When Karen DeSalvo was first asked to interview for the role of National Coordinator for Health IT, she declined, thinking it wasn’t the right fit. After, she lacked the technology expertise that other candidates could offer. What she did have, however, was experience as both a physician and a leader, having spent the prior three years as Commissioner of Health for the City of New Orleans. And so DeSalvo followed her own advice and ran toward the opportunity to make a difference. In this interview, she talks about what she enjoyed most about her role with HHS, why she has become a crusader for public health, what she’s doing now (and hopes to do next), and why it’s critical to “find your true north.”
- Call for “one voice” to represent cybersecurity at HHS
- Action items for CIOs — “Most people don’t even have a baseline.”
- No. 1 issue in HHS Wall of Shame
- Beyond HIPAA risk assessments — “That’s a small piece of the bigger security puzzle”
- Lessons learned from the process
- “Everyone sees the importance of protecting patients.”
- Next steps for HHS
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I’d go from one end at HHS with the younger innovators, then go to the Office of the Secretary, where we still used paper for clearance. It was a really nice blend. From an operational standpoint, I was able to take some of the more innovative, modern approaches and techniques that were happening in ONC and apply them to OAS, and vice versa.
I just kept going further upstream; the more I learned about the barriers to wellness for my patients, the more I wanted to be a part of public health opportunities to create the conditions in which people could be healthy.
Health is more than healthcare, and if we’re going to really advance health in this country, we’re going to have do that together, and we’re going to have to do it in such a way that we aren’t just fixing people when they arrive in the healthcare system, but doing everything we can to keep them well.
Public Health is at risk of becoming obsolete at the local level if it doesn’t learn to modernize and step out of some of the traditional ways that it’s been practicing.
You cannot make decisions on data that is three years old. You need timely, granular, actionable information to keep everybody in the game and to know that what you’re doing is actually improving the Public Health. That will be a reinforcing cycle, and I think that the Health IT and the healthcare world has such a huge role to play.
Gamble: You were also Acting Assistant Secretary for Health, so I wanted to ask, did those two roles dovetail pretty well or was it a little tricky in balancing the two?
It made for interesting days. If I went from one team to the next team — which I did when my offices were on the same floor — I’d go from one end at HHS with the younger innovators, then go to the Office of the Secretary, where we still used paper for clearance. It was a really nice blend. From an operational standpoint, I was able to take some of the more innovative, modern approaches and techniques that were happening in ONC and apply them to OAS, and vice versa. The teams themselves were already working together on content, particularly in areas like vaccines and family planning, and they continued to work together in other ways such as the dietary guidelines for Americans. So there was a lot of cross pollination already, and I would like to think I helped strengthen that and build stronger bridges.
I did borrow staff from one to lend to the other to facilitate data sharing. I tried to make sure we were taking the best of the best and applying not only talent and the knowledge, but some of the processes to both environments.
It’s definitely worth mentioning something that a lot of people don’t know, which is that the Office of the National Coordinator was created by a group of folks who are Public Health informaticists. And so the origins of ONC are in Public Health. That was beautiful for me to always remember that there’s a Public Health good embedded in everything ONC is supposed to do. It helped inspire a lot of the thinking for Public Health folks, and I really hope that continues. I think it will. There’s a preparedness Task Force that they’ve started, which something we had done some dabbling in when I was there. I think the timing is right for the world to want to apply the public good of all of data — not just to healthcare and science, but to the improvement of Public Health.
DeSalvo: I’d love to talk about it. Starting from when I was pretty young, somewhere around 13 or 14, I knew I wanted to be a doctor. I had no idea what doctors really did. I didn’t know any doctors. I really didn’t understand what it was, but I had this idealistic notion from watching television that it looked like a way to apply science to helping people. Those are two things that I like. And as I was going through my education, I worked my way through college and ended up getting a job at the State Laboratory Institute in Massachusetts. I worked for the Department of Public Health and had the amazing opportunity to be exposed to public health there and to work in a laboratory and then in policy and public health education at a very broad level, including the focus on HIV when it was a fairly new epidemic.
So I had this really rich broad experience in public health that led me to want to study it further and to think about having that as part of my work going forward. And so when I went to med school, I got an MD and a Masters in Public Health at the same time. It probably was no surprise that it was ingrained in my thinking, and I was doing a lot of health services research and teaching that was related to public health.
But it wasn’t really until Hurricane Katrina that I began to actually do more applying of public health in community. There were a series of iterations that led me on a pathway of understanding the determinants of health. Whereas I had been thinking that if we could improve the healthcare system, we would improve health, I got better educated by my patients, by the community and the literature, and by brilliant people from around the country and the world about the other determinants of health, including the social determinants. I wanted to understand how to push and drive those to create better health for people, and do it at a population level. It’s one thing to be able to educate somebody about the right ways to eat and be active if they have diabetes and it’s part of their care plan. It’s another thing to have the bandwidth to educate them about going to YMCA or how to exercise. If they live in a neighborhood that’s riddled with violence or stray dogs, it’s hard for them to get out and exercise. If they don’t have access to healthy food, it’s hard for them to eat well.
And so I just kept going further upstream; the more I learned about the barriers to wellness for my patients, the more I wanted to be a part of public health opportunities to create the conditions in which people could be healthy, and to think about how public health law and institutional policy — both big P and little P — can decide where buses go and don’t go and which parks and playgrounds are safe and healthy.
I couldn’t make the right decisions for my community based on data that was three years old, especially in this community of New Orleans where every month the population was changing because we were recovering from a catastrophe. I had a lot of new folks coming into the community, and so something that happened in 2009 was barely reflective of my community in 2011, for example.
I think that for me, public health grew very naturally. I had some work and some training and research exposure, but it really for me was just a practical place that I landed wanting to improve the health of my community. I kept finding that the obvious thing that we needed — certainly in New Orleans and I believe across the country — is for strong, local, public health to be a bridge and to bring the various provider systems and technology purveyors and the business community and faith-based leaders and others to the table to develop shared goals to improve health. I had wonderful experience as health commissioner here working on lighter things, like physical activity and nutritional fitness in our community, and on heavier things like murder and how civil society works together, or sometimes doesn’t. I saw every day what the literature tells us, which is that health is more than healthcare, and if we’re going to really advance health in this country, we’re going to have do that together, and we’re going to have to do it in such a way that we aren’t just fixing people when they arrive in the healthcare system, but doing everything we can to keep them well so they can have all the quality of life.
As health commissioner working in New Orleans, it was really broad. As a health commissioner you touch everything. And going deep into technology was a big shift for my brain, but something that I really wanted to do. As I got there, I began to love it, but I also began to realize how critical health information technology is to the future success of everything that we wanted to do to improve health. If I could support building more bridges between Health IT and not just Public Health, but other sectors, that I think we have a much better chance at improving health.
DeSalvo: The ‘how’ is the hard part. I think the ‘what’ was when I had the chance to think some more about public health and my role as Secretary for Health. When I was with HHS, I had two and a half jobs for a while. I was also co-leading the delivery system reform work, which appropriately took up quite a lot of time. But I was itching to get further upstream to think about the broader determinants of health, and when the delivery system reform work was cooking along really well, I was able to step back. It gave me some time to see what I’d like to think about while I have this chance, and it was how is public health reinventing itself in the new world that’s emerged, as the epidemiology has changed and the root causes of morbidity and mortality aren’t communicable disease/infectious disease. They’re not just chronic disease like heart disease, but it’s increasingly the social ills and challenges our society faces. How are they addressing that and how are they leveraging data and relationships or partnerships? How are they measuring and marking success in a modern world, and how are they paying for it? How are they funding themselves?
That’s what we we’re doing in New Orleans, so I had first-hand experience of reinventing our health department. We broke it down and rebuilt it in the framework of an accredited health department — a more modernized version, but in that journey, we’re really focused on the big social determinants. We did that with partners and used funding we got from mostly foundations because it was fairly flexible, but we’re starting to think about how to take blended and braided funds from the Department of Justice and SAMHSA through grant programs that aim to address challenges around violence in our community, as well as mental health and behavioral health disorders.
I was beginning more of the finance work when I went to HHS in 2014, and I wanted to learn from some other communities. So we set out a framework describing what Public Health 3.0 was, how communities were beginning to pioneer in five areas: leadership (and workforce, which is more meta-leadership); using big data and community level metrics; stepping up their accountability and infrastructure game, becoming accredited and being more transparent with others about their performance; partnerships where they were reaching out not just to healthcare, but to business and technology and maybe some more unusual partners; and finally, how they are leveraging funding and what were the new sustainability models.
We spotlight some great communities that are doing exciting work. I was just recently at a regional meeting in Kansas, and before that I was in Kentucky. I hear all the time about local and state health departments that are doing incredibly innovative work to reinvent what Public Health is, to modernize it and make it not something that is as siloed and under the radar, but really a part of the community conversation. We call for there to be a chief health strategist in every community, for enhanced funding for Public Health, and for data to be unlocked and available, and also actionable, and for there to be accredited health departments serving every community in this country. It’s the first time HHS has really stood up and said, it’s time for Public Health to be accredited by an external body.
Finally, the most disruptive thing I saw was that it wasn’t just Public Health working by itself in communities; they were forming new organizations that share services with other public health departments and share money and governance and data with the business community and healthcare community and payers. So they’re restructuring the way they do their work every day, which is giving access to more resources for all who are on the frontline.
The disruptive part is why the ‘how’ part it’s difficult. I got as much done as I could before I left. I put a few wedges in door in the funding, accreditation, and data space. There’s an intense amount of support the Feds need to give from just a policy standpoint. But Public Health is frankly at risk of becoming obsolete at the local level if it doesn’t learn to modernize and step out of some of the traditional ways that it’s been practicing. There’s enough successful models of local Public Health that we shouldn’t question whether it can happen.
They’ve shared with us what we need to do. It’s all in the report. There’s some action happening to make those changes, but I think at the end of the day, the ‘how’ is going to come from more demonstrations on the frontlines and from states deciding the they’re going to change the way that they make resources available for local communities to work together.
It gets a little policy-wonky, but it has to do with things like how do you better align programs like SNAP and private pay? How do you better align housing money from the private sector and the public sector to see that you have access to affordable housing? So it’s not just the government. It’s about local communities showing what needs to happen, identifying where there are policy — both big P and little P — barriers, and then the state and the federal governments being willing and able to get out of the way.
It is such an exciting time for that, right? The new administration and Congress want states and local communities to solve their own challenges, but they can’t always do it unless they have the right resources, and unless the funding is well lined up. And going back to the health IT leader’s role, they’ve got to have data. You cannot make decisions on data that is three years old, which Public Health tries to do all too often. You need more timely, granular, actionable information to keep everybody in the game and to know that what you’re doing is actually improving the Public Health. That will be a reinforcing cycle, and I think that the Health IT and the healthcare world has such a huge role to play, as do retailers. But healthcare has a pretty rich trove and I think could really help modernize Public Health quite quickly if they do a better job of sharing.