Overview

With the poorest outcomes and highest cost compared with the rest of the industrialized world, the health care system in the United States is failing. According to a 2014 independent Commonwealth Fund report, the United States ranks last among 11 industrialized countries on health care quality and access, despite having the costliest care. The report ranked the United Kingdom first overall, even though its per-capita health spending is less than half that of the United States.

Health care is a complex adaptive system and a dynamic knowledge enterprise that evolves rapidly over short periods of time. Too often, the knowledge and information generated is not put into practice at the point of care and not made accessible to individuals and their families. In this rapidly evolving era of genomic science and information overload, the need for actionable health information to be more available and accessible is greater than ever.

A transformed health care system will provide the right care to the right patient at the right cost at the right time. This will only be possible, however, if the most up-to-date scientific and personal health information is instantly accessible at the time of need. Achieving this requires an advanced, comprehensive, national health information technology infrastructure for an interoperable, secure, real-time exchange of clinical data. No such infrastructure exists in the United States today.

The Chan Soon-Shiong Institute for Advanced Health (IAH), a nonprofit organization, was established to assemble this national scale, open architecture, data sharing platform (a medical information highway) to support a diverse marketplace of high-quality health care applications. This cloud-based medical information highway provides an open infrastructure for health information to be shared seamlessly across disparate end-user systems, securely. In pursuit of these goals, IAH is creating data centers in Phoenix and Scottsdale dedicated to health information storage, and is funding the development in Phoenix of a dedicated supercomputer for genomic science. Utilizing this medical information highway, NantHealth has focused its attention on targeting the root cause of poor outcomes and higher costs in the nation, including:

• diagnostic errors ¹
• inappropriate treatments ²
• inability to keep up with increasingly complex changes in standards of care
• expensive, reactive rather than proactive and preventive care, in high-risk populations with chronic and lifethreatening diseases.

IAH and NantHealth believe that actions taken by the CEO Council on Health and Innovation (a “do tank”) will catalyze a commitment by national leaders in philanthropy, academia, government, and the private sector to chart a new course toward health integration for patients in the United States and to share this innovation with the world. IAH and NantHealth re-imagine the way patients, providers, caregivers, and researchers across the nation can securely access actionable health information at the point of care, in the time of need, for the lowest cost—a next-generation Internet for secure health information, transforming complex big data to evidence-based care and a continuously learning health care system in America—driving the age of cognition to everyday care.

Institute for Advanced Health and NantHealth’s Strategies for Improving the Health Care System

Paving a Medical Information Superhighway

In this highly fragmented U.S. health system, there is a need today for virtual organizations to form and provide coordinated, proactive, evidence based care on a local, regional and national level. Rather than trying to consolidate health data into physical databases, a virtual patient-centered electronic health record will allow data to be stored locally and to be assembled and accessible in dynamic fashion.

To truly provide high-quality, cost-effective care, the disparate entities involved in the care delivery process must interact more efficiently and effectively. Traditionally, the primary care physician, sub-specialist, laboratory center, and insurer operate as separate institutions, with unrelated and disjointed processes. To improve health care in the United States, these competing entities must dynamically function as one single “virtual” organization designed around and firmly committed to patient interests. Such organizations are being formed today—accountable care organizations, for example—to address population health management and coordinated care in the era of health care complexity and ever-rising costs. However, currently, even when medical information is in digital formats, data is not accessible because it resides in different “silos” within and between organizations.

A comprehensive, national health information technology infrastructure is necessary to support these virtual organizations. As researchers argued in a New England Journal of Medicine Perspective article, “No Small Change for the Health Information Economy,” this infrastructure should focus on the development of a general-purpose health care computing platform with low barriers to entry rather than on pre-defined end user products. The platform should in turn support a wide variety of health care applications through open architectures. This choice will allow patients, physicians, hospitals, and employers to select the set of applications most appropriate for their local environments.

IAH’s medical information highway addresses this challenge through the advanced and proven technology of grid computing, a technology model designed to promote the coordinated sharing of resources in dynamic, multi-institutional virtual organizations. Grid-computing is particularly well suited to address the complexity of the fragmented health care system.

This infrastructure allows for the interoperable, secure sharing of health care data between institutions that likely have different information systems and policies. The IAH infrastructure is open to third-party end-user applications, including NantHealth applications, which will create a seamless ecosystem of functionalities that together form a distributed “virtual” longitudinal health record platform. Rather than trying to consolidate health data into physical databases, this “virtual” electronic health record will allow data to be stored locally and to be assembled and accessible in a dynamic fashion.

IAH is working with the National Coalition for Health Integration (NCHI) to design and develop this innovative, groundbreaking infrastructure. NCHI was formed in 2009 to build a public private coalition of health care partners and academia dedicated to transforming health care by enhancing the availability and integration of health information across the country.

The IAH infrastructure allows for the interoperable, secure sharing of health care data between institutions that likely have different information systems and policies and is open to third-party end-user applications, including NantHealth applications, which will form a seamless eco system of functionalities that together form a distributed “virtual” electronic health record platform.

In 2011, NCHI provided funding to maintain the viability of the National LambdaRail (NLR), a fiber infrastructure for numerous large research projects including users such as NASA, the National Science Foundation and US institutions connecting with the Large Hadron Collider in Switzerland. The NLR fiber infrastructure was designed for basic science and the physics scientific community. There is now an urgent national need to replace this aged infrastructure with a modern fiber network integrated into clinical practices and hospital facilities across the nation, and connected to the NCHI supercomputer in Arizona.

NantHealth’s integrated health platform will address each domain of the health system. Its multi-tiered approach of linking technologies, professionals, patients, payers, and the delivery of health services across the nation will transform the health system along four fronts:

• Transitioning population health management to 21st century care
• Decreasing costs, enhancing efficiencies, improving outcomes, and coordinating care
• Increasing access to care
• Enhancing patient-centered care across wellness, “willness,” and illness

Through the Power of supercomputing and mobile ubiquity, IAH and NantHealth are building the world’s first patient centered cloud-based “continuous health care learning system” to enable 21st century care for all, and a modern platform for population health management and care coordination across the continuum of wellness to willness (chronic disease) to illness (acute, life-threatening disease).

Benefits and Impact

NantHealth has built the first patient-centered, cloud-based continuous health care learning system for population health and care coordination across the continuum of a patient’s life: from (a) acute life-threatening episodes (“illness”); to (b) high-cost chronic co-morbid disease management (“willness”); to (c) the daily maintenance of health and wellness of individuals (“wellness”).

NantHealth’s Platform Technologies

Building and testing this comprehensive, holistic, patient centered cloud required the individual development of multiple layers of the ecosystem: NantHealth’s platform technologies. From 2005 to 2014, these platform technologies were built and robustly tested, either individually or in combination. This included the innovation and development of:

• Real-time wireless and vital sign health boxes (known as HBoxes) collecting patient vital signs whether at home, hospital or clinic;
• Intelligent wireless sensors capturing critical vital signs remotely;
• A clinical operating system, based on grid-computing, capable of integrating disparate electronic health records, financial systems, inventory systems, and care pathways at a national scale;
• An advanced fiber network enabling the rapid and secure transmission of clinical data;
• Comprehensive cancer databases of clinical protocols, clinical trials, drug efficacies andtoxicities, and costs for clinical decision support; and
• Supercomputer systems for real-time genomics and predictive proteomic analysis (in 47seconds).

These infrastructure platforms are described in more detail in Appendix A.

Wellness Programs: Daily Maintenance of Health and Wellness for Individuals

To support health and wellness of individuals, IAH and NantHealth are building the infrastructure for wireless connectivity and patient portals for the secure, real-time delivery of health information to patient and caregiver. Initiatives in this category include:

1. Launching the HBox in partnership with wireless carriers
2. Launching secure, mobile, patient portals with mobile operators
3. Integrating wearable devices with HBox
4. Providing secure, HIPAA compliant data storage

Willness Programs: High-Cost Chronic Co-morbid Disease Management

Platforms designed to help providers and patients effectively manage chronic conditions are focused on:

Care coordination and reduction in hospital admissions for patients with chronic comorbid diseases. Ongoing pilots focus on patients who are elderly and frail (UC Irvine), cancer care (IOBS Come Home), diabetes and wound care (Wound Technology Network), reduction in hospital admissions (Providence Health & Services at Saint Johns Hospital), and real-time monitoring of heart rate, respiration, and temperature in emergency rooms and the ICU using intelligent wireless sensors (Providence Health & Services at Saint Johns Hospital and Hurley Medical Center)

Infrastructure for automated assessments and proactive identification of patients likely to be at risk for repeat readmissions, and a care planning and care execution infrastructure for delivering proactive care (UK NHS Trusts in Warrington and East Cheshire and Providence Health & Services at Saint Johns Hospital)

Real-time medication adherence programs utilizing NantHealth’s Vitality GlowCapswith health care providers (Healthcare Partners), pharmaceutical companies (Novartis), mobile operators, and large employer groups (Bank of America)

Delivery of bedside pharmacy services that reduces risk of readmissions throughmedication fulfillment

Intelligent decision theater and remote monitoring (Dartmouth-Hitchcock HealthSystem)

Illness Programs: Acute Life-threatening Episodes The broadband fiber, supercomputing cloud, decision support engines, and mobile ubiquity have been converged by NantHealth to establish a cloud-based cognitive support platform (“the smart machine era”) to provide advanced 21st century care in the following case studies in progress:

Coordination of care across the United States through the creation of advanced virtual organizations across 55 practices, 170+ partner companies, 1,200 payers, 2,400 providers and 1,500 users: receiving 80GB of clinical data extracts every day, and handling updates of 50,000 patient charts daily. This system currently stores 21 million patient encounters, 240 million rows of lab results and 220 million rows of service line data and has been in operation since 2008.

Driving cognitive support and evidence-based care across the United States. More than 60 percent of oncology practices and well over 8,000 oncologists and nurses have adopted this tool, called eviti (www.eviti.com). Health plans have also adopted this tool and eviti will serve as the platform for next-generation molecularly driven clinical decision-making. To date, multiple health plans have launched eviti including WellPoint and Aetna. By the end of 2014, a number of states will have adopted this decision support engine including Georgia, Alabama, Florida, Ohio, California, Colorado, Nevada, Kentucky, Massachusetts, and Nebraska.

• In 2013, results were released of a multi-year study performed in association with professionals from Abramson Cancer Center of the University of Pennsylvania and Johns Hopkins Carey Business School. The study showed that 28.7 percent of cancer patients had oncology treatments prescribed that did not conform to evidence-based standards or could not be medically justified. The study also revealed that the cost of the unwarranted components of these treatments averaged $25,579 per patient. At current annual cancer incidence rates in the US, this translates to more than $10 billion per year in unnecessary costs that could be significantly reduced by eliminating unwarranted, non-evidence-based cancer treatment.

Driving molecularly-driven clinical decisions in cancer care. A virtual organization of a Cancer Knowledge Action Network, the Cancer Collaborative, has been established for the sharing of genomic and phenotypic data among City of Hope, Childrens Hospital of Los Angeles, Childrens Hospital of Phoenix, Dartmouth-Hitchcock Health System, John Wayne Cancer Institute, Methodist Cancer Center, Providence Health & Services, University of California Davis, University of California Los Angeles Health System, University of Colorado Denver, The University of Texas MD Anderson Cancer Center, The University of Utah. The collaboration of these entities has resulted in astounding findings in a short period of time:

• In July 2012, the collaborative collected 6,017 tumor and germline exomes,representing 3,022 cancer patients with 19 unique cancer types. The sample collection included: 999 breast cancer; 1,156 kidney and bladder cancer; 985 gastrointestinal cancer; 744 brain cancer; 745 lung cancer; 670 ovarian, uterine, and cervical cancer; 436 head and neck cancer; 177 prostate cancer; 70 melanoma cancer; and 35 blood tumor samples. This massive amount of data totaled 96,512 gigabytes. It was transferred and processed via our supercomputing, high-speed fiber network in 69 hours. This overall transfer speed represents a stream of one sample every 17.4 seconds, and the supercomputer analysis for genetic and protein alterations between the tumor and normal sample completed every 47 seconds per patient.
• In 2014, at the ASCO Annual Meeting, NantHealth presented on the rapidmolecular analysis of more than 10,000 tumor and germline whole exomes from 5,000 patients across more than 20 cancer tissue types, concluding—in stark contrast to widely held medical assumptions today—that the molecular signature of a cancer patient is independent of the anatomical tumor type. The finding suggests, for example, that a hypothetical breast cancer patient could potentially have more in common with a lung cancer patient than another person with the same “type” of cancer.
• In 2014, results of a collaborative study between OncoPlex Diagnostics, Valld ́Hebron Institute of Oncology (VHIO), and Memorial Sloan Kettering Cancer Center, defined for the first time that a quantitative HER2 protein level measured by mass spectrometry is  associated with longer disease free and overall survival in patients receiving anti-HER2 treatment. This is the nation’s first demonstration of quantitative measurements of cancer proteins from human tissue and the study demonstrated that a breast cancer mutation HER2 could be quantitatively measured and shown to be predictive of improved response to anti-HER2 therapy in breast cancer.This is the nation’s first demonstration of quantitative measurements of cancer proteins from human tissue and the study  demonstrated that a breast cancer mutation HER2 could be quantitatively measured and shown to be predictive of improved response to anti-HER2 therapy in breast cancer.
• Providence Health, NantHealth and the Chan Soon-Shiong Institute of Molecular Medicine partnered in August 2014 to create the country’s first health network for clinical whole genomic sequencing. This health network spans 5 western states and serves 22,000 new cancer  patients and 100,000 cancer cases per year. The partnership is installing an Illumina HiSeq X Ten sequencing system to enable the nation’s first clinical whole genome sequencing paired with RNA–\sequencing and proteomics.

Lessons Learned

The discovery of “the God particle” (in the Large Hadron collider project) involved the collaboration of hundreds of physicists across the globe, collaborating in real-time by analyzing millions of bits of data. This achievement occurred through the creation of virtual organizations committed to a common cause, utilizing grid-computing and an information highway (the National LambdaRail) created for large science projects. This is the inspiration for IAH’s and NantHealth’s medical information highway and cloud-based, supercomputing, cognitive support engine. Very much like the billions of atoms in the universe, the biology of a human being involves millions of protein interactions. In order to establish a continuous health care learning system, which could address real-time management of patient care, technology platforms had to be built. IAH and NantHealth embarked on building these technology platforms, testing the platforms individually and then integrating the platforms into a common, holistic medical information system.

These exhaustive disparate health platforms have never been integrated at a national and global scale. Only when they are integrated into a holistic system (the medical information highway enabling cognitive support), can the country hope to address the root cause of its failing systems, change outcomes, and reduce costs. IAH and NantHealth are answering this call to action.

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¹ Yifei Ma et al., “Failure to Comply with NCCN Guidelines for the Management of Pancreatic Cancer Compromises Outcomes,” Journal of the International Hepato-Pancreato-Biliary Association 14, no. 8 (2012): 539-547.

² Maeve Duggan and Aaron Smith, “Cell Internet Use 2013,” Pew Research Center: Internet Project, September 2013. http://www.pewinternet.org/2013/09/16/cellinternet-use-2013/

View Appendix A: Initiatives of the Institute for Advanced Health and NantHealth