Dr. Karen DeSalvo has completed her leg of the federal government's marathon program to promote the adoption and meaningful use of health information technology. And she managed to finish without tripping over some of the biggest hurdles in the initiative's 12-year history.
DeSalvo, who finished her 30-month stint Aug. 12, was the fifth and longest-serving head of the Office of the National Coordinator for Health Information Technology at HHS.
DeSalvo said she'll remain in her position as acting assistant secretary of health at HHS until the Obama administration ends in early 2017. It's a post she's held since the fall of 2014, concurrently with the ONC job.
DeSalvo handed off ONC leadership to Dr. Vindell Washington, previously the agency's principal deputy national coordinator, who DeSalvo described as “a great leader” who will “be able to take the mantle and move forward the agenda we have laid out.”
Most healthcare IT experts give DeSalvo high marks for performing well under trying circumstances.
“You have to realize where in the race she was handed the baton,” to fairly evaluate DeSalvo's legacy, said Russell Branzell, president and CEO of the College of Healthcare Information Management Executives. CHIME is a professional association of hospital and health system CIOs.
During the DeSalvo years at ONC, CHIME both praised and criticized the government's performance in health IT, but, often due to circumstances beyond DeSalvo's control, it was an unenviable position from the start.
By the time DeSalvo had taken office on Jan. 12, 2014, the gush of federal money into initiatives led or coordinated by the ONC was ending.
The programs, authorized under the 2009 American Recovery and Reinvestment Act, had been devised under her ONC predecessor Dr. David Blumenthal (2009-11) and implemented by his successor, Dr. Farzad Mostashari (2011-13).
They included initiatives in workforce education and development, establishing a national health IT extension service and a Beacon Communities program and funding state-based efforts to promote health information exchange. All were financed by $2 billion placed directly under ONC's stewardship. By 2014, most of those funds were either spent or committed.
In addition, by the end of 2014, $31.8 billion—91% of total EHR incentives paid out thus far—had been disbursed.
Meanwhile, during DeSalvo's first year, the clock started on penalties—cuts in federal reimbursements—for those Medicare providers not in compliance with the program's meaningful use objectives, which were scheduled to be ratcheted up to more stringent Stage 2 levels but whose implementations were delayed.
“Dr. DeSalvo's era included important meaningful use Stage 2 refinements that reflected the reality of hospital and clinician workflow and technology capabilities,” said Dr. John Halamka, CIO of CareGroup, Boston, and a member of several federally chartered advisory committees to the ONC. “Time frames were extended and thresholds reduced to enable culture change, which takes longer than most assume."
To top it off, many participants in the EHR incentive payment program were doing the math and deciding there wasn't enough financial upside to warrant the hassle of achieving meaningful use. By then, clinicians also were questioning whether meeting the government's meaningful-use targets would yield patient benefits commensurate with their efforts to achieve them.
CHIME, the American Medical Association and various medical specialty and state medical societies, the Medical Group Management Association and other provider groups, frequently pushed back on program timelines and criteria, putting both the ONC and the CMS in their crosshairs.
Added to that burden, Branzell said, was the Obama administration's payment reform initiatives that require interoperability of health IT systems to enhance communication and data sharing between not only hospitals and office-based practices but also home health, behavioral health and long term care providers, which were not recipients of EHR incentive payments.
To her credit, Branzell said, DeSalvo didn't hammer providers with the penalty.
“She really did try to reboot the system,” he said, which included “trying to get focused on the things that were really important and doing what the administration wanted to do to move to a new reimbursement model.
“We're not there yet” with closing the gaps in information sharing between these previously siloed organizations, “but we're farther down the road,” Branzell said.
Several IT leaders praised DeSalvo for her listening skills.
“She spent an amazing amount of time with the constituency, IT people, administrators, physicians, nurses—to hear what went well in the past and to focus on what people were complaining most about,” Branzell said.
“She was the leader that listened and heard what people said and tried to push the administration to get off of its top-down approach,” said Dr. David Brailer, CEO of Health Evolution Partners, a San Francisco-based private equity firm specializing in healthcare technology companies. Brailer was the first ONC leader, serving from 2004 to 2006.
Brailer said DeSalvo adroitly handled the issue of healthcare “information blocking” in 2015 with the right mix of threat and diplomacy that produced a swift round of announced fee cuts for interface development and information exchange by some of the nation's largest health IT vendors.
Brailer also said DeSalvo guided the agency past a “pivot point,” shifting the ONC from an agency awarding grants and running programs to a future not yet defined. That definition won't be complete until well into the next administration, he said, “but she began the dialog.”
To Beth Friedman, founder of healthcare public relations and marketing Agency Ten22, Cumming, Ga., a healthcare IT veteran and a member of HIT Chicks, an informal support group for women in health IT, DeSalvo served as a role model.
“When I started in healthcare,” in medical records at a Catholic hospital in 1981, “the only women in leadership in healthcare were the nuns.”
DeSalvo was “a strong proponent for women in health IT roles,” Friedman said. “It was meaningful to me to see a woman in that leadership position at ONC. She was the first one, and it was good to see a woman put in that position. It was motivating.”
Several industry experts, including DeSalvo herself, foresee her greatest hit at ONC will prove to be the agency's foundational work promoting interoperability, and particularly the use of application programming interfaces as a means to connect both providers and patients to patient health information.
Halamka said that under DeSalvo's leadership, “the evolution from complex, hard-to-use standards to simpler, agile standards began and we're likely to see a much richer ecosystem of healthcare information sharing in the next era."
Indeed, DeSalvo said she hopes her tenure will be recalled as “one in which we freed data for individuals and to work on an approach that put consumers first and saw that we were creating a world in which the learning health system supported them, not just the health system.”