THE LEARNING HEALTH SYSTEM SERIES
EMERGING STRONGER
FROM COVID-19
Priorities for
Health System Transformation
National Academy of Medicine
NAM Leadership Consortium
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a contribution worthy of public attention, but does not constitute endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; the NAM; or the National Academies of Sciences, Engineering, and Medicine.
International Standard Book Number-13: 978-0-309-69173-4
International Standard Book Number-10: 0-309-69173-7
Digital Object Identifier: https://doi.org/10.17226/26657
Library of Congress Catalog Number: 2022947719
Copyright 2023 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academy of Medicine. 2023. Emerging Stronger from COVID-19: Priorities for Health System Transformation. A. Anise, L. Adams, M. Ahmed, A. Bailey, P. S. Chua, C. S. Chukwurah, M. Cocchiola, A. Cupito, K. Kadakia, J. Lee, and A. Williams, editors. NAM Special Publication. Washington, DC: The National Academies Press. https://doi.org/10.17226/26657.
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Willing is not enough; we must do”
—GOETHE
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EMERGING STRONGER FROM COVID-19: PRIORITIES FOR HEALTH SYSTEM TRANSFORMATION
Steering Committee and Lead Authors
AMY ABERNETHY, Verily
JEFFREY BALSER, Vanderbilt University Medical Center
CAROLYN CLANCY, Veterans Health Administration
NAKELA COOK, Patient-Centered Outcomes Research Institute
KAREN DESALVO, Google
KATE GOODRICH, Humana
ROBERT HUGHES, Missouri Foundation for Health (former)
FREDERICK ISASI, Families USA
MICHAEL LAUER, National Institutes of Health
PETER LEE, Microsoft Research
JAMES MADARA, American Medical Association
MATHAI MAMMEN, Janssen/Johnson & Johnson
MARK MCCLELLAN, Duke University
SUZANNE MIYAMOTO, American Academy of Nursing
VASANT NARASIMHAN, Novartis
MARY NAYLOR, University of Pennsylvania
RAHUL RAJKUMAR, Optum Care Solutions
JAEWON RYU, Geisinger
DAVID SKORTON, Association of American Medical Colleges
NAM Staff
Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of J. Michael McGinnis, Leonard D. Schaeffer Executive Officer and Executive Director of the NAM Leadership Consortium: Collaboration for a Learning Health System:
LAURA ADAMS, Special Advisor
MAHNOOR AHMED, Associate Program Officer
AYODOLA ANISE, Deputy Director, NAM Leadership Consortium
ARIANA BAILEY, Senior Program Assistant (until August 2021)
PEAK SEN CHUA, Consultant
CHINENYE STEPHEN CHUKWURAH, Research Associate (until July 2021)
MICHAEL COCCHIOLA, Associate Program Officer (until July 2022)
ANNA CUPITO, Associate Program Officer (until July 2021)
KUSHAL KADAKIA, Consultant (until August 2021)
JENNIFER LEE, Special Advisor (until August 2022)
JENNA L. OGILVIE, Deputy Director of Communications
ASIA WILLIAMS, Associate Program Officer
REVIEWERS
The papers in this volume were reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine (NAM).
We wish to thank the following individuals for their contributions:
The reviewers listed above provided many constructive comments and suggestions, but they were not asked to endorse the content of the individual papers, and did not see the final draft before it was published. Review of these papers was overseen by AYODOLA ANISE, Deputy Director, NAM Leadership Consortium; LAURA ADAMS, Special Advisor; MAHNOOR AHMED, Associate Program Officer; JENNIFER LEE, Special Advisor; and J. MICHAEL MCGINNIS, Leonard D. Schaeffer Executive Officer. Responsibility for the final content of this publication rests entirely with the authors, the editors, and the NAM.
PREFACE
We know from Isaac Newton’s third law that forces come in pairs: for every action, there is an equal and opposite reaction. But when it comes to human catastrophe, a post-acute human tendency often sets in to diffuse the reactive forces from what ought to be their primary directionality. Without a strong resolve to keep sharp focus on the most basic lessons learned about preparedness shortfalls, the stage is set, seamlessly and senselessly, for the tragedy of the next event. In 2001, terrorism on American soil drew collective attention to the gaps in national security that made our nation vulnerable to attack. In 2004, Hurricane Katrina made clear the need for infrastructure that is resilient to natural disaster. Both responses have led to focused change, albeit imperfect, in the nation’s preparedness. On the other hand, the tragedy of mass murders, such as the 2014 shooting in Sandy Hook, have been followed by societal inaction, and left the nation unprotected from the full force of the occurrence of similar catastrophes.
To date, in mid-2022, the United States has lost more than a million people to the COVID-19 pandemic. We have been real-time witnesses to heroic frontline responses to the disease, death, inequity, and economic strife unleashed by the virus. We have also been real-time witnesses to the consequences not only of poor preparedness to contend with newly emerging health threats, but especially to the consequences of structural failures of our health system. The nation’s health system is poised at a critical junction point, with the opportunity to emerge stronger not merely in resistance to a novel infectious disease threat, but as a secure and sustained steward of the human condition over time.
For decades, the U.S. health system has fallen far short of its potential to produce individual and population health. In contrast to health care spending that exceeds that of any Organisation for Economic Co-operation and Development (OECD) nation, the U.S. experiences lower life expectancies, higher suicide rates, higher chronic disease burdens, higher obesity rates, and higher hospitalization rates from preventable causes than any of its peers. The inequities, lack of community
engagement, misaligned resources and incentives, untapped digital potential, and slow rate of evidence mobilization that belie these trends were also at the root of the nation’s experience with COVID-19. To fully realize health system effectiveness, efficiency, equity, and continuous learning that will translate to better and more holistic health and well-being, leaders from across the U.S. health system must take action to leverage both the learnings and the transformational opportunities that have accompanied the pandemic’s devastation.
Cognizant of the potential near-term and long-term importance of understanding in detail the features, impacts, and responses within and between various health sectors during the pandemic, the National Academy of Medicine’s (NAM’s) Leadership Consortium, comprised of the leadership of organizations from all major health system sectors, has undertaken a sector-by-sector review of the U.S. health system. The papers contained within assess the weaknesses that existed prior to COVID-19, how each sector has responded to the pandemic, and the opportunities that exist for health system strengthening and transformation. The resulting sectoral impact assessments are presented here in Emerging Stronger from COVID-19: Priorities for Health System Transformation. Each assessment team has been led by members of the NAM Leadership Consortium. Emerging Stronger is comprised of nine chapters that summarize the findings, opportunities, and collaborative options for sectoral transformation, followed by a chapter on cross-sector priorities for change, including:
- Patients, Families, and Communities
- Clinicians and Professional Societies
- Care Systems
- Digital Health
- Public Health
- Health Care Payers
- Health Product Manufacturers and Innovators
- Biomedical Research
- Quality, Safety, and Standards Organizations
- Health System Transformation: Common Priorities Across Sectors
The summary insights, drawn from the shared perspectives of the sector authors, underscore three deeply rooted common features leading to the core problems within each sector:
- Systemic fragmentation,
- Perverse incentives, and
- Structural inequities.
Accordingly, the authors note the importance of forceful collaborative engagement of transformational opportunities for stakeholders setting priorities for organizations in each of their sectors:
- Financing that is linked, integrated, seamless, and focused on outcomes for people and populations;
- Digital interoperability and shared data;
- Culture and accountability focused on outcomes most important to people and their communities;
- Learning that is real world, continuous, and timely; and
- Public health integrity as an explicit responsibility of every organization.
Taken together, the assessments in Emerging Stronger provide a unique and comprehensive review of the U.S. health system’s experience throughout the pandemic, as well as a roadmap toward a healthier future. It integrates the deep and growing knowledge base of the NAM with the expertise of leaders engaging the pandemic in real-time, offering both information and inspiration for aligned action on key opportunities. In this respect, we extend our deep appreciation to the members of the NAM Leadership Consortium, the project Steering Committee composed of the lead authors of each sector assessment, their collaborating colleagues from the field, the expert reviewers of each of the papers, and the superb NAM staff who coordinated and facilitated their work.
As Americans, innovation, improvement, and invention is our shared birthright. This publication underscores the imperative and the promise of applying the full strength of the nation for system-wide transformation as we apply the clarity of the lessons learned to create a health system that is effective, efficient, equitable—and continuously learning.
Victor J. Dzau | J. Michael McGinnis |
President | Leonard D. Schaeffer Executive Officer |
National Academy of Medicine | National Academy of Medicine |
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5 Public Health COVID-19 Impact Assessment: Lessons Learned and Compelling Needs
6 Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needs
8 Biomedical Research COVID-19 Impact Assessment: Lessons Learned and Compelling Needs
Nakela L. Cook, MD, MPH; and Michael S. Lauer, MD
10 Health System Transformation: Common Priorities Across Sectors
BOXES, FIGURES, AND TABLES
BOXES
1-1 Stories of Lived Experience: Impact of Being a Frontline Employee During COVID-19
1-2 Stories of Lived Experience: Impact of Isolating to Prevent Transmission to Family Members
1-5 Stories of Lived Experience: Impact of Suicide on Loved Ones
1-6 Stories of Lived Experience: Health Care Disparities During COVID-19
1-7 Stories of Lived Experience: Communicating Science to the Public
1-8 Stories of Lived Experience: Perceptions of the Pandemic Response
1-9 Stories of Lived Experience: Challenges with Communicating COVID-19 Messaging
1-13 Considerations for Prioritizing Investment in Solutions Designed to Advance Health Equity
2-1 Considerations for Investing in Clinician Well-Being
2-2 Considerations for Advancing Innovations in Clinician Practice
2-3 Considerations for Promoting Financial Resilience for Clinicians
2-4 Considerations for Transforming Education and Training
2-5 Considerations for Addressing Health Disparities
3-1 Considerations to Enhance the Financial Resiliency of Health Systems
3-2 Considerations to Strengthen Health System Supply Chains
3-3 Considerations for Investing in Workforce Development
3-4 Considerations for Health System Capacity Building
3-5 Considerations for Renewing Commitments and Instituting Concrete Actions for Health Equity
3-6 Considerations for Addressing Subsector-Specific Challenges
3-7 Considerations for Fostering Linkages Between Health Systems and Public Health
4-1 Definition of Digital Health
5-1 Considerations for Transforming Public Health Funding
5-2 Considerations for Affirming the Mandate for Public Health
5-3 Considerations for Promoting Structural Alignment Across the Public Health Sector
5-4 Considerations for Investing in Leadership and Workforce Development
5-5 Considerations for Modernizing Data and IT Capabilities
5-6 Considerations for Supporting Partnerships and Community Engagement
6-1 Considerations for Accelerating the Transition to Value-Based Payment
6-2 Considerations for Extending Flexibilities for Virtual Health Services and Capabilities
6-3 Considerations for Rethinking Benefit Design Using the Lens of Value-Based Insurance
6-4 Considerations for Aligning Incentives and Investments to Address Health Inequities
6-5 Considerations for Creating Mechanisms for Collective Action During Public Health Emergencies
6-6 Considerations for Coordinating Payment Reforms with Public Health Functions
10-1 Centering Health System Actions and Accountability on Individuals, Families, and Communities
10-2 Committing to the Pursuit of Equity as Core to Health System Performance
10-3 Securing the Public Health Infrastructure to Address 21st Century Population Health Challenges
10-4 Building a Robust and Integrated Digital Health and Data Sharing Infrastructure
10-5 Integrating Telehealth into Payment and Delivery Systems
10-6 Investing in Workforce Capacity and Readiness
10-7 Streamlining Innovation Pathways for Biomedical Science
10-8 Enhancing Stewardship of the Health Product Supply Chain
10-9 Restructuring Health Care Payments to Focus on Outcomes and Population Health
10-10 Fostering Communication and Collaboration Across Sectors and Stakeholders
FIGURES
1-1 Impact of the Pandemic on Patients, Families, and Communities
1-2 Experiences of Patients, Families, and Communities During COVID-19
1-3 Impact of COVID-19 on Patients, Families, and Communities’ Relationship to the Health System
2-1 The Clinician Response to COVID-19
2-2 COVID-19 Stressors for Clinicians
2-3 Priority Areas for the Clinician Sector
3-1 Landscape of U.S. Health System
3-2 Health System Functions During COVID-19
3-3 Cross-Cutting Public Health Functions for COVID-19
3-4 Priority Actions for Sector Transformation and Emergency Preparedness
4-1 Lifecycle for Continuous Management and Refinement of AI Models
5-1 Models of Public Health Governance
5-2 Frameworks for Essential Services and Foundational Capabilities in Public Health
5-3 Pre-Pandemic Challenge Areas for the Public Health Sector
5-4 Key Challenges for Local and State Health Departments During COVID-19
6-1 Overview of America’s Multi-Payer Landscape
6-2 Payer Responses to COVID-19 Challenges
6-3 Key Challenges for Payers for the Post-Pandemic Era
6-4 Opportunities for Sector-Wide Improvement
6-5 Select Examples of Clinical Use Cases for Telehealth
7-1 Profile of the Health Products Sector
7-2 Elective Procedure Volume Weekly Trends
7-3 Weekly Volumes of New Prescription (Rx) of Branded Therapeutics
7-4 Telemedicine Use Among Health Care Provider Organizations
7-5 Opportunities for Sector-Wide Transformation
9-1 Key Levers for Care Quality and Safety
9-2 Vulnerabilities in Quality and Standards Exposed by COVID-19
10-1 COVID-19 Stakeholder Sectors Legend
10-2 Overview of Sector Changes, Challenges, and Transformation Opportunities
10-3 Select Examples of Leadership and Advances During COVID-19
TABLES
1-1 Pre-Pandemic Experiences of Patients, Families, and Communities
1-2 The Disparate Impact of COVID-19 on Communities of Color
2-1 Key Challenges for the Clinician Sector
3-1 Health System Challenges During COVID-19
3-2 Drivers of Supply Chain Vulnerability
4-1 Digital Health Challenges and Opportunities Revealed in the Eight Other Sector Papers
5-1 Role of Foundational Capabilities for Public Health During the COVID-19 Response
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ACRONYMS AND ABBREVIATIONS
AACN | American Association of Colleges of Nursing |
AAMC | Association of American Medical Colleges |
AAP | American Academy of Pediatrics |
ACA | Patient Protection and Affordable Care Act |
ACCORD | Accelerating COVID-19 Research & Development platform |
ACGME | Accreditation Council for Graduate Medical Education |
ACLA | American Clinical Laboratory Association |
ACO | accountable care organization |
ACTIV | Accelerating COVID-19 Therapeutic Interventions and Vaccines |
ADHD | attention deficit and hyperactivity disorder |
AHA | American Hospital Association |
AHRQ | Agency for Healthcare Research and Quality |
AI | artificial intelligence |
AMA | American Medical Association |
AMC | academic medical center |
ANA | American Nurses Association |
AO | accrediting organization |
APA | American Psychological Association |
API | application programming interface |
APM | alternative payment model |
ARPA-H | Advanced Research Projects Agency for Health |
ASC | ambulatory surgical center |
BARDA | Biomedical Advanced Research and Development Authority |
BBC | British Broadcasting Company |
BLS | Bureau of Labor Statistics |
CAH | critical access hospital |
CARES Act | Coronavirus Aid, Relief, and Economic Security Act |
CBO | community-based organization |
CCNE | Commission on Collegiate Nursing Education |
CCO | coordinated care organization |
CCPA | California Consumer Privacy Act |
CDC | Centers for Disease Control and Prevention |
CDM | PCORnet Common Data Model |
CEAL | NIH Community Engagement Alliance |
CHART | Community Health Access and Rural Transformation Model |
CHW | community health worker |
CLIA | Clinical Laboratory Improvement Amendments |
CMS | Centers for Medicare & Medicaid Services |
CoP | condition of participation |
COVID-19 | coronavirus disease 2019 |
CoVPN | COVID-19 Prevention Network |
CPT | Current Procedural Terminology |
CRS | Congressional Research Service |
CTL | Crisis Text Line |
DOD | U.S. Department of Defense |
DOJ | U.S. Department of Justice |
DPA | U.S. Defense Production Act |
DR2 | NIH Disaster Research Response Program |
ED | emergency department |
EHR | electronic health record |
EUA | Emergency Use Authorization |
FAIR | findable, accessible, interoperable, and reusable |
FCC | Federal Communications Commission |
FDA | U.S. Food and Drug Administration |
FEMA | Federal Emergency Management Agency |
FFS | fee-for-service |
FHIR® | Fast Healthcare Interoperability Resources® |
FTC | Federal Trade Commission |
FY | fiscal year |
GDPR | General Data Protection Regulation |
GME | graduate medical education |
GPO | group purchasing organization |
HaH | Hospital at Home |
HAI | hospital acquired infection |
HCBS | home- and community-based services |
HHS | U.S. Department of Health and Human Services |
HIPAA | Health Insurance Portability and Accountability Act |
HITECH Act | Health Information Technology for Economic and Clinical Health Act |
HIV | human immunodeficiency virus |
HPMI | health product manufacturers and innovators |
HRSA | Health Resources and Services Administration |
ICU | intensive care unit |
IDN | integrated delivery network |
IDSA | Infectious Diseases Society of America |
IHI | Institute for Healthcare Improvement |
IMP | investigational medicinal product |
IOM | Institute of Medicine |
IoT | internet-of-things |
IP | intellectual property |
IT | information technology |
JHU | Johns Hopkins University |
KFF | Kaiser Family Foundation |
LGBTQ+ | lesbian, gay, bisexual, transgender, queer or questioning, and other gender identities and sexual orientations |
LHS | learning health system |
MIPS | Merit-based Incentive Payment System |
ML | machine learning |
MLR | medical loss ratio |
N3C | National COVID Cohort Collaborative |
NAM | National Academy of Medicine |
NCHS | National Center for Health Statistics |
NCQA | National Center for Quality Assurance |
NGS | next generation sequencing |
NHLBI | National Heart, Lung, and Blood Institute |
NHSN | National Healthcare Safety Network |
NIAID | National Institute of Allergy and Infectious Diseases |
NIH | National Institutes of Health |
NPI | nonpharmaceutical intervention |
NQF | National Quality Forum |
NRC | National Research Council |
OASH | Office of the Assistant Secretary for Health |
OASPE | Office of the Assistant Secretary for Planning and Evaluation |
OCR | Office for Civil Rights |
OHDSI | Observational Health Data Sciences and Informatics |
OHRP | Office for Human Research Protections |
OIG | Office of Inspector General |
ONC | Office of the National Coordinator for Health Information Technology |
OSHA | Occupational Safety and Health Administration |
OSTP | Office of Science and Technology Policy |
OWS | Operation Warp Speed |
PA | physician assistant |
PCORI | Patient-Centered Outcomes Research Institute |
PCR | polymerase chain reaction |
PHAB | Public Health Accreditation Board |
PHR | personal health record |
PHRASES | Public Health Reaching Across Sectors |
PPE | personal protective equipment |
PTSD | posttraumatic stress disorder |
QIN-QIO | Quality Innovation Network-QIO |
QIO | Quality Improvement Organization |
QR | quick response |
R&D | research and development |
RADx | Rapid Acceleration of Diagnostics initiative |
RN | registered nurse |
RWD | real-world data |
SAMHSA | Substance Abuse and Mental Health Services Administration |
SARS-CoV-2 | severe acute respiratory syndrome coronavirus 2 |
SDoH | social determinants of health |
SNAP | Supplemental Nutrition Assistance Program |
SNF | skilled nursing facility |
SNS | Strategic National Stockpile |
UCSF | University of California, San Francisco |
UK | United Kingdom |
UPMC | University of Pittsburgh Medical Center |
U.S. | United States |
USCDI | United States Core Data for Interoperability |
USNS | U.S. Navy Ship |
VA | U.S. Department of Veterans Affairs |
VAERS | Vaccine Adverse Event Reporting System |
VTEU | Vaccine and Treatment Evaluation Unit |
WHO | World Health Organization |
WIC | Special Supplemental Nutrition Program for Women, Infants, and Children |