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The Ecosystem to Support People With Heart Failure

  • Robert M. Califf
    Correspondence
    Reprint requests: Robert M. Califf, MD, Scientific Advisor, Verily Life Sciences, 269 East Grand Avenue, South San Francisco, CA 94080-4804.
    Affiliations
    From Verily Life Sciences and Google Health (Alphabet), South San Francisco, California
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Published:November 06, 2021DOI:https://doi.org/10.1016/j.cardfail.2021.11.002
      Heart failure (HF), already an enormous health problem, is growing rapidly in the United States. The recent development of a host of effective therapies for HF
      • Greene S.J.
      • Butler J.
      • Fonarow G.C.
      Simultaneous or rapid sequence initiation of quadruple medical therapy for heart failure-optimizing therapy with the need for speed.
      could usher in dramatic improvements in outcomes for these patients. But, if we are to use these therapies in ways that maximize benefit, value, and efficiency for both individuals and populations, a substantial reimagining and reorganization of the environments in which care, research, education, and compensation take place is necessary.
      If we think of the organizations, lay persons, and health care professionals who care for patients with HF as an ecosystem, the patient logically resides at its center, with all of the ecosystem's elements focused on improving HF outcomes at both individual and population levels. However, despite frequent rhetorical invocations of “patient centeredness,” the reality of HF care falls far short of this aspiration. The present ecosystem, although made up of well-intentioned, talented people, yields a whole that is less than the sum of its parts—a problem further exacerbated by financial incentives that run counter to the goals of patient-centered care.
      Fixing these issues will require multiple changes to the status quo. First, unless we adopt technologies to automate repetitive tasks and decrease needless bureaucracy, these distractions will continue to obscure the needs of patients and their families. Second, clinician teams and support structures must be reformulated to better serve the well-being of patients, clinicians, carers, and caregivers. Third, payment systems will need to be reformed to align payment with activities that improve health. Fourth and finally, transparent, readily accessible information should be available to all components of the ecosystem, furnishing both immediate operational benefits as well as identifying care approaches and medical products that are both effective and efficient.

      Defining the Problem

      At least 6 million people in the United States have HF according to an older definition of the condition. Yet, nationwide there are only 1200 HF specialists and 33,000 cardiologists, the latter of whom also provide care for the full spectrum of cardiovascular conditions. The new Universal Definition of Heart Failure
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      • Albert N.
      • et al.
      Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure.
      has increased awareness that the relevant HF population is much larger than previously appreciated and also includes persons with underlying structural and functional precursors of HF symptoms (even if they do not yet display those symptoms). An analysis of the National Health and Nutrition Examination Survey database
      • Xanthakis V.
      • Enserro D.M.
      • Larson M.G.
      • Wollert K.C.
      • Januzzi J.L.
      • Levy D.
      • et al.
      Prevalence, neurohormonal correlates, and prognosis of heart failure stages in the community.
      reveals that the prevalence of all levels of HF grows steadily for each decade of life: almost 90% of people aged more than 80 years have some stage of HF; almost 10% have stage C or D disease. Rates of survival in persons with stages A and B are only modestly less than in otherwise healthy people, but those with stage C or D HF have mortality rates that exceed those for most types of cancer.
      The outcomes of Americans with HF are inextricably enmeshed in the overall performance of the U.S. health system. U.S. life expectancy has been decreasing for a decade and the gap relative to other high-income countries is widening.
      • Woolf S.H.
      • Masters R.K.
      • Aron L.Y.
      Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data.
      Before the coronavirus disease 2019 pandemic, U.S. life expectancy was 3.05 years less than the average of peer countries, and contemporary estimates widen this difference to almost 5.0 years. A recent Commonwealth Fund analysis places the United States last in almost every measure of health system function compared with other high-income countries.
      However, this ranking is not due to uniformly poor health system performance. U.S. health outcomes and life expectancy are heavily impacted by social determinants that include race, sex, ethnicity, wealth, and education—and these differences are growing, as can be easily seen in geospatial-temporal visualizations.
      • Dwyer-Lindgren L.
      • Bertozzi-Villa A.
      • Stubbs R.W.
      • Morozoff C.
      • Mackenbach J.P.
      • van Lenthe F.J.
      • et al.
      Inequalities in life expectancy among US counties, 1980 to 2014: temporal trends and key drivers.
      One recent and striking recent trend is a notable decline in the health of people living in rural areas.
      • Cross S.H.
      • Califf R.M.
      • Warraich H.J.
      Rural-urban disparity in mortality in the US From 1999 to 2019.
      In addition, some of these factors are closely correlated with political views in an increasingly polarized society.
      • Curtis L.H.
      • Hoffman M.N.
      • Califf R.M.
      • Hammill B.G.
      Life expectancy and voting patterns in the 2020 U.S. presidential election.
      Although multiple causes are contributing to the devastating decline in Americans’ health, shortage of money (in an absolute sense) is not the primary factor. The U.S. health care system continues to spend enormous amounts (an estimated $3.8T in 2019) relative to other high-income countries despite relatively poor overall outcomes.
      Centers for Medicare and Medicaid Services
      National Health Expenditure Data.
      At a recent health care policy meeting, an engineer (one not primarily focused on health care) put it aptly: “The healthcare business has never been better. The healthcare system is a disaster.”
      A critical culprit in this disconnect between spending and outcomes is the phenomenon of suboptimization.
      • Reilly B.M.
      On suboptimization - Cadillac care at the Mecca.
      In a fragmented system with a surplus of money, each element within the system is incentivized to optimize their own situations without regard to impact on the whole. This fragmentation of mission is mirrored in the sequestration of information, which makes pursuing systemic optimization extremely difficult. For example, if building a new facility causes a retraction in investment in primary care or in HF clinics, the overall outcomes in the system may deteriorate although the function of the new facility is optimized. Even our best health systems have great difficulty constructing holistic views of the outcomes of the people they serve and do not make it a priority because they have little incentive to do so, except when contracted for services through population capitation.
      Amid this fragmentation, our clinical decision-making often lacks high-quality evidence to support it. Although cardiovascular medicine probably has more evidence per unit of decision-making than other specialties, only about 15% of major clinical practice guideline recommendations from the American College of Cardiology/American Heart Association and the European Society of Cardiology are based on high-quality evidence
      • Fanaroff A.C.
      • Califf R.M.
      • Windecker S.
      • Smith Jr., S.C.
      • Lopes R.D.
      Levels of evidence supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018.
      —a proportion that reflects little progress over the preceding decade. Guidelines specific to HF are similarly grounded in lower-quality evidence or expert opinion. The discovery, translation, and marketing arms of the medical products industry are moving much faster than the system that generates the evidence needed to guide the rational use of those products. Assessment of care delivery systems is similarly lagging, as exemplified by the ongoing debate about whether the focus on hospital readmissions in patients with HF may have inadvertently increased the risk of death.
      • Gupta A.
      • Allen L.A.
      • Bhatt D.L.
      • et al.
      Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure.
      ,
      • Khera R.
      • Dharmarajan K.
      • Wang Y.
      • Lin Z.
      • Bernheim S.M.
      • Wang Y.
      • et al.
      Association of the hospital readmissions reduction program with mortality during and after hospitalization for acute myocardial infarction, heart failure, and pneumonia.
      The result of this information deficit is not only fragmentation of care, but also uncertainty about which diagnostic and treatment strategies are best for which people; this in turn leads to an enormous misallocation of money. Recent estimates indicate that 30% of U.S. health care expenditures are wasted,
      • Shrank W.H.
      • Rogstad T.L.
      • Parekh N.
      Waste in the US health care system: estimated costs and potential for savings.
      much of it on bureaucracy intended to control costs in the absence of clear evidence.
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      Administrative simplification and the potential for saving a quarter-trillion dollars in health care.

      Improving the Ecosystem

      The goal of a systematic approach to the whole rather than concentrating on fragmented segments within it is to deliver personalized precision medicine for individuals
      • Califf R.M.
      Future of personalized cardiovascular medicine: JACC state-of-the-art review.
      and precision population health (Fig. 1)
      • Pearson T.A.
      • Califf R.M.
      • Roper R.
      • Engelgau M.M.
      • Khoury M.J.
      • Alcantara C.
      • et al.
      Precision health analytics with predictive analytics and implementation research: JACC state-of-the-art review.
      for people joined together by common demographic, biological, clinical, behavioral, social, and environmental characteristics. Enabling this approach will require a dramatically different strategy for data aggregation and transparency, one that integrates this previously fragmented information into a framework for decision support that can be presented to patients and decision-makers at every level.
      Fig 1
      Fig. 1Optimizing currently available technologies for better patient outcomes. Note the importance of using data to guide the alignment of the ecosystem to produce measurable benefits to patients and families, as well as the clinicians who care for them. This system contrasts with the current ecosystem, which comprises multiple entities that are currently incentivized to optimize their own well-being without taking into account impacts on the rest of the system, particularly with regard to the long-term well-being of patients. EHR, electronic health record; R&D, research and development.
      Few would argue against the precept that the health care system should focus on the well-being of patients and those who help to care for them. This latter category includes family members or friends who support the patient or, in some cases, help the patient make decisions (Fig. 2). For example, women make many of the health care decisions for the men in their lives,
      • Matoff-Stepp S.
      • Applebaum B.
      • Pooler J.
      • Kavanagh E.
      Women as health care decision-makers: implications for health care coverage in the United States.
      and many elderly patients cede primary decision-making to a family member. A variety of unpaid people (“carers” in British terminology)

      National Health Service England. Who is considered a carer? https://www.england.nhs.uk/commissioning/comm-carers/carers/. Accessed September 24, 2021.

      may also be helping the patient, and particularly in the case of elderly patients, caregivers may be paid to provide support in the home.
      Fig 2
      Fig. 2Merging precision medicine and precision public health.
      (A) Data and measurements from sources, including genetics, genomics, integrative physiology, electronic health records, digital phenotypes, and the environment can be analyzed, combined with external data, interpreted in the context of clinical treatment guidelines, and integrated into clinical pathways to support decision-making tailored to the specific needs of patients, caregivers, and clinicians. her, electronic health record. Adapted from: Califf RM. Future of Personalized Cardiovascular Medicine: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018 Dec 25;72(25):3301-3309. doi: 10.1016/j.jacc.2018.09.079. PMID: 30573033.
      (B) Extending the precision medicine paradigm to precision public health. Adapted from: Pearson TA, Califf RM, Roper R, et al. Precision Health Analytics With Predictive Analytics and Implementation Research: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jul 21;76(3):306-320. doi: 10.1016/j.jacc.2020.05.043. PMID: 32674794.
      (C) The data-driven merger of precision medicine and precision public health. Adapted from: Pearson TA, Califf RM, Roper R, et al. Precision Health Analytics With Predictive Analytics and Implementation Research: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jul 21;76(3):306-320. doi: 10.1016/j.jacc.2020.05.043. PMID: 32674794.
      When people have significant illness, relationships with trusted, competent, and reliable clinicians are essential. The term “provider,” denoting someone who submits bills for payment for health care services, has become standard, but in my view, the term “clinician” is preferable.
      • Walsh M.N.
      What's in a name?.
      Clinicians, who by professional definition have a fiduciary responsibility to the patient's well-being, should work with the patient, family, and carers to improve length and quality of life through research and evidence-based, high-quality care. In a similar manner, public health professionals work for the well-being of the community.
      All elements of the ecosystem should judge their success by the degree to which they support the well-being of patients, carers, caregivers, and clinicians in measurable ways. Unfortunately, fragmented systems and information bases encourage segmentation of information to improve the part of the system controlled by the specific entity involved—a problem described by Porter in his initial formulation of the concept of value-based care.
      • Porter M.E.
      A strategy for health care reform–toward a value-based system.
      To build synergy, the system should be tuned to key metrics for individuals and populations: longevity, functional status, and quality of life. These measures should then be shared across the ecosystem. Yet remarkably, these holistic outcomes are not routinely or systematically measured in our health system. In addition, neither patients nor the clinicians who care for them have access to the kind of information that allows them to see their own status in the context of others like them.
      Patient advocacy and voluntary health organizations increasingly play crucial roles not only in advocating for people with a given disease, but also in raising money and contributing significantly to evidence generation and quality assessment of their health care. The connectedness enabled by the digital environment should foster much broader, inclusive, and efficient networking of people with common health concerns, as exemplified by the success of the multiple myeloma, type 1 diabetes, and cystic fibrosis communities.
      • Ramsey B.W.
      • Nepom G.T.
      • Lonial S.
      Academic, foundation, and industry collaboration in finding new therapies.
      The Heart Failure Collaboratory

      The Heart Failure Collaboratory. https://hfcollaboratory.com/. Accessed September 24, 2021.

      represents a promising start on this concept in the domain of HF.
      Although health systems and clinicians have many common interests, there is ample evidence of divergence of priorities.
      • Topol E.
      Why doctors should organize.
      Increasingly, clinicians are employed by health systems or work in large groups contracted with particular health systems. Thus, for any clinical specialty, there is a need for negotiation on the allocation of resources and management approaches, including a formulary, the use of specific devices, and the development of clinical strategies. Clinical research sites are increasingly owned by health systems, but their special role in supporting evidence generation deserves note in light of the growing tendency of health system administrators to act as gatekeepers regarding which research protocols are allowed to enroll participants.
      • Whicher D.M.
      • Miller J.E.
      • Dunham K.M.
      • Joffe S.
      Gatekeepers for pragmatic clinical trials.
      Payment coverage for health services also increasingly determines the choice of diagnostic and therapeutic interventions. Together, private and government payers have a great deal of influence over clinical decisions based on their assessment of the value of services and technology. Clinicians are constrained to choices within the formularies and supply purchasing contracts of the systems that employ them. Because almost all financial transactions flow through the payers, this purchasing power has given rise to large aggregations of proprietary patient data, creating in turn an enormous market for data aggregators hosting deidentified patient data. However, this information is not transparently available to fine-tune health system functions; each of these entities leverages data to optimize its own function. Berwick and Gilfillan
      • Gilfillan R.
      • Berwick D.M.
      Medicare Advantage, direct contracting, and the Medicare ‘money machine,’ part 1: the risk-score game.
      ,
      • Gilfillan R.
      • Berwick D.M.
      Medicare Advantage, direct contracting, and the Medicare ‘money machine,’ part 2: building on the ACO model.
      recently depicted the enormous financial windfalls that accrue to payers when algorithms are gamed without the knowledge of the clinicians who are dealing with day-to-day clinical issues and are inundated by demands to spend precious time coding for billing purposes. Although financial data tend to be highly curated and complete, clinical outcomes data have major gaps and inaccuracies.
      For medical products companies that develop drugs, biologics, devices, and information technology, priorities would be substantially better aligned if profit were closely linked with the development and distribution of products that produce a measurable benefit for patients and carers. Significant societal investment in the National Institutes of Health to distribute funding for discovery science at U.S. universities produces a steady flow of new technology, and the medical products industry is adept at translating science into useful products. However, our clinical trials system is expensive and inefficient,
      • Woodcock J.
      • Araojo R.
      • Thompson T.
      • Puckrein G.A.
      Integrating research into community practice - toward increased diversity in clinical trials.
      and fragmentation makes it difficult to conduct comparative effectiveness research that could determine which interventions are best for which patients and enable rational calculation of value.
      As noted elsewhere in this article, these elements coexist in an environment in which the incentives reward the refinement of each constituent part's own particular mission. Although it might seem that if every group were to optimize its own part of the system, the combined whole would be most efficient, this is not the case—an activity that provides profit to one part of the system is a cost to another and the lack of symmetrical access to information prevents an assessment of value to individual patients or populations.

      Picturing a Highly Functional Ecosystem

      A highly functional ecosystem would produce a different environment in all three major locations of health care: home, clinic, and inpatient facility. The digital environment can provide a communications backbone that supports human services at every level and enables continuous measurement to refine the allocation of people, technologies for assessing disease status and trajectory, and interventions, as discussed elsewhere in this article.
      The majority of health outcomes are determined by daily habits and choices made at home or at work. Fortunately, most people spend only a tiny fraction of their time in a clinic. Accordingly, the assessment of clinical trajectory and educational and feedback systems are best conducted as close to home as possible. In essence, the system's current emphasis on hospitals should be inverted to an emphasis on where people live (“home inversion”) (Fig. 3). In the case of HF, the underlying approaches to prevention (diet, exercise, avoidance of tobacco products and addictive substances, and attention to mental health) need bolstering through better information and feedback. Although some persons with HF are completely self-sufficient and need only periodic clinic visits for adjustment of treatment, the vast majority require support networks. Such networks should include frequent communication through virtual visits and monitoring of health status using sensors. The more passively sensors can collect needed information, the more complete the information will be to inform medical decisions. Education should be tailored to the language, health literacy, and cognitive needs of the patient and should include family and carer education. Combinations of adaptive written and video materials can be viewed at the convenience of the patient, family, and carers. The network should also encompass community health workers who can help with routine health functions and logistics, including optimizing the physical environment. Assistance in adapting to digital technology is especially important for the elderly HF population, as are the articulation and enactment of privacy, security, and commitments to use information to benefit the patient and others with HF.
      Fig 3
      Fig. 3The evolution of care for heart failure (HF) in the modern US health system.
      (A) Previously, HF care in the health system was premised on the assumption that patients make periodic visits to a doctor when they perceive a problem. This approach limited the access that patients with HF had and resulted in long intervals without care or interactions with clinicians.
      (B) The system depicted in (A) evolved to incorporate a medical team comprising multiple clinicians working together with the patient and family, often called a “medical home.” The inclusion of nurse practitioners, physician assistants, and pharmacists, coupled with the integration of primary and specialty care, enabled much more effective interaction in caring for patients with HF.
      (C) Health systems continue to evolve to integrate clinics and services in a geographic region. This approach brings care closer to home and work. It also brings much-need social and logistical support to the patient with HF and their family.
      (D) A digital support system can enable this integrated system to move beyond the neighborhood clinic into home and the workplace so that health workers, patients, and families are supported by ubiquitous decision support that can be accessed from anywhere at any time.
      In HF, adherence to medicines proven to decrease the risk of death and prevent the deterioration of clinical status deserves special mention. We have ample evidence that U.S. prescribing patterns need improvement,
      • Greene S.J.
      • Butler J.
      • Fonarow G.C.
      Simultaneous or rapid sequence initiation of quadruple medical therapy for heart failure-optimizing therapy with the need for speed.
      and the gap between prescription and actual ingestion of pills is well-known. The idea that periodic clinic visits are the best way to improve adherence is obviously flawed. Instead, a combination of behavioral reinforcement and monitoring of status for medication adjustment should be continuously available where people live and work.
      Efforts to increase the national availability of high-speed internet such as those funded through pandemic-related economic stimulus programs should make it possible to equip all homes with sensors and communication systems that can contribute to optimizing outcomes. Finding the right balance of technology and human support, as well as determining which sensors are most effective, will require iterative research that encompasses health outcomes and human factors assessment. A personalized dashboard could be constructed for each individual and support network to integrate available information into useful decision support and “nudges” for agreed-upon behavioral patterns that improve outcomes.
      Although technology now allows us to use aggregate information to improve decision support for individuals and populations, the rules governing this use require considerable attention. The enormous benefits of knowing how other people in similar circumstances have fared, as well as the ability to combine forces to identify new treatment targets and assess proposed interventions must be balanced with essential respect for principles of privacy and confidentiality. A lack of trust in institutions and systems will attenuate benefits unless we reach a new equilibrium regarding the governance and control of health information. The vast majority of people want to share their information for their own good and the benefit of others,

      Pew Trusts. Most Americans want to share and access more digital health data. Issue brief. July 27, 2021. Available at: https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/07/most-americans-want-to-share-and-access-more-digital-health-data. Accessed October 18, 2021.

      but they also want more assurance of safeguards and seek affirmation from the clinicians who care for them.
      The health care team must also be reconfigured, with a workforce of community health workers and nurses providing basic care. A much larger role for primary care and nurse practitioners and physicians assistants in cardiovascular practice will be necessary, given the numbers of patients relative to the number of specialists. Just as patients need expanded access to data organized into understandable dashboards, so too will health care teams need ready access to critical information organized into the clinical workflow. The current overwhelming deluge of information
      • Hilliard R.W.
      • Haskell J.
      • Gardner R.L.
      Are specific elements of electronic health record use associated with clinician burnout more than others?.
      as typified by the “inbox problem” can be ameliorated by inserting algorithms that decrease information to actionable summaries, just as the airline industry did decades ago.
      • Thomas Craig K.J.
      • Willis V.C.
      • Gruen D.
      • Rhee K.
      • Jackson G.P.
      The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout.
      As relevant information, perhaps presented in different levels of detail or formats, is increasingly shared among clinicians, patients, and designated carers, it becomes more likely to guide healthy decisions (Fig. 4). For clinicians, an emphasis on clinical practice guidelines, quality measures, and integrated measures of the “quadruple aim” (better health outcomes, better patient experience, better clinician experience, and lower cost)
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      should be included. The time has come to move from concept to reality in enabling each member of the health care workforce to work at the peak of their professional competence, supported by digital resources that provide useful information and access to consultation as needed.
      Fig 4
      Fig. 4Integrating digital systems to remove administrative burdens and facilitate evidence-based decision-making.
      (A) U.S. clinicians are overwhelmed by compressed time and a steadily growing amount of poorly organized information and interactions, with too many of the latter focused on arcane billing systems.
      (B) Clinicians and patients need a digital system that integrates complex information to provide streamlined decision support, while storing and analyzing the complexity in the background so that clinical interactions can be focused on human need and decision-making rather than tedious, repetitive tasks.
      The clinic should be a place for intense personal interactions between clinicians and patients, with a minimum of perfunctory administrative or clerical work that can be done elsewhere. If the system optimizes the home health setting, most people would come to clinic with necessary bureaucratic information (registration, insurance, etc) already done, basic elements of the clinical course already outlined, and issues identified for review and discussion in clinic. The clinician, no longer required to enter data into a computer during a patient visit, would be freed to focus on patient needs identified before the clinic as well as those that emerge during examination and discussion.
      The hospital should be used when necessary because of the intensity of services required and cost, but decisions about use of the hospital should be based on health calculations, not rewards for optimizing finances. As the information base grows, algorithms can be deployed to predict the need for hospitalization in both individuals and populations so that expensive facilities can be maintained at appropriate levels. The number of highly technical procedures would likely increase in a system that actively identifies people who would benefit rather than depending on inefficient, fragmented referral patterns.
      Evidence generation would be built into such a clinical system, and participation in research would be part of the expected work of a high-quality clinician and health system.
      • Pessoa-Amorim G.
      • Campbell M.
      • Fletcher L.
      • Horby P.
      • Landray M.
      • et al.
      Making trials part of good clinical care: lessons from the RECOVERY trial.
      A digital permissions system would track the patient's preference for research participation in a flexible manner. End-of-life care should likewise be built into the system. As technology for the care of advanced HF continues to improve, patients will have many options for aggressive, high-quality, evidence-based care focused on maintenance of health and quality of life. However, when the time comes, management of de-escalation and comfort are equally important.

      Summary

      Patients with HF are surrounded by an ecosystem comprising multiple people and entities that are suboptimally deployed and not equipped to produce the desired result: better outcomes at a lower cost that also yield a better, more equitable experience for patients, their families, and the clinicians who serve them. It is now technically possible to construct a digital support system that enables patients, families, and clinicians to work with advocacy groups, health systems (and their research sites), medical products companies, and payers—all supported by a readily accessible, transparent base of information needed to optimize outcomes at individual and population levels. Although technology and workflow reform can create significant improvements, the ultimate human limitations on achieving this different state mostly stem from a payment system that paradoxically punishes care that yields the greatest health benefits. Accordingly, payment reform will be critical to a transformed health care system, but transparent, holistic information can enable a realignment of the ecosystem to produce significant incremental progress even under the current system.

      Acknowledgments

      Author disclosures: Dr. Califf reports employment and equity holdings in Verily Life Sciences and Google Health (Alphabet). He serves as a member for the National Academy of Medicine's (NAM) Health Sciences Policy Board and Committee on Security of America's Medical Product Supply Chain, and co-chairs the NAM's Forum on Drug Discovery, Development and Translation. He reports sitting on boards of directors for Cytokinetics, Centessa, Clinetic, Keystone Symposia, the Center for Policy Analysis on Trade and Health (CPATH), the Clinical Research Forum, and One Fifteen. He also reports membership on advisory boards/scientific advisory boards for Verily Life Sciences, Duke Clinical Research Institute, Launch & Scale Speedometer, Think Tank, Mayo Cardiovascular Research Center, Vanderbilt Biomedical, Human Health and Potential International Advisory Council (Singapore), the National Institutes of Health All of Us Research Program, Medicxi, and the Clinical and Translational Science Award Programs for the Medical University of South Carolina and the University of Colorado.

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