Chip Kahn (00:11):
Hello and welcome to Hospitals in Focus. I’m your host Chip Kahn. Thanks for joining us for a special episode on the coronavirus pandemic. Joining us today is Dr. Jon Perlin, the chief medical officer and president of clinical services at HCA Healthcare. HCA Healthcare is battling this virus on many fronts for its patients and Jon’s role puts him right in the middle of the fight. I know that you are very busy, Jon, so I appreciate your stepping out for a moment to take time to talk with us.

Jon Perlin (00:45):
Chip, it’s always a pleasure to be with you. I just wish the circumstances are different, but whatever we’re doing in HCA Healthcare, we’re certainly joining in force with all of our colleagues in the healthcare community and in government. Our goal is the same, which is really to minimize the effect of this pandemic on our patients, on our communities, on our economy, but certainly hospitals and healthcare systems are at the very front lines. And even as we speak, across our system, we have an excess of 1,200 patients under investigation and about 10% of those are positive for COVID at this moment.

Chip Kahn (01:27):
Gosh, you know, Jon, I’ve been doing health policy in Washington for 40 years, and I don’t think I’ve ever seen any kind of threat to America’s healthcare like we see today. So, to get started, can you talk about why this disease is more of a threat and different from swine flu, SARS, and earlier challenges from viruses?

Jon Perlin (01:53):
Yeah, so let’s break that important question into a few pieces. Let’s start with the importance of it as a pandemic. May not realize this, but since 1900 there have actually been 10 pandemics. The greatest one, of course, or greatest in terms of scope but tragic was the flu pandemic of 1918 really through 1920. This was a time before influenza vaccination, of course, and the importance of that is directly relevant to this coronavirus of 2020, that is, we’re not immune to it.

In 1918 and 1920, population had seen other strains of flu. In 2020, population has seen other strands of coronavirus. Most coronaviruses are just nuisance colds. There are a few forms like SARS and MERS that are very serious in terms of their [inaudible 00:02:51] but not transmitted terribly well. They sort of died out quickly. So, this is an important pandemic for two reasons. One, it’s novel. No one in the population has immunity to it. So, everyone is susceptible, and it’s fairly effective, as effective as flow in person to person transmission. And two, in 2020, unlike 1918 to 1920, we’re connected as a world through air transport, and so this pandemic is accelerating simultaneously in many quarters of the world.

Chip Kahn (03:31):
So what is this virus, which is so virulent, what does it mean for physicians, other caregivers, hospitals? Why is facing this crisis different than other healthcare challenges that we’ve had in past years?

Jon Perlin (03:48):
The magnitude. The sheer magnitude is different with coronavirus now called COVID-19. The magnitude is extraordinary in that it’s in so many different parts of the world and corners of our country at the same time, and the fact that no one has immunity to it means that it’s a respiratory disease that’s fairly easily transmitted. If you and I were within six feet of each other, and I were carrying COVID, I would be dispersing with every breath some particles of the virus. If I were symptomatic, we know that I have a higher viral load. So, if I were coughing or febrile, there would be more particles of the virus, and your being within six feet would mean that you invariably would inhale some of those particles.

So, the transmissibility is substantial. Unlike the flu, we think this particular coronavirus can transmit a little further, maybe six feet instead of three feet, and this is why breaking the cycle of transmission with masks ironically more importantly on the source… Important in healthcare settings on a potential recipient, but on the source is really important in breaking that cycle. So, the fact that none of us have immunity, the fact that each one of us can infect more people, more than one, means that this has the opportunity to accelerate to a susceptible population very, very quickly. I want to break it into a couple parts. We’ve heard that older individuals… And we can talk about this more later, have a higher likelihood of mortality, but here’s the problem. If there’s a rapid acceleration by a person who’s infected infecting more than one other person, then the epidemic in a particular area, the outbreak in an area, increases more rapidly.

So, the conversation that’s going on right now is all about not only protecting people from getting the infection in the first place, but also making sure that the peek isn’t as tall in a short period of time so that those individuals who normally get the virus… And frankly most will be asymptomatic or have minimal symptoms, kind of consistent with a cold, but for those people who develop serious respiratory illness, need hospitalization or even critical care don’t arrive all at once. That’s this concept of flattening the curve, changing this from a tall peak that overwhelms the system into a more moderate flow that ultimately either doesn’t affect as many individuals or at least tempers the pace of all those individuals being sick simultaneously.

Chip Kahn (06:47):
Hospitals are prepared every season to take care of patients with the flu, very sick patients, or patients with pneumonia, illnesses that may be aren’t so different from this one. How is the effect and the advent of this pandemic though going to change the day-to-day running of hospitals and make the very management of hospitals have to contend with something that’s very different from earlier experience?

Jon Perlin (07:20):
Well, the rapidity of spreading an infection in community, for the reasons we just talked about, could potentially be overwhelming to the healthcare infrastructure in that community. So, hospitals have to be prepared for a surge of patients in a very short period of time. Second, unlike flu, none of the health care workers are immunized against COVID or coronavirus. So, there’s one degree of susceptibility there. Like flu, however, like any respiratory, the hospital or healthcare environment has to be prepared to use what some people call universal, others call standard, respiratory precautions, and those are barriers to interrupt the flow of transmissible, respiratory diseases. Because no one has immunizations or immunity, everyone is susceptible. So, it’s critically important that those patients with coronavirus or COVID are separated from those individuals who are susceptible and don’t.

It’s kind of like parents say when they take their child to a pediatrician’s office and there’s a well baby side and a sick baby side. You don’t want the well babies going in the area with the kids with infectious diseases. So, the hospitals and health settings are working really hard to keep a sort of hot zone, if you will, or flow of individuals who either potentially or do have COVID away from those individuals who don’t, who still are afflicted by the melodies that occur on a daily basis; a fall with a broken hip, a stroke, a heart attack, any of those things.

So, the amount of activity simultaneously, the fact that no one’s immune to this, the fact that there needs to be extraordinary precautions in terms of respiratory care, the fact that that protective equipment to enact those precautions is in short supply, the fact that that equipment is manufactured in an area of China that is the seat of the initial outbreak of this now global pandemic, are all the things that are really transitioning the health system from its usual activities to trying to do its usual activities while being intensely prepared and focused on taking care of patients with COVID.

Chip Kahn (09:43):
Jon, let’s talk a little bit about the effect of this surge on hospital operations, but more importantly on the patients that have some of those other maladies and illnesses that you talked about. I’ve heard that the government may tell hospitals, I know they’ve just done it in Pennsylvania, I believe, that elective procedures have to be postponed or canceled in hospitals in preparation for this potential coming surge. What’s going to happen to those patients, and how will that be managed?

Jon Perlin (10:21):
Well, first and foremost, let me assure you that HCA Healthcare is committed to our mission, the care and improvement of human life. A patient shows up with heart disease, a heart attack or a stroke or a broken hip. We will be there. We will take care of them. That’s emergency care. That continues on, and we will find the way. I have confidence that our colleagues throughout all of healthcare will find the way to do those things. Those things that are truly elective, a screening mammogram, a screening colonoscopy, it really may not make much of a difference if those things happen today or three months from now. And in fact, CMS has released guidance that have said those things that won’t change a patient’s health over three months really should be postponed, and that’s really to both create the capacity for taking care of COVID as well as to make sure that the protective equipment, like masks that would be used in those procedures, is conserved for those COVID patients … Are not used on patients who frankly can wait.

But there are certain things that are scheduled, but they’re really not elective. So, take for example, a patient with unstable coronary artery disease. Now, their procedure may be scheduled for next week, but within three months they could have an extraordinary catastrophic event. That needs to continue on, and we’ll find ways for those things to continue on. But here’s the problem. There’s no perfect, right line or celestial knowledge of who for someone with an advancing cancer, with heart disease, other vascular disease might not have a bad event in that period of time.

So, those things have to continue on. Those things that are truly and fully discretionary have to be postponed. So, we and all of our colleagues throughout healthcare are trying to draw that line to differentiate between the patients who have needs that are emergent, take care of. Needs that are discretionary postpone, and we have to work with our physicians and other clinicians to really assess those conditions that are scheduled but have inherent instability or potential to deteriorate and make a judgment about getting those needs met so that the patient can have the best possible outcome. It’s really a both/and equation.

Chip Kahn (12:59):
You know, Jon, this issue of the PPEs and having the protective equipment for staff and obviously to protect patients is actually one of the driving forces on public policy right now at many local areas. I know Pennsylvania just acted to require hospitals to cancel many of their elective procedures, and the reason that they did that was concerned over the current shortage of PPEs. But that has an effect on the hospitals, and I hope that the Congress will recognize that as requirements across the country begin to be put in place in anticipation of the surge and having the proper equipment, that hospitals are going to have to put off many procedures which frankly are very important for hospital cashflow and they help keep the doors open. Those patients that are not going to be receiving those procedures, they’re going to be replaced as the surge comes by very expensive, very sick, in many cases elderly patients who are going to have experiences in many of them in the ICU for long periods of stay.

And that’s going to change the dynamic of hospital finance, that hydraulic that makes hospital finance work and frankly keeps the doors open and keeps the high quality of care going. I hope that Congress will take that into account and just as they’re looking at other industries that are being affected by this pandemic, that this industry, which is so critical, it’s at ground zero in terms of the public, and this is the challenge of this pandemic, that they’re going to come up with the funding to make sure you have the resources that other hospitals have, the resources to provide the care and be there for those patients today and frankly those patients that we’ll have tomorrow.

Jon Perlin (15:04):
Well, Chip, thanks for that comment. I think you’re absolutely right is that it does create a complex set of circumstances where revenues are down on one side and expenses are up on the other. I think the other message that I would hope the Congress takes home is that our healthcare infrastructure is absolutely integral toward the defense and security of our nation. I think this event is showing us the fragility that when we operate just on the margins in terms of the adequacy of the numbers of beds across our communities, that we’re not fault resistance against big threats, and I hope that for the men and women who day in and day out are there in their communities to serve their communities, that they have the opportunity to know that their government backs what they’re do. When we look back on the other side of this event that we look back and say this is part of who we are. This is part of the integrity of our communities, the fabric of our society, and essential infrastructure, and we make the necessary investments to keep that infrastructure robust.

Chip Kahn (16:17):
America has done it before, and I hope America will do it in this case in terms of meeting an existential challenge and coming out on the other end maybe a bit stronger, Jon.

Jon Perlin (16:29):
I think it’s an opportunity to learn and grow. There are insights certainly into our supply chain, single channels of distribution, distribution and not only from a single supplier but a single geographic area. I think there are also positive lessons. We’ve expanded our use of telehealth, as an example. And there are things that will go back to normal, and there are things that will not go back to normal. This event will forever change us. Shame on us if we fail to heed the lessons on the one hand, but also let’s look at the opportunities for the increased use of technology as an adjunct to an essential part of our healthcare infrastructure.

Chip Kahn (17:09):
So, Jon, HCA Healthcare has almost 200 hospitals, and is in cities across the country, has large systems in many of these cities. What’s unique in terms of responding to this crisis? What’s unique about your size and scale in terms of how you benefit your patients, and what lessons do you think could be generalized from having a system like yours bring scale to this kind of crisis?

Jon Perlin (17:43):
The privilege of scale in a system like HCA Healthcare with 2,200 sites of care is really the ability to learn at speed. As we look at what’s going on around the country, COVID is surfacing but not at all places at all times. So, we’ve seen pockets in Northern California, in a suburb of Atlanta that were the first sites where we in HCA Healthcare saw patients with COVID, and we were able to learn from the experiences and take those learnings and broadcast it out to the rest of the system.

The second opportunity with scale is the ability to synthesize a great deal of information very quickly. The information is changing, not only on a day-by-day basis, but sometimes CDC and other elements of the Department of Health and Human Services are releasing guidance on surveillance, on care, on the use of personal protective equipment every few hours. The ability to have teams actually work through that information, synthesize it, organize it, and get it to our frontline providers is, I think, unique. So, if one part is the ability to learn from the vanguards that are experiencing the epidemic, and the second is the synthesis of material for distribution, the third is that we’re also serving as a national resource.

We’re actually using our surveillance data and our experiences around the country as data feeds to the Centers for Disease Control and departments in Health and Human Services, and as of yesterday, committed to sharing data with FEMA on some academic researchers so that we can not only detect outbreaks in particular communities but also really examine the big data that are an inevitable byproduct of the provision of healthcare to help to understand what confers more risk to particular patients or, in fact, what sorts of features of treatment, what medications, either purposeful or incidental, actually confer benefit. So, those are the things that we’re working on and the advantages of a large system. Learning fast, scaling information, and contributing to really the care of our nation and, I believe, the care of humanity more broadly.

Chip Kahn (20:07):
Jon, looking at national policy beyond just care, what do you think are the implications for hospitals of the president declaring a national emergency? How will that be enabling to you?

Jon Perlin (20:21):
The president’s declaration of a national emergency is very helpful. I mean first it sets a tone that we are faced with a global pandemic. This is not business as usual. Second, in terms of enlisting capacity to do things differently, let me give you an example of how that helps in practical terms. So, for example, if a hospital is already taking care of quite a number of patients and is at capacity, EMTALA would usually require that you do a medical screening exam before sending a patient to an alternate site. We know that we want to keep hotspots and examinations of patients potentially with COVID away from patients without COVID, and so the ability to do something that EMTALA wouldn’t usually allow, allows for a better flow of care for patients with non-COVID need and for patients with COVID needs.

We know that if there are surges we’ll need to press others into service. In the past we haven’t been able to use telemedicine, telehealth as efficiently as it might be used because sometimes the best support is across the state line. Now, the ability to provide telehealth services across state lines or offer temporary emergency credentials to people across state lines really allows expansion of the workforce. So, these are a number of facilitators. There’s been a good bit of regulatory relief and that’s important because I can assure you, whether it’s clinician at the bedside or an administrator, throughout our hospitals and I am certain throughout every hospital in the United States, everybody is heads-down focused on making sure that there’s the capacity to care for COVID patients and the capacity to care for the needs of patients with the usual range of emergencies or other urgent needs.

Chip Kahn (22:20):
Jon, so to close out here, let me ask you about the activity on Capitol Hill. There’s been a coronavirus, one bill, a coronavirus two bill. How do you see the importance of the Congress acting to support the needs of your patients in HCA Healthcare hospitals?

Jon Perlin (22:43):
I think the most important work executive branch, legislative branch or otherwise has to do with the issue that’s the most acute at the moment, and that is the shortage of personal protective equipment. The National Defense Production Act, I think, is incredibly important. If I were king and had the authority of that act, I would direct the manufacturer of additional masks and additional other protective equipment such as face shields. That’s the long pull, and we need to make sure that we use both the policy that is regulatory authorities as well as the statutory authorities to really meet these particular needs.

Chip Kahn (23:26):
Jon, thank you so much for joining us this afternoon. I know it was difficult to walk away from your immediate responsibilities, and it’s great that we have an opportunity to have you here on a podcast with us informing the public from the standpoint of HCA Healthcare and the work you do there about the challenge for the hospitals of the United States, not just HCA Healthcare, of this pandemic crisis.

Jon Perlin (23:55):
Chip, let me thank you for the opportunity. Let me just say that we are learning along with everyone else, so we look forward and appreciate the exchange of ideas. We’re really thinking about, how do we manage surge? How do we care for the usual needs? How do we expand our workforce to meet both of those two, and how do we keep our care providers and our patients safe as possible? This is our focus. This is our priority. It’s a 24/7 job right now, and the teams are really nose-down as are their brethren across the United States. We look forward and appreciate the opportunity to learn together. Thanks so much for your leadership and creating this forum for that.

Chip Kahn (24:39):
Good luck, Jon. Join us next time as we speak with experienced leaders on new ideas about healthcare delivery and financing. Please listen, rate, and subscribe wherever you get your podcasts, and if you haven’t already, you can follow the Federation on social media at FAH Hospitals and me at Chip Kahn. This was Hospitals in Focus. I’m Chip Kahn. Thanks again for listening.

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.