Don't mistake Jonathan Perlin's pensiveness for passivity. It's just the opposite. Perlin, a physician with a Ph.D., is a fervent believer that the health care system — and the providers that form its foundation — can change social policy radically and lead the nation toward healthier communities. It's something that was ingrained in his DNA at a young age as he watched his father bring mental health services from the hospital to the streets of Baltimore in the 1960s. He's carried that philosophy with him from his early clinical days fighting big tobacco in Virginia to transforming care for the nation's veterans to his current role as an executive at Hospital Corporation of America. And it is a philosophy that Perlin plans to bring to the American Hospital Association as he moves into the role of chair-elect.
My First Patient
I didn't set out to go into health administration or health policy. After studying English and philosophy at the University of Virginia, I ended up at Virginia Commonwealth University's school of medicine in the combined M.D./Ph.D. program. After completing my Ph.D. in molecular neurobiology, I went back to my clinical work.
My first patient was 10 days post-op after a heart transplant. I thought that was exciting. I went to look for him in his room and the nurse winked at me and said, "He's doing really well. He's probably out on the deck getting some air."
I encountered him indeed doing very well, but "getting some air" was a euphemism for smoking. Here he was, 10 days post-heart transplant and smoking through his tracheotomy. I went back to my attending and said, "This is the highest level of care society can offer?"
He looked at me and said, "We don't want to be a smoking hospital any more than you."
He sent me to talk to the dean and the dean sent me to talk to some other faculty. We discussed that Virginia was a tobacco state and taking on tobacco had its challenges, but if enough people got behind this, we could make it happen.
With leaders like Kevin Cooper, M.D., [pulmonary disease, internal medicine and critical care medicine specialist], the hospital became smoke-free.
For me, it was an object lesson in the power of policy. It was really the moment when I realized that whatever was gratifying about social change as a physician could be amplified by the opportunity to change social policy.
Smoking cessation for a patient is important, but if you create a construct where you reach a number of lives simultaneously, that is really exciting in terms of making a positive contribution.
I grew up mostly on the East Coast. I was born in New York, lived in Baltimore, moved to Los Angeles and moved back to the Washington, D.C., area. I was peripatetic, with a father who was an academic physician — a psychiatrist — and a mother who was an art historian.
During the 1960s in Baltimore, my father was a strong proponent of community mental health. At the time, I didn't realize how I was being imprinted with the understanding that health care and life as a physician were terrific tools for constructive social change.
Looking back on it now, as a physician, offers a really interesting perspective. Bringing mental health to the community in the 1960s was extraordinarily progressive because health care, and certainly mental health, was practiced in the hospital.
It was a time of social unrest and social change in our country. It was a progressive idea to think that part of the social change could occur by improving access to health services for vulnerable individuals not just in the hospital, but also in places where they worked and lived.
Fast forward to college. I was an English and philosophy major, but I knew that I wanted to go into medicine. The critical thinking that's required of a philosophy major has been extremely useful in a professional life that has segued from clinical practice to policy and administration.
The Pursuit of Health (and Happiness)
I think that health care professionals, across all clinical and administrative disciplines, have an opportunity to help individuals and communities attain their highest levels of function. It is one of the reasons I am passionate about the American Hospital Association.
The AHA's vision statement is "a society of healthy communities where all individuals reach their highest potential for health." That highest potential for health is a door for accessing educational, occupational and social success. I am really proud of the AHA, its member institutions and all of the individuals who are part of a community that aspires to exert constructive social change.
I think that's one of the reasons the American Hospital Association and its members support increased access to timely health services.
From Sick Care to Health Care
Imagine a world in which we could turn back the clock and put the attention on preventing end-stage disease burdens. Imagine a world in which we can actually work on the social determinants of health that could keep people on a path to reduce their risks. As we move into an era of molecular medicine, precision medicine and personalized medicine, we might even be predictive.
Imagine a world in which we say, "Hey, you are headed for high cholesterol, but before you damage your arteries, we are going to intervene." In that way, we can turn the hands of the clock back and offer people their greatest opportunity for a healthy and creative life.
Our nation's institutions have been honed to focus on sick care. It is a tough transition, but we have to learn how to move from sick care to health care. Society is imploring us to build a system in which we can predict health risks; prevent health complications; build, maintain and restore people to their highest level of function; and, when necessary, intervene safely, effectively, efficiently and compassionately to treat disease.
I'm not sure that any of us — big system; small, rural hospital; academic health center; government; or private sector — fully understands or knows the recipe. This is one of the most important roles for the AHA to play. It can use its formidable convening power to help us think through how we move to a future that builds a more prominent role for health care, but also includes a place for sick care.
Staying Out of the Water
My passion for improving health care and personal health means that I am equally passionate about the institutions. They are the vehicles to deliver the services. I fully recognize that change has multiple dimensions. It can make us feel vulnerable because things are different, but change also means that there's a positive opportunity to do things differently. One of my priorities as chair-elect and then as chairman will be to seek input across the breadth of the membership. Part of the AHA mandate is not only to understand the circumstances impacting the various sectors of the membership, but also to recognize and value that diversity.
The world is not homogenous. The circumstances of communities, social institutions, economy and infrastructure can be different in different parts of the country. We can share aspirations and direction, but our starting points may be different. This is why it is so important for the AHA to work with the state hospital and allied associations to get their input and understand the activity in their environments.
The AHA won't always come to unanimity, but by valuing diversity and understanding heterogeneity, we can come to consensus in a way that is inclusive and creates a progressive, informed path that meets people where they live.
What does that mean in actual terms? There are certain markets across the country where the elements of accountable care are quite advanced and providers are exploring social and economic models for population health management. The boat has already left the dock. There are also rural and more traditional communities that may have one foot on the dock — the world we've always known — and one foot on the boat over turbulent waters and are trying not to fall. Regardless of which environment you may be in, all AHA members share values and the vision for healthy communities.
We are a big enough tent to support those organizations and communities that already have shifted much of the weight to the boat as well as those that are still on the dock. There is an opportunity to learn. Those who have taken the first step are a source of knowledge for those who are figuring out how to shift weight from dock to boat.
There are communities facing another set of challenges around sustainability — safety net institutions facing daunting odds, or academic institutions that are trying to figure out sustainability. One of the most important issues is for us to learn adaptive strategies to achieve our mission in a changing world.
A Process of Discovery
We don't all have to suffer the N.I.H. syndrome — Not Invented Here. We can tap into our collective intellect. Look at the Health Research & Educational Trust website, for instance, and the breadth of work that's available on performance improvement. Or look at the Center for Healthcare Governance tools on the board's work in an increasingly accountable world.
At HCA, I am proud of the work and learning we've done around combating Methicillin-resistant Staphylococcus aureus. We partnered with the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the University of California, Irvine's School of Medicine, and Harvard Medical School and Harvard Pilgrim Health Care Institute on one of the largest health services research studies ever conducted. The results were published May 29 in the New England Journal of Medicine.
In 18 months, we pulled together 43 HCA-affiliated hospitals and focused on a single question: What's the best approach to preventing MRSA in the intensive care unit?
The answer was staggering. We compared screening and isolating patients, which is not necessarily the best care for critically ill patients; screening and isolating patients plus decolonization against MRSA; and decolonizing all patients upon entry into the ICU. We found that universal decolonization reduced all bloodstream infections — not just MRSA — by 44 percent. It sets new standards for infection prevention that saves lives. It shows a shared commitment to improving health care and improving the lives of patients.
A lesson from that experience is that we can learn together more effectively and efficiently than we can learn individually.
While the study was notable for its size, speed and efficiency, one wonders whether the answer didn't already exist in the data from the experience of caring for thousands of patients. The Institute of Medicine in 2007 issued a report defining the learning health care system as one that considers, generates and applies evidence in practice. Imagine if multiple hospitals could tap into our collective memories and understand what worked and what didn't. The promise of the increasing use of electronic health records is "big data" that may someday answer questions of this sort as a by-product of the care itself.
Communicating the Vision
We need to be able to talk not only about our quality of care and aspirations for quality, but we also need to channel that into constructive policy recommendations for federal and state legislators and policymakers. We need to provide the business case for what we are for, not just argue about what we are against.
I look forward to working with the membership in a process of shared discovery where we push ourselves forward and are able to articulate a robust vision; a vision that is compelling to legislators and policymakers so that they, too, can join in constructive social change that supports access and recognizes the treatment of disease, and builds toward a healthier tomorrow.
The 1990s were not just a point of reflection for the Veterans Administration, but a point of crisis. The question on the table was one of value: Could the VA succeed in producing the expected performance given its mission and resources? Was value being delivered?
The notion of performance measures is common now, but in the VA at that time colleagues like Kenneth Kizer, M.D., and Tom Garthwaite, M.D., were asking, "How can we begin to measure the care?" We began to focus on a number of elements of quality and performance: quality as best we could measure it, patient functional status, access to care, patient experience and community health. We looked at all of that in relation to the cost provided. I'm beginning to paint an equation of value representing quality over cost. I realize it is not that simple, but we needed to understand how we were doing in terms of providing and proving value. We had to take a step back and say, "We can envision not only the best sick care, but the best health care."
The transition, of course, required reconsideration of how resources were used. That's not too different from the pressures we face today with care moving from hospitals to ambulatory clinics.
I am excited about EHRs, because health care is too complicated for pencil and paper. Clinical decision-support, error-checking, and information available where and when the patient and clinician need it are huge improvements over paper. The electronic record also provides insight into how well we are performing.
One of the highest objectives in the progression of meaningful use is not single quality measures, but rather building a capacity for measurement. That is important not only for what hospitals and other health care institutions can report, but for what they can use internally for self-directed improvement.
However, it is brutally difficult to design a good electronic measure. One of the things I've observed as chair of the federal Health IT Standards Committee is the importance of field testing measures before they are deployed. While the science might be good and even if the measure works well on paper, that is not a guarantee that it will work well electronically.
I believe in performance measurement. We can't demonstrate value without it. We are in an era of accountable care and we need to be able to demonstrate our performance through good, validated, reliable evidence-based measures. The problem is we don't have a lot of good, validated, reliable evidence-based measures.
When it comes to standards development, if the government doesn't facilitate, then there are no cues to the marketplace. Vendors may be reluctant to build in a particular direction because they are worried that they may have bet on the wrong horse. Providers may be hesitant when considering a particular EHR because they are concerned about betting on the wrong horse, too. On the other hand, if the government is so extraordinarily prescriptive, it determines the winners and losers in the marketplace. That is not good either because it stifles innovation.
There needs to be enough leadership to help identify clear market direction and sufficient flexibility for innovation.
Technology is a means, not the end. The objective is health and health promotion and disease prevention. Technology can be a terrific tool. We are learning how to imagine ways to use and implement technology, but we are also learning how to create a system that allows us to transition from the understood economics of sick care to the emerging economics of value and health care.
The Perlin file
2006–Present: president, clinical and physician services group; chief medical officer, Hospital Corporation of America
2004–2006: undersecretary for health, Department of Veterans Affairs
2003–2004: acting chief research and development officer, Veterans Health Administration
2002–2003: deputy undersecretary for health, Veterans Health Administration
1999–2002: chief quality and performance officer, Veterans Health Administration
1997–1999: medical director, quality improvement/utilization management, Medical College of Virginia Hospitals
• Chair, Health IT Standards Committee, Department of Health & Human Services
• Co-chair, Digital Learning Collaborative, Roundtable on Value & Science-driven Healthcare, Institute of Medicine
• National Patient Safety Foundation
• Friends of the National Library of Medicine
• Lipscomb University College of Pharmacy
• Meharry Medical College
• Sarah Cannon Research Institute
• Adjunct professor of medicine and biomedical informatics, Vanderbilt University
• Adjunct professor of health administration and associate professor of medicine, Virginia Commonwealth University
• University of Virginia, bachelor's degree, interdisciplinary honors (philosophy)
• Virginia Commonwealth University, M.D., medical scientist training program; Ph.D., pharmacology (molecular neurobiology)
• Virginia Commonwealth University, master of science, health administration