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U.S.	News	Best	Hospitals	
Healthcare	of	Tomorrow	
David	Shulkin,	M.D.	
Under	Secretary	for	Health	
Department	of	Veterans	Affairs		
November	3,	2016
VETERANS	HEALTH	ADMINISTRATION	
Predictive Analytics in Issues
That Are Critical to Veterans
2
•  Oncology		
•  PTSD	
•  TBI	
•  Suicide
VETERANS	HEALTH	ADMINISTRATION	
Cancer Moonshot
3
VETERANS	HEALTH	ADMINISTRATION	
VA National Precision Oncology Program
Federal Agencies-NCI, FDA, NIH, DOE, DOD
•  VA	Molecular	Oncology:	80	geneHc	counselors	supporHng	clinicians	from	SLC			
•  NCI	SPORE	(Specialized	Programs	of	Research	Excellence)	predicHve	models	for		
prostate	cancer	
•  VA-DOE	collaboraHon-		VA	EHR	and	genomics	
•  FDA-	INFORMED”	iniHaHve	-Integrate	EHR	data	with	data	on	approved	drugs	
•  VHA	and	DoD-medical	and	administraHve		outcomes	research	
•  NIH-		Interagency	agreement	on	precision	medicine	iniHaHve		
	 4
VETERANS	HEALTH	ADMINISTRATION	
Genomics Data- 520,000 Enrolled
5
VETERANS	HEALTH	ADMINISTRATION	
MVP and PMI Summary Objectives
6
State-of-the-art	computaJonal	
environment	
MVP	parJcipaJon	
available	to	all	
Veterans	and	DoD	
Data	access	leading	to	
scienJfic	discoveries		
and	publicaJons	
MVP		
ParJcipants	
Veterans	
DoD	
Genomic	
Data	
VA	
InvesJgators	
Non-VA	
InvesJgators	
Medical	
Records	
Survey	
Responses	
•  Current	enrollment	520,000	Veterans	
•  Enroll	at	least	1	Million	by	2020	
•  Expand	secure	computaHonal	capacity	to	serve	more	than	1,000	simultaneous	VA	and	non-VA	
researchers	by	2020	
•  Safe/secure,	CLIA-compliant	biorepository	with	back-up	
•  Establish	mechanisms	to	return	results	responsibly	to	providers,	EHR,	and	parHcipants
VETERANS	HEALTH	ADMINISTRATION	
Partnership with DOE
•  Leverage	DOE’s	compuHng	capabiliHes	and	VA’s	genomic	experHse	
to	unlock	and	develop	beXer	ways	of	prevenHng,	detecHng,	
treaHng,	and	curing	disease	
	
•  VA	and	DOE	sign	interagency	agreement	to	establish	governance	
throughout	the	5-year	relaHonship	
	
•  Pilot	to	be	launched	on	June	1,	2017	
	
•  Joint	program	named	MVP	Champion	
	
7
VETERANS	HEALTH	ADMINISTRATION	
VA and IBM’s Watson
8
VETERANS	HEALTH	ADMINISTRATION	
Precision Mental Health (PMH)
Based	on	the	Million	Veteran	Program	(MVP),	VA’s	Precision	
Medicine	plaUorm,	and	QUERI	Evidence	Synthesis	recommendaJons,	
a	naJonal	study	involving	more	than	2,000	Veterans	intended	to:	
	
•  Understand	the	genomics	and	pharmacogenomics	of	depression		
•  Test	the	effecHveness	of	individualized	treatment	for	depression		
based	on	their	unique	geneHc	informaHon		
•  Empower	clinicians	and	paHents	with	geneHc	data,	thereby	
ensuring	the	right	drug,	at	the	right	dose,	given	at	the	right	Hme	
9
VETERANS	HEALTH	ADMINISTRATION	
VA Clinical Care for TBI
•  In	FY	2015,	VA	provided	care	for	98,426	unique	Veterans	with	TBI	
	
•  VA	has	screened	more	than	1	million	Veterans	since	2007		
•  Using	MVP	data	and	EMR	big	data	analyHcs	to	understand	beXer	ways	of	
prevenHng	and	treaHng	TBI		
	
10
VETERANS	HEALTH	ADMINISTRATION	
Chronic Effects of Neurotrauma Consortium
Research into TBI and PTSD
•  $62.175	million	VA	and	DoD	funding	
•  130	acHve	PTSD	Studies	and	10	TBI	studies	
across	more	than	30	parHcipaHng	insHtuHons*	
*	as	of	AUG	2016	
11
To establish the
association (onset,
prevalence, and severity)
of the chronic effects of
mild TBI (mTBI) and
common comorbidities*
Determine whether there
is a causative effect of
chronic mTBI/concussion on
neurodegenerative
disease and other
comorbidities*
Identify diagnostic and
prognostic indicators of
neurodegenerative
disease and other
comorbidities associated
with mTBI/concussion
Develop and advance
methods to treat and
rehabilitate chronic
neurodegenerative
disease and comorbid
effects of mTBI/concussion
Consortium
Objectives
VETERANS	HEALTH	ADMINISTRATION	
Suicide in America
In	2014,	there	were	41,425	suicides	
	
Of	those,	7,403	(17.9%)	were	Veterans	
• 	20	per	day	
12
VETERANS	HEALTH	ADMINISTRATION	
Predictive Analytics
REACH VET
13
•  Rollout		naHonally	
•  Uses	data	to	idenHfy	
Veterans	at	high	risk	
for	suicide	
•  NoHfies	VA	providers	
of	the	risk	assessment
VETERANS	HEALTH	ADMINISTRATION	
Background: The Predictive Model
•  Developed	by	VA,	NIMH,	and	university-based	researchers	
•  Includes	clinical	and	administraHve	data	for	each	Veteran	using					
VA	health	care	services	
14
Outcome	 Top	.1%	
Top	Risk	
Suicide	(one	month)	 33	x	
Suicide	(one	year)	 15	x	
Suicide	aXempt	(one	year)	 81	x	
Calculated	Risk	
*As compared to overall VHA population
VETERANS	HEALTH	ADMINISTRATION	
Identified At-Risk Veterans Provide
Opportunities for Enhanced Care
Of	those	in	the	top	.1%,	only	30%	were	
idenHfied	as	high	risk	for	suicide	based	on	
clinical	signs	and	symptoms	
	
15
VETERANS	HEALTH	ADMINISTRATION	
REACH VET Roles and Responsibilities
REACH	VET	Coordinators	
	
•  Ensure	that	noHficaHons	regarding	idenHfied	paHents	reach	the	appropriate	providers	
	
	
Mental	Health	and	Primary	Care	Providers	
	
•  Acknowledge	noHficaHon	of	idenHfied	at-risk	paHents	
•  Contact	paHents	and	assess	them	
•  Re-evaluate	diagnoses	and	treatment	plans	
16
VETERANS	HEALTH	ADMINISTRATION	
Mental Health and Social Media
– Monitor VA social media to identify troubling/concerning posts
– Veterans Crisis Line locates the individual to provide information, intervention,
life saving services.
– Since 2011, VA has posted 16,343 responses via Facebook and YouTube
(average of 318 per month). Concerning posts have been escalated to VCL
217 times throughout the campaign’s lifetime.
VETERANS	HEALTH	ADMINISTRATION	
Exploring Use of Analytics and Social Media
•  Research	suicide	behavioral	indicators	and	online	content	to		
advance		understanding	of		Veterans	at	high-risk	for	commieng	
suicide	
•  PotenHally	develop	an	automated	and	real-Hme	algorithm	
which	can	effecHvely	predict	Veterans	at	risk	for	suicide
VETERANS	HEALTH	ADMINISTRATION	
Center for Compassionate Innovation
Mission:	To	enhance	Veterans’	health	and	well-being	by	offering	
emerging	therapies	that	are	safe	and	ethical,	parHcularly	afer	
tradiHonal	treatments	have	been	unsuccessful	
	
•  Evaluate	proposals	that	lack	rigorous	science	but	the	evidence																			
is	compelling		
•  Consider	proposals	where	clinical	benefits	outweigh	the	risks		
•  Incorporate	Veteran’s	voice	in	emerging	therapies		
•  Leverage	innovaHon	to	address	the	unique	needs	of	the													
Veteran	populaHon		
•  Maintain	fundamental	principle	to	Do	No	Harm	
19

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VA Healthcare Predictive Analytics Critical to Veterans

  • 2. VETERANS HEALTH ADMINISTRATION Predictive Analytics in Issues That Are Critical to Veterans 2 •  Oncology •  PTSD •  TBI •  Suicide
  • 4. VETERANS HEALTH ADMINISTRATION VA National Precision Oncology Program Federal Agencies-NCI, FDA, NIH, DOE, DOD •  VA Molecular Oncology: 80 geneHc counselors supporHng clinicians from SLC •  NCI SPORE (Specialized Programs of Research Excellence) predicHve models for prostate cancer •  VA-DOE collaboraHon- VA EHR and genomics •  FDA- INFORMED” iniHaHve -Integrate EHR data with data on approved drugs •  VHA and DoD-medical and administraHve outcomes research •  NIH- Interagency agreement on precision medicine iniHaHve 4
  • 6. VETERANS HEALTH ADMINISTRATION MVP and PMI Summary Objectives 6 State-of-the-art computaJonal environment MVP parJcipaJon available to all Veterans and DoD Data access leading to scienJfic discoveries and publicaJons MVP ParJcipants Veterans DoD Genomic Data VA InvesJgators Non-VA InvesJgators Medical Records Survey Responses •  Current enrollment 520,000 Veterans •  Enroll at least 1 Million by 2020 •  Expand secure computaHonal capacity to serve more than 1,000 simultaneous VA and non-VA researchers by 2020 •  Safe/secure, CLIA-compliant biorepository with back-up •  Establish mechanisms to return results responsibly to providers, EHR, and parHcipants
  • 7. VETERANS HEALTH ADMINISTRATION Partnership with DOE •  Leverage DOE’s compuHng capabiliHes and VA’s genomic experHse to unlock and develop beXer ways of prevenHng, detecHng, treaHng, and curing disease •  VA and DOE sign interagency agreement to establish governance throughout the 5-year relaHonship •  Pilot to be launched on June 1, 2017 •  Joint program named MVP Champion 7
  • 9. VETERANS HEALTH ADMINISTRATION Precision Mental Health (PMH) Based on the Million Veteran Program (MVP), VA’s Precision Medicine plaUorm, and QUERI Evidence Synthesis recommendaJons, a naJonal study involving more than 2,000 Veterans intended to: •  Understand the genomics and pharmacogenomics of depression •  Test the effecHveness of individualized treatment for depression based on their unique geneHc informaHon •  Empower clinicians and paHents with geneHc data, thereby ensuring the right drug, at the right dose, given at the right Hme 9
  • 10. VETERANS HEALTH ADMINISTRATION VA Clinical Care for TBI •  In FY 2015, VA provided care for 98,426 unique Veterans with TBI •  VA has screened more than 1 million Veterans since 2007 •  Using MVP data and EMR big data analyHcs to understand beXer ways of prevenHng and treaHng TBI 10
  • 11. VETERANS HEALTH ADMINISTRATION Chronic Effects of Neurotrauma Consortium Research into TBI and PTSD •  $62.175 million VA and DoD funding •  130 acHve PTSD Studies and 10 TBI studies across more than 30 parHcipaHng insHtuHons* * as of AUG 2016 11 To establish the association (onset, prevalence, and severity) of the chronic effects of mild TBI (mTBI) and common comorbidities* Determine whether there is a causative effect of chronic mTBI/concussion on neurodegenerative disease and other comorbidities* Identify diagnostic and prognostic indicators of neurodegenerative disease and other comorbidities associated with mTBI/concussion Develop and advance methods to treat and rehabilitate chronic neurodegenerative disease and comorbid effects of mTBI/concussion Consortium Objectives
  • 13. VETERANS HEALTH ADMINISTRATION Predictive Analytics REACH VET 13 •  Rollout naHonally •  Uses data to idenHfy Veterans at high risk for suicide •  NoHfies VA providers of the risk assessment
  • 14. VETERANS HEALTH ADMINISTRATION Background: The Predictive Model •  Developed by VA, NIMH, and university-based researchers •  Includes clinical and administraHve data for each Veteran using VA health care services 14 Outcome Top .1% Top Risk Suicide (one month) 33 x Suicide (one year) 15 x Suicide aXempt (one year) 81 x Calculated Risk *As compared to overall VHA population
  • 15. VETERANS HEALTH ADMINISTRATION Identified At-Risk Veterans Provide Opportunities for Enhanced Care Of those in the top .1%, only 30% were idenHfied as high risk for suicide based on clinical signs and symptoms 15
  • 16. VETERANS HEALTH ADMINISTRATION REACH VET Roles and Responsibilities REACH VET Coordinators •  Ensure that noHficaHons regarding idenHfied paHents reach the appropriate providers Mental Health and Primary Care Providers •  Acknowledge noHficaHon of idenHfied at-risk paHents •  Contact paHents and assess them •  Re-evaluate diagnoses and treatment plans 16
  • 17. VETERANS HEALTH ADMINISTRATION Mental Health and Social Media – Monitor VA social media to identify troubling/concerning posts – Veterans Crisis Line locates the individual to provide information, intervention, life saving services. – Since 2011, VA has posted 16,343 responses via Facebook and YouTube (average of 318 per month). Concerning posts have been escalated to VCL 217 times throughout the campaign’s lifetime.
  • 18. VETERANS HEALTH ADMINISTRATION Exploring Use of Analytics and Social Media •  Research suicide behavioral indicators and online content to advance understanding of Veterans at high-risk for commieng suicide •  PotenHally develop an automated and real-Hme algorithm which can effecHvely predict Veterans at risk for suicide
  • 19. VETERANS HEALTH ADMINISTRATION Center for Compassionate Innovation Mission: To enhance Veterans’ health and well-being by offering emerging therapies that are safe and ethical, parHcularly afer tradiHonal treatments have been unsuccessful •  Evaluate proposals that lack rigorous science but the evidence is compelling •  Consider proposals where clinical benefits outweigh the risks •  Incorporate Veteran’s voice in emerging therapies •  Leverage innovaHon to address the unique needs of the Veteran populaHon •  Maintain fundamental principle to Do No Harm 19