directly employed physicians and 1500 directly employed advanced practice personnel, but across really the medical executive committees, and the 40 to 50,000 other affiliated physician staff. We’ve introduced new letters, new videos, and we’ve created a learning community.

Jon Perlin (10:22):

And that community is one that my colleague Jane Englebright, our chief nursing executive has really fostered with the roughly 100,000 nurses, and other essential health personnel that are part of her professional responsibility.

Jon Perlin (10:37):

So, I think, we’ve created a culture and an environment that really has been much more interactive and communicative and that’s accelerated the diffusion of information.

Chip Kahn (10:50):

So, for part of this, Jon is the sheer scale of HCA Healthcare, and that offers the opportunity for the use of big data for unprecedented analysis and research in the COVID experience, you’ve described that. But you’ve done it on other conditions too. The first time we spoke, back in 2018, we discussed how you all did this to develop new protocols in the fight against sepsis.

Chip Kahn (11:17):

How have you brought this capacity to bear in the pandemic? What have you done to use this big data to change care?

Jon Perlin (11:28):

As I mentioned, it’s really been on the back of a decade of investment in building a learning health system. We know that today every patient encounter generates digital information, both structured that is numbers and things that can be mathematically related, as well as unstructured data, the text. And for the last decade, we’ve captured all of that information, it goes into our data warehouse. And you alluded to our SPOT, Sepsis Prediction and Optimization of Therapy module that actually brings those data back to the bedside.

Jon Perlin (12:01):

What’s important about SPOT in this instance is not that it’s already proven itself to have saved 8,000 lives by earlier identification of sepsis, but that it’s a model, it’s a platform. And we quickly used that platform for something called [NA-TE 00:12:16], which is our program to actually bring these sorts of warnings back to the bedside, AND to the care providers.

Jon Perlin (12:24):

We useD NATE at the outset to accelerate transformation in terms of how we cared for COVID patients, by being able to visualize where the COVID patients were in the system, whether it was a hotspot in a particular city, or a particular hospital, we can identify how we could optimize the cohorting of patients. Realized that if you have a number of COVID patients and non-COVID patients, first, we want to keep them separate. Second, we want to minimize the staff exposures. And third, we want to really optimize the skills. So, we were able within, literally, the first 10 days or so to create a program based on the SPOT platform that actually showed each hospital where their COVID patients were, so they could be aggregated in one unit. And that, at the outset, when PPE, personal protective equipment, was so incredibly precious allowed us to conserve those supplies as well.

Jon Perlin (13:18):

NATE evolved, and one of the things that we learned, both from the literature, and our own observations was that patients with the fragile lung conditions, the respiratory distress syndrome, that is somewhat of a by-product of the inflammatory process of COVID need to have mechanical ventilation that’s very particular. You don’t want to overexpand the lungs, that is the tidal volume needs to be controlled. You don’t want the pressures to be high. And we can optimize the lung capacity by about 30% by putting the patient on their belly, something called proning. We automated that process and now we can look at every patient across the system who has COVID and give signals to the care team that suggests when their patients may have room for optimization of the particular parameters.

Jon Perlin (14:09):

What’s so important here is that this not only improves survival and other outcomes for COVID patients, but when you think about the acuity of care in a contemporary hospital, whether it’s for cardiovascular services or any surgical intervention, or for cancer, what we’ve actually built is not a COVID module, but a ventilator optimization module that improves outcomes for patients, reduces the time on the ventilator and introduces new efficiency. And that’s what we mean by being a learning health system. We have the extraordinary privilege of over 37 million clinical encounters with patients every year. And those data helped to, as I mentioned earlier, really accelerate learning.

Chip Kahn (14:55):

I understand, that Jon, that you’ve developed a program, a project to go beyond just HCA Healthcare. That you’ve put together a consortium to make your research capacity available to government and other institutions, so they can learn from the data that you’re learning from. Can you tell us a bit about that project?

Jon Perlin (15:18):

Yeah. The project is known as CHARGE, the Consortium of HCA and Academia for Research Generation. But, fundamentally, it takes advantage of that learning health paradigm to create a new model for research. Most, importantly, that we feel it’s our social responsibility.

Jon Perlin (15:36):

I mentioned, in 2020, we had the privilege, and the challenge of caring for 111,000 inpatients with COVID. There is no health system in the United States that has cared for more inpatients with COVID. There is no, we don’t believe, system in the world that has integrated relational data that are a by-product of a learning health system’s data warehouse that has the capacity to offer new insights into the understanding of COVID and the improvement of its therapy. And so, what we did was really created a new mechanism to share data securely and privately with a number of academic and federal partners. So, the Consortium of HCA Academia for Research Generation invited the Agency for Healthcare Research and Quality, I’m going to call out Dr. David Myers, as well as a number of prominent academic institutions. Some of which are under Agency for Healthcare Research and Quality’s home run hospital re-engineering network program to really accelerate the real-world learning.

Jon Perlin (16:46):

And some of the partners in this include locally Mary Medical College, one of the nation’s four historically Black medical colleges, a terrific partner, as well as Harvard, and Duke, and Columbia, and a number of other prominent institutions, UCSF, UMass, Bay State as well. And we’ll be looking at everything from the social determinants impact on COVID outcomes, to the challenges of not just age, but frailty, to looking to better understand what therapies and approaches to respiratory support really optimized care.

Jon Perlin (17:28):

And we believe that partnering with the already productive HCA research, as I mentioned more than 50 publications out already, we believe that we can contribute not only to the well-being of HCA patients or American patients but, frankly, to humanity by really creating additional commons for the responsible conduct of accelerated research.

Jon Perlin (17:51):

And, in that vein, we see this, again not having a life just in terms of COVID, but serving as a fundamentally new paradigm for research. And we find that pretty exciting, whether it’s bringing new cancer drugs to patients, or new devices to market. But we see this as a way to just accelerate learning, and improve healthcare.

Chip Kahn (18:14):

These are really great goals for this consortium, Jon and I know you’ve already actually achieved some of these on conditions in HCA Healthcare.

Chip Kahn (18:25):

What is this process due to time? Right now, research in a single institution can take years, frankly. I assume that you’re clipping that off significantly because of the scale. Can you give us some sense of how you can, in a sense, redo time in terms of medical research and the processes you’re developing?

Jon Perlin (18:47):

That’s a great question, Chip. You alluded to some of our research with the Harvard Pilgrim Health Care Institute, UC Irvine, a reduced MRSA study, didn’t take one hospital 60 plus years, 63 years. It took 43 hospitals, 18 months to discover a new mechanism to cut ICU hospital acquired infections roughly in half published in the New England Journal.

Jon Perlin (19:11):

And in 2021, the experience of a single institution may be idiosyncratic. So, when you can pull together multiple hospitals, multiple institutions, you really can test will an approach really prove out at community hospital, a tertiary or quaternary teaching center, or otherwise. So, they have high capacity for generalization.

Jon Perlin (19:35):

And, as well, one of the things I’m most proud of, whether it’s in our infection prevention work, or in our reductions of maternal mortality, the population that HCI cares for is actually more heterogeneous, more diverse than the US population at large. And by virtue then of pulling together large numbers of hospitals to answer these questions, we know that they will generalize not only to different hospital types, but to different diverse members of the broader US population.

Chip Kahn (20:05):

Jon, this is all further proof that HCA Healthcare is at the cutting edge of research and uses of big data.

Chip Kahn (20:12):

What other things do you have in your research pipeline, right now, that our audience might be interested in?

Jon Perlin (20:18):

Well, before I go to the big data, sometimes it’s the small data, the n of one. You may have read about a woman who was treated at our Sarah Cannon Cancer Center and our Sarah Cannon Research Institute whose sickle cell was essentially cured. Cured is a big word. Sickle cell is a genetic abnormality, and instead of having adult hemoglobin, the hemoglobin codes… or the genes that code for the hemoglobin lead the proteins to bend the cells such they become inflexible and you can’t get blood to the end organs. Strokes, heart attacks, and incredible bone pain characterized. And for this really vivacious woman were just debilitating.

Jon Perlin (21:02):

Well, over the course of last year and her story has been followed on NPR, this woman went from almost bedridden to absolutely engage and functional because we use the CRISPR gene editing technology. One of our premier oncologist researchers, Dr. Haydar Frangoul, actually, inserted new genes to displace the sickle gene and re-establish the prominence of, what’s called, fetal hemoglobin, which actually carries oxygen even better than adult hemoglobin. And in this process of knocking out the defective chain and replacing it with a gene that turns back on the fetal hemoglobin. This wasn’t a case of what I used to offer to my sickle cell patients, just controlling pain as their body’s fully endured the torture, and piece by piece death. But, in fact, an absolute reconstitution of the genetic makeup of her red blood cells such that her disease is cured. And it’s just really inspiring.

Jon Perlin (22:08):

I’m proud of our Sarah Cannon Research Institute, which has in fact, delivered over 400 first to human compounds. Our GME program now has over 4,000 house staff, and that has really amplified the research substantially. And my own team is focused very much on what’s called implementation science, which is how do you take things like knowing that hydroxychloroquine doesn’t work, or that steroids later in COVID do work and really generate adoption faster? Or how do you measure the effectiveness of using tools like SPOT and NATE, that I mentioned, to really change behavior not in 17 years, not even in 17 months, not even in 17 days, but hopefully in the 17 minutes from when you have the knowledge to really having the capacity to change behavior and improve healthcare?

Jon Perlin (23:02):

So, we think this is really a key to adding value, to change the nature of how healthcare is delivered, to bringing research practice and operations closer together. And I think it’s driven by a desire not only for excellence, but for social responsibility, and the mission commitment to the care and improvement of human life.

Chip Kahn (23:23):

Jon, thank you so much for that summary of what you’re working on. It really is inspiring. And I also think that, in terms of COVID, HCA Healthcare is an example of what a health system can do. If we look across the COVID pandemic with all the issues that it raised for operations and logistics, the one institution in our society that clearly worked was the hospital, was the health system in terms of figuring out how to help these patients, and saving so many of them.

Chip Kahn (24:01):

So with that, Jon, I just want to thank you, and appreciate all the progress you’ve described. And, frankly, look forward to our next conversation on our podcast, Hospitals In Focus.

Jon Perlin (24:15):

Chip, let me thank you for your leadership. Thank you for helping create the conditions to make what we do possible. And I know you join me in thanking the legions, the tens of thousands of caregivers not only in the HCA Healthcare system, but across the country who have really shouldered the responsibility of caring for COVID. I look forward to our next conversation, but I appreciate your work. And I know we appreciate all of those who are at the very front lines. Thanks.

Announcer (24:45):

Thanks for listening to Hospitals In Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media @fahhospitals, and follow Chip @chipkahn. Please rate, review, and subscribe to Hospitals In Focus. Join us next time for more in-depth conversations with health care leaders.

Dr. Jonathan Perlin, CMO and President, Clinical Services, HCA Healthcare

Dr. Jonathan B. Perlin is president, clinical services and chief medical officer of Nashville, Tennessee-based HCA Healthcare, one of the nation’s leading providers of healthcare services. Dr. Perlin leads HCA’s Clinical Operations Group, which consists of nationally recognized clinical leaders, data scientists, researchers and improvement experts who drive HCA Healthcare’s clinical excellence agenda.

HCA Healthcare is a learning health system that uses the significant data it collects from over 35 million annual patient care episodes to inform and improve the care provided to patients. Dr. Perlin’s team completed the landmark REDUCE MRSA study that demonstrated a 44 percent improvement on known best practices for reducing bloodstream infections in ICU patients. Their follow-up ABATE study, published in The Lancet, demonstrated a 31 percent reduction in bloodstream infections and nearly a 40 percent reduction in antibiotic-resistant bacteria among non-ICU patients with central line catheters and lumbar drains. Dr. Perlin also spearheaded the development of HCA Healthcare’s Sepsis Prediction and Optimization of Therapy, or SPOT, an algorithm-driven sepsis early warning technology that received the prestigious 2019 John M. Eisenberg Patient Safety and Quality Award.

Before joining HCA Healthcare in 2006, “the Honorable Jonathan B. Perlin” was Under Secretary for Health in the U.S. Department of Veterans Affairs. Nominated by the President and confirmed by the Senate, as the senior-most physician in the Federal Government and chief executive officer of the Veterans Health Administration (VHA), Dr. Perlin led the nation’s largest integrated health system.

At VHA, Dr. Perlin directed care to more than 6 million patients annually by more than 250,000 healthcare professionals at 1,400 sites, including hospitals, clinics, nursing homes, counseling centers and other facilities, with an operating and capital budget of nearly $40 billion. A champion for early implementation of electronic health records, Dr. Perlin led VHA quality performance to international recognition as reported in academic literature and lay press and as evaluated by RAND, the Institute of Medicine and others.

Dr. Perlin was appointed to the Medicare Payment Advisory Commission (MedPAC) in 2018 and the Congressional Budget Office Panel of Health Advisors. He also serves as chair of the Secretary of Veterans Affairs’ Special Medical Advisory Group. Dr. Perlin was the 2015 chair of the American Hospital Association. In 2014, Dr. Perlin took a “sabbatical” from HCA Healthcare to serve as senior advisor to the Secretary of Veterans Affairs to help improve operations, accelerate access and rebuild trust with America’s Veterans. Dr. Perlin has served previously on numerous boards and commissions including the Joint Commission and the National Patient Safety Foundation and currently serves on the board of Meharry Medical College, a historically black graduate institution (HBGI), and is chair of the National Quality Forum. In 2009, he was appointed as the inaugural chair of the U.S. Department of Health and Human Services Health IT Standards Committee.

An elected member of the National Academy of Medicine (formerly the Institute of Medicine), Dr. Perlin co-chairs their recently formed “Action Collaborative on Countering the U.S. Opioid Epidemic,” and leads the “Digital Learning Collaborative of the Consortium on Value and Science-Driven Healthcare.” Perennially recognized as one of the most influential physician executives and health leaders in the United States by Modern Healthcare, Dr. Perlin has received numerous awards including Distinguished Alumnus in Medicine and Health Administration from his alma mater, Chairman’s Medal from the National Patient Safety Foundation, the Founders Medal from the Association of Military Surgeons of the United States, and is one of the few honorary members of the Special Forces Association and Green Berets.

Broadly published in healthcare quality and transformation, Dr. Perlin is a Master of the American College of Physicians and Fellow of the American College of Medical Informatics. He has a Master of Science in Health Administration and received his Ph.D. in pharmacology (molecular neurobiology) with his M.D. as part of the Physician Scientist Training Program at the Medical College of Virginia of Virginia Commonwealth University (VCU).

Dr. Perlin has faculty appointments at Vanderbilt University as Clinical Professor of Medicine and Biomedical Informatics and at VCU as Adjunct Professor of Health Administration.