Karen DeSalvo, MD, took the helm at the Office of the National Coordinator for Health Information Technology on Jan. 13. Though she says she is still in "the listening phase," it would be incorrect to say she is still getting her bearings. Whether today as ONC chief, or as a medical resident in the 90s, or as a practicing physician at Charity Hospital in New Orleans, or as vice dean for community affairs and health policy at Tulane University School of Medicine, or as New Orleans’ health commissioner, DeSalvo has kept a steady course on doing everything she could to help improve care.
The story has already been told several times. She grew up poor in Austin, Texas. She and her two sisters were raised by a single mother.
"I experienced healthcare through the public system, in public clinics that were not as a consumer-friendly as we would like," DeSalvo told the Health IT Policy Committee during her second day on the job.
It’s one of the experiences that guides her today as she takes on the ONC mantle to continue her pursuit for better care.
DeSalvo talked with Healthcare IT News Editor Bernie Monegain about the challenges ahead.
[See also: ONC chief's early years inform her work.]
Q: What in your previous experience will inform your work at the ONC?
A: It’s my experience as a patient and as a doctor, but also in that caregiver setting that informs a great deal of my work. I always try to think about what are the end results of any kind of policy or administrative decision we might make on that special moment of encounter between the doctor or health professional and the patient. Which is complex enough and we want to make sure we’re enabling it for them.
My experience professionally has spanned from direct service through education, through administration, through public health policy work. And, I also have experience at working in and around a variety of disasters that make you think about the importance of preparedness and resilient systems, not just for disaster, but everyday. So, I guess I bring a lot to this table here as the kind of experiences I’ve had in all of those roles.
One of the common themes is always that to make good decisions for that person or population that you’re serving, you need good information that’s not just data that actually can inform your decision-making at the right time. That’s why I think there’s so much promise and power in health information technology. Done right, it’s the way the patient’s voice and the clinical decision making, the clinical findings can either help improve health or protect health, as the case may be, in public or population health, but also really begin to move us as a country to a place where making the informed and best decision and non-redundant decision is the easiest decision for everybody involved, including the patient.
Q: What in particular did you learn from the disasters?
A: The epiphany for me in Katrina was the realization that most patients were in a system, or a health sector, that was paper-based, and that meant that I, for example, as a doctor, would have a systematic way of identifying whether my patients were going to need care urgently. So, they were on a prescribed regimen for something like a blood thinner that required close monitoring and follow-up. In that setting, your brain begins to remember the names of a host of patients.
I’m one doctor. Multiply that across a lot of doctors. You do move to try to remember everybody, what medication they were on that’s not in front of you, but you know, you’re not going to have a comprehensive ability to identify everybody in the community – certainly not for every physician. You may have thousands of patients.
The epiphany was, 'wow, it would be so beneficial if this information were available in a structured format that was accessible and could help us find those in need quickly and get them that care by transferring that information to community care providers.'
I have a picture that I show in some of the talks that I give that I took in St. Bernard Parish, which is south of New Orleans, of a doctor’s office that was destroyed by flooding and storm waters. The doctor had spray-painted on the outside of the building their name and phone number. It said, 'Dr. Billings patients, please call,' and it showed the phone number for the doctor. That exemplifies for me this non-systematic way that every doctor was trying to find every one of their patients who might need them, and this particular doctor resorted to spray-painting his name on outside a building. In America, even in 2005, there had to be a better way.
So it molded my thinking about the importance in health IT being embedded in all the work we did in care transformation, in payment reform and financing reform and our thinking around quality, that there had to be that underpinning – again, not just for disasters, but that everyday the system would help identify those patients for the doctor, to fill that gap and for better screening.
Q: What is your first order of business at ONC?
A: I’m not going to be able to respond with one thing. We have some immediate responsibilities that are related to the HITECH Act – important work that we are engaged with everyday all the time. That’s around meaningful use and the work that happens in partnership with CMS. It also involves the support of our clinics on the ground. Also, there’s work we have supporting adoption, and then beyond adoption, the use of electronic health records through our meaningful use certification program. What I guess we’re putting at the forefront of every conversation right now is how HIT and all of its iterations, including information exchange, is a clinical supporter of healthcare delivery reform. So, in other words, not just to move ourselves beyond the responsibility of thinking about having the right system in the right hands, but then making sure we’re doing the right things in the care system and creating the right information to help with decision support.
Q: Part of that is interoperability. Why is it taking so long to make that happen?
A: I’m going to tell you back what I’m hearing from stakeholders. I’m in a listening phase about all of this. What I’m hearing is that there are some technical aspects to it that are real and important. There have to be some standards to allow for that interoperability to occur. There are some business issues that relate to not just the business model, but to the marketplace itself and providers, which are themselves right now undergoing a lot of evolution and change because of quality and payment reform. It’s a dynamic place. I think from a business case standpoint, there’s been work to do to get some of that appreciation.
I think there are some issues that we have to think about that come from consumers about seeing that that information follows them across the care continuum and that it is private and secure, but also that it is able to incorporate their own human values. So, there’s a layer of complexity around consumer wishes that I think is valid and reasonable.
I think the last piece that I’m hearing about is that we’ll have to have a conversation around how we insure that there is enough equity in the information network so that everybody is in – meaning it’s not just something available to the wealthier providers or payers or patients, but is a thing that is available to save everyone’s life, save costs across the board and improve health. So, there’s a larger conversation that that I’m starting to learn about, hear about. I’m asking a lot of questions about it because I really want to understand it, because to me it is actually a really critical part of the important work of improving the value of care. And, to me, that is the central question of our generation.
Q: Do you think the Meaningful Use EHR Incentive Program is accomplishing what it is meant to do?
A: I think meaningful use is accomplishing what it’s meant to do in a couple of ways. One, it has led to increased adoption of electronic health records. It is driving and supporting adoption of more advanced technology that allow for things that matter to folks like interoperability and the ability to have better decision support at the point of care for not just providers, but for consumers. It’s also helping HHS to think broadly about how we work together across agencies to improve health because it’s a multi-agency effort. So, it’s really helping us to think about how we all define quality, how we have available quality information that’s real-time enough that it can actually inform things like quality improvement, but also value-based payments.
[See also: Health leaders react to ONC's new chief.]
Q: Of all the pressing matters that face the healthcare IT industry – EHR uptake, interoperability, data exchange, privacy and security, for example – which one presents the greatest challenge and why?
A: They’re all completely interrelated. That, I think, is one of the really important roles of ONC and the national coordinator for health information technology – is to be that convener who can lead the conversation so that we keep everything in sync and ensure that we’re getting to goal, which is, again, that better care, lower cost, better health – and using IT along the way. All those elements that you list are important, and I’d add usability, because that’s right there in front of you – for the clinicians and patients.
Q: Have you always used an electronic health record?
A: I’m 48 years old. I used paper. I’m old enough and Tulane is old enough that when I was a resident still, in the nineties, to get your lab results, you had to go upstairs and pull them off a little slip of paper that was in a wooden box in the lab area. They would throw it in a box with your name on it, and you’d go pull them out of this big wooden mailbox. That’s how you started rounds; you’d give them to your interns or students. That was also during an era where you did your own lab studies nights and weekends. So now it’s on your smart phone. It’s so phenomenal to see. When I talk to med students about health information technology and patient generated data, adoption and all that, I explain to them I’m from an era where we did what we did and how far technology has come in a relatively short period of time. Just begin to imagine, if you can – and I guess that’s what the dreamers of the world do for us – what we could do, if we really put our minds to it and put aside anything that’s not focused on improving patient care and outcomes, which we’re all in this for, it’s really almost an impossibility of how advanced technology could become.