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.”
- Community health assessment & improvement programs
- “It’s a perfect story of how the private & public sector can come together to create change.”
- Public health’s reliance on “stale” data
- 3.0’s continued momentum – “People keep talking about it.”
- Her focus on “Building bridges at the national & local level”
- Katrina’s impact on EHR adoption
- Finding your “true north”
- The balance of vulnerability & confidence in leadership
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It’s a perfect story about how the private sector and the public sector, big business and small business, and healthcare and public health can come together to create change in the community; how something as simple as a leash law prevents wellness, but you wouldn’t have known about it if you weren’t on the ground. You couldn’t know that from Washington. You have to know that from being in a community.
I don’t think it’s going to be solved by public health alone, by healthcare alone, by technology alone, or by any other sector. And so I’m thinking through what’s the right way to build the right bridges at the national and local level so we can quickly get the ‘how,’ and find solutions that work for everyone.
It really is about everybody working together to create conditions in which this community can be healthy, and it’s going to be more than a great healthcare system. It’s going to take attention to all of the determinants of health.
Find your true north. Apply the skills you have, and if you don’t have them, try to keep gaining and learning throughout the journey. When you’re not sure, tap back into where you think you can make the most difference and where you feel most passionate.
I knew I was going to have to say to my staff and my stakeholders, ‘I don’t know what that is, but teach me. Help me learn. Tell me what to read, and I will get as smart about it as quickly as I can and see how we can put it all together.’
Gamble: There is so much potential for what could be done and I guess a lot of it does come down to using that data to show improvements and kind of selling these things to take the initiative.
DeSalvo: I’ll give you an example of connected disconnect. A community that was not in our report but I’ve recently learned about is called Nevada, Missouri. Cerner wanted to learn what they as a company could do to advance the community’s health in partnership with them, so they brought together a coalition and provided some seed funding. They set out some shared goals and realized there’s a community that they needed to target the leading causes of death, which are essentially nutritional and physical fitness and tobacco use
They did a lot of the things that are done from the healthcare lens of encouraging people to be more active. In community efforts, they used things like movement trackers to get people to exercise and had competitions. But there was one neighborhood that was not exercising, and they wanted to understand why, and so they had some conversations — in public health, we call those community health improvement and assessment plans (CHA/CHIPs). So they did this naturally — without knowing that’s what it was called — but that’s where the process led them. And they learned that in this community they wanted to exercise, but they didn’t want to go outside and walk, because there were a lot of unleashed dogs in the neighborhood. There wasn’t a leash law, so the community came together and wrote and passed a leash law ordinance, which then freed people to go out and exercise, and now they are.
It’s a perfect story about how the private sector and the public sector, big business and small business, and healthcare and public health can come together to create change in the community; how something as simple as a leash law prevents wellness, but you wouldn’t have known about it if you weren’t on the ground. You couldn’t know that from Washington. You have to know that from being in a community. They solved it themselves. It was a policy problem, but they solved it.
When I asked about the data, I learned that the team was using county health rankings, which public health commonly uses. But that data is about three years out of date. Even the report that came out in 17 — it’s wonderful, we all use it in public health. I’ve certainly used it. But in reality, it’s stale, so we don’t actually know how well they’re doing. And here you have this innovative technology company, Cerner, and all these healthcare folks who are involved, and even they are not using the EHR real-time data from the community, and so I encouraged them to think about other sources of data and see if they could get a little more timely to keep the community energized. I think it’s a beautiful story. I’m excited about all of that, but it reminds us that even when we have the data, sometimes we forget to use it, and we’re still relying on more traditional Public Health measures.
Gamble: Really interesting. Is there something where more people are needed to start carrying the torch for it? I know it’s tricky as to how to increase the need for these types of public health programs.
DeSalvo: You asked me earlier what I have been up to, and this is part of the journey I’m on. We talked about what needs to happen and why, and not it’s ‘how.’ I’m learning from communities how they have done it and how some of them are sustaining it to try to understand what are the undergirdings and principles. I do think it’s more complex than just leash laws; I’m perfectly aware of that. There’s some elements to that though that have to do with civic engagement and the ability to get to ground and have those local structural relationships.
What I’m hearing also is that the ‘how’ has to do with aligning funding streams and policy, and some interesting academic work that has to do with savings. Let’s say you pass a leash law and people exercise more, so their glucose gets better, their A1cs get better, and the clinics get better payments because they get a quality bonus or the ACOs do better in the shared savings — I don’t that’s going to happen in this community, I’m just hypothesizing. But let’s just say you went upstream and you fixed leash law, and that then resulted in the healthcare system having some shared savings. You would think some of those shared savings should accrue to that collective group, the coalition that came up with the idea to pass the leash law in the first place, right?
DeSalvo: It should accrue back to public health — and I’m using a very loose definition of public health — and we don’t have kind of structure right now. I think when you talk about ‘how’ it’s not just the how for the local groups, but it’s also how do we make sure that we have savings in one pocket. In the healthcare system, it accrues to the right pocket, which is further upstream, and I think it’s going to increasingly be for these kinds of coalitions of this new Public Health 3.0 model. So I want to understand the ‘how.’
What surprised me so much in leaving is I thought that when I walked out the door, we’d do the report and it would be done. There would be a new administration and nobody would ever talk about Public Health 3.0 again. But people keep talking about it. I just got invited to another conference where they want me to talk about 3.0 and have some community conversations, and I’m so excited. I was just recently in the Midwest, and I’m going to be doing some more visits. I’m excited that it’s taken on a life of its own, because it’s the right thing. People know this is where we have to go. The Public Health community does, as do many others. We need to figure how, and quickly. I’m thrilled to get to keep trying to solve what I think is the most important challenge that we have in this country.
If anybody wasn’t sure if social ills were causing morbidity and mortality — if it sounds like a vague idea, we only need to look at death from substance use disorders, which, as the headlines have said, are deaths of despair. We’ve reached a point in this country where what’s killing people is hopelessness and lack of economic opportunity. It always has killed people, it’s just been invisible. Now that it’s touching more communities and affecting life expectancy overall in the US, it’s getting an awful lot more of attention.
I couldn’t possibly be more passionate about it, but I don’t think it’s going to be solved by public health alone, by healthcare alone, by technology alone, or by any other sector. And so I’m spending my hours thinking through what’s the right way to build the right bridges at the national and local level so we can quickly get the ‘how,’ and find solutions that work for everyone.
Gamble: Looking at your career path, you’re now focused more on being a student, like you said, but looking at public health as well. It’s really interesting to me the different places your career has taken you. Can you give some thoughts about the importance of staying open to different opportunities, and the direction your career has taken you?
DeSalvo: My career has been a really interesting journey. Some of it was forced, because I had to make my own way by working and paying for my own schooling. To be truly honest, some of it I stumbled on, like Public Health. I don’t think I would have found it if I hadn’t been offered this great opportunity at the State Laboratory Institute, where they paid me this like $10 or $12 an hour — that was a lot of money in the late 80s, and it allowed me to work and go to school. When I was in medical school, I got a National Health Service Corps Scholarship, which meant that I was going to do outpatient care, and it meant I was going to probably stay in an urban environment. And what that also meant was instead of doing academic, global health, public health-type work or being an EIS officer, I went to work at a clinic at Charity Hospital. I had a really quick schooling from patients there about what really mattered to them and what was on their mind in a way that medical school and residency did not give me. These were my patients for seven years, and they told me things they had never told anyone else. I learned a lot from them.
That got me to really thinking about how I could use my skills in a way that would amplify their voice, and it caused me very early in my career to have this intersection of practical public health and practical medicine that joined up with technology, particularly in the aftermath of Katrina. Although I had been chair of the medical records committee at Charity Hospital the first time we were talking about electronic health records, it was way too early to even think about it. It was the 90s, but after Katrina, from necessity we were building clinics from tents and card tables on the streets. We needed to know who we were serving, and I needed population level data. We couldn’t have pieces of paper. And so very quickly, my clinics and others said, ‘we’ve got to get on electronic health records. It just became a necessary part of doing better for the people that we were serving at a population level. And as I shared, that brought me back to public health again, because it really is about everybody working together to create conditions in which this community can be healthy, and it’s going to be more than a great healthcare system. It’s going to take attention to all of the determinants of health.
I definitely have always been open to the experience and journey, and I think I’ve stumbled into things because of what life has brought me. But when there was a fire, I ran to it. I didn’t leave Katrina. I didn’t try to get out of being in National Health Service Corps or being at a clinic. I tried every opportunity when I was at the State Laboratory Institute, because I wanted to learn as much as I could, thinking it might be the only time I experience those things, but also because I wanted to be of use if I could. I think that’s a theme in my life.
I don’t entirely know what’s next. I’m unemployed. Come noon Eastern Time on January 20, I no longer had a job. And it’s the first time in my career that I’ve had to ask myself — absent a disaster, an expected change of timing in my medical career, a new mayor getting elected and needing help in Public Health, or being called to service in Washington — where do you want to press your shoulder? How do you want to make a difference in the world? I think the journey is that I want to learn right now so I can make sure that I’m prepared when that knock happens at the door.
The most important thing I could say is find your true north — I know where mine is. Apply the skills you have, and if you don’t have them, try to keep gaining and learning throughout the journey. When you’re not sure, tap back into where you think you can make the most difference with the skills that you’re best at and where you feel most passionate. And don’t prefix, ‘I’ve got to have this job by a certain date.’ I think that’s a missed opportunity to make the most difference, and to get the most out of the opportunities that come your way in life.
Gamble: That’s good advice. With a lot of leadership in healthcare and health IT, we’re seeing more variety in the backgrounds people come from, and I think that will only benefit the industry going forward to have all these different perspectives.
DeSalvo: Right. You talked about openness; one of the things that I’m not afraid to do is say, ‘I don’t know,’ and I think people need to be comfortable with that. You don’t have to be an expert in everything.
On the other hand, I think sometimes — and maybe women are more prone to this — we think that because we don’t know or we’re not experienced, we shouldn’t try something new, or make a shift. I think there are core foundational leadership and management and intellectual curiosity and emotional maturity skills that you bring to any situation, and they can be applied. If you’re good with complexity, that’s something that’s similar in all kinds of situations, and so I think it’s having the confidence to know you can take experiences that you’ve had in life and apply them. If something new comes, be open to trying it, even if it’s a little bit out of your comfort zone.
When I was Health Commissioner, I stepped right into the public health leadership. I knew I was going to have to say to my staff and my stakeholders, ‘I don’t know what that is, but teach me. Help me learn. Tell me what to read, and I will get as smart about it as quickly as I can and see how we can put it all together.’ So there’s a vulnerability part to it, but there’s also a confidence, and it’s a very hard thing to balance. I just encourage people to always be thinking of that balance, and being open to new opportunities that come their way.
Gamble: That’s a really good point. We’ve seen the statistics with men and women; if they’re not 100 percent sure they can do a job, men are so much more likely to go for it. I think sometimes all of us, especially women, need a push to get in there to try it and to see how you can grow, rather than just saying, I’m not ready.
DeSalvo: I think that’s true, and I certainly saw it in my junior faculty when I would hire a cohort of equally qualified men and women. You could throw the male faculty on the teaching wards and they would act with all due bravado like they knew everything, and of course they didn’t. And the stereotype with the new junior female faculty was they’d say, ‘I’m not really sure, let’s go look that up together.’ And the students didn’t always react great to that, to be frank with you, but I did notice over the course of my 10 years that the world began to be more accepting of this balance of confidence and vulnerability. I saw that women became more confident and men became more appropriately vulnerable, and I think that’s a healthy thing, because if you want to get into patient safety, it’s healthy to make sure that if you don’t know, you’re willing to say it. I hope the world continues to evolve and people are more comfortable with that reflection just as much as they are with the confidence.
Gamble: Great. Well, I think that covers what I wanted to talk about. Thank you so much for your time. This has been so interesting, and I really think it’s going to be a great perspective for our readers.
DeSalvo: It was my pleasure and I really enjoyed talking with you.
Gamble: Thanks again and I hope to meet you at some point in the future.
DeSalvo: That would be great.