The VA Precision Oncology Program and a Learning Healthcare System – wearing the short white coat

Traditionally, the length of a doctor’s white coat is a reflection of his or her experience and seniority. Medical students start with a short white coat (think a white blazer). Senior doctors wear a knee-length white coat. At my Internal Medicine residency program, one of the senior Medicine professors would always wear a short white coat instead of the full length white coat. When asked about the short white coat, he would always explain that he saw himself as an eternal student in service to the person who is the patient. After one particularly busy overnight shift, I was wrapping up my admission notes and he happened to find me. He asked how much I learned overnight. I laughed and said something to the effect of “just keeping up with the number of patients.” He got an intense look on his face and leaned in like he was going to tell me a secret. He said (in his particular way of phrasing), “The thing is … is, learn from the routine. Learn something from every time you care for a person. The thing is if you do that, you can’t help but be better the next time.”

Later, I when I heard about the rapid, learning healthcare system (rLHS) described by the Institute of Medicine, I remembered the short white coat. I remembered the idea of “can’t help but be better.” That is to say, learning wasn’t delegated to special (and isolated) moments. Rather, learning permeated every patient interaction; the act of delivering care itself (without additional overhead) would accrue useful knowledge. Active effort would be needed to avoid learning.

Can you imagine? “We” (care providers, the system, patients) would always wear the short white coat. “We” have long since started our journey into the word of Precision Medicine i.e. medical care tailored to and based upon the fundamental biologic processes of an individual. The rate of genomic, proteomic, metabolomic, omic discoveries and their implications for health, illness, and treatments boggle the mind. With the recent national focus from the White House and the NIH, the Precision Medicine domain will continue to grow rapidly and bring major changes in healthcare. If there was ever a time “we” needed to wear a short white coat and continually learn … this is it. If we ever needed a rapid learning healthcare system…now is that time.

The Department of Veteran Affairs (DVA) has recognized the need to balance patient-centered and compassionate care with responsible creation of generalizable knowledge on safety and effectiveness of Precision Medicine treatments. The DVA is one of the oldest integrated and outcomes-focused healthcare systems in the US and is already a leader in the Precision Medicine domain with the Million Veteran Program. Consequently, the VA is uniquely positioned to gain a holistic understanding of the interaction between Precision Medicine and “real-world” clinical care i.e. truly “bedside to bench to bedside.” The VISN 1 clinical network and MAVERIC have created a new Precision Medicine-focused rapid learning healthcare system program called the Precision Oncology Program (POP), with an initial focus on lung cancer. Precision Oncology, a type of Precision Medicine, tailors cancer care based on the cancer’s genome, the cancer’s DNA. By knowing the cancer genome, Oncologists are able to choose therapies that specifically target the patient’s cancer and markedly improve treatment outcomes.

The functions of the Precision Oncology Program (described in detail here) are as follows:

• Offer expanded cancer genomic testing for Veterans receiving VA Oncology care
• Establish a “virtual” molecular tumor board to provide the interpretation of the ever-increasing number of clinically-relevant cancer genomic features to assist a Veteran’s treating Oncologist
• Establish a learning healthcare system that delivers actionable insights for an individual Veteran to the treating Oncologist and tumor board by combining and learning from:
  • Generalized knowledge from external sources about molecular medicine in cancer
  • Experiences of other veterans in the program
  • The patient’s own tumor genomic information and history with prior therapies
• Systematically present opportunities for Veterans to participate in clinical trials of targeted therapeutics, regardless of Veteran location – thereby reducing disparities of access to cutting-edge targeted therapeutics based on geographic location
• Maintain a public de-identified data set that describes the types of cancers, cancer mutations, stages, and treatments to attract new research and cutting-edge targeted therapeutics for benefit to the Veterans under VA care.
• Improve cancer quality outcomes and clinical-effectiveness across the VA network of clinical centers

The knowledge and data repository generated by the POP will be a unique, continually growing, and detail-rich resource. This repository will include clinical data (text progress notes, procedures, laboratory data, imaging reports, pathology reports, hospitalizations, clinic visits, medications), cancer genomic data (mutation panel and whole cancer exome), and raw imaging data. The POP is seeking many interdisciplinary collaborators to make the most effective and innovative use of this unique repository and ultimately return value to the Veterans under the care of the DVA.V

Valmeek Kudesia is a practicing internist, board-certified clinical informatician, and engineer trained at Boston University and Harvard University. He thrives in the challenging overlap of clinical, administrative, and technical domains in healthcare. Valmeek is the director of Clinical Informatics at the Massachusetts Veterans Epidemiology and Information Center (MAVERIC). He is an experienced leader who uses his multidisciplinary background to align stakeholders and forge new pathways for progress.  He guides interdisciplinary teams to equip healthcare networks with informatics platforms, clinical analytics tools, and change-processes in order to support cutting-edge research (including Precision Medicine) and a learning healthcare system that continually improves care outcomes. As a physician, he believes healthcare informatics systems should be invisible and bring care-providers and patients closer together instead of wedging them apart. As an engineer and informatician, he knows those systems can be created, and we can made a tremendous positive impact by building them.