Q&A: Karen DeSalvo on Meaningful Use, ONC Reorg

In an in-depth interview, National Coordinator for Health Information Karen DeSalvo, MD, discusses meaningful use, EHR usability, innovation, and the recently announced restructuring at the Office of National Coordinator. Part one of two.

At the annual Health Datapalooza in Washington D.C., last week, I spoke with Karen B. DeSalvo, MD, MPH, MSc, National Coordinator for Health Information Technology, one-on-one for the first time.

DeSalvo, who was appointed to the ONC position in December, has a record of public service. She served as Health Commissioner for the City of New Orleans and as a senior health policy advisor to the mayor. After Hurricane Katrina in 2005, she led the creation of a neighborhood-based primary care and mental health services model for underserved individuals.

In the first part of our conversation, we covered everything from ONC's restructuring to what to do about buggy software that could threaten patient safety.

HLM: The proposed rule on meaningful use Stage 2 – what was the thinking behind that, how do you help large healthcare providers make sense of where Stage 2 is going from here?

DeSalvo: Meaningful use as a program has a large policy goal of advancing adoption of electronic health records in the clinical environment, and seeing that they were not just set up but used in ways that could improve patient care and outcomes.

The reason I start with all that is because we should keep in mind that the goal is to push as many folks forward as possible, and help offset the cost of the installation and use of electronic health records in the clinical environment. That's the incentive payments.

Those who are in the meaningful use program think meaningful use Stage 1 is very successful, [with] huge adoption across the country, incredibly rapidly.

For Stage 2, as you know, we have recently done a couple of things. One is [we've] clarified a hardship exemption that existed in the law, so that if providers, for whatever reason, wanted to claim hardship, it would be clear what those options might be.

But then we just put out a notice of proposed rulemaking that we seek comment on, which gives some flexibility that we think might help providers. [Providers] who, through no fault of their own, have been unable to install a 2014-edition product, and see that it is part of their workflow, so all of the patches— everything's installed.

That's what we're asking for some feedback on.

There are some small and rural critical access providers who sometimes are at the end of the queue for an install, or perhaps it takes them longer to change the workflows, etc., so we want to make sure that the original policy goal of bringing as many providers along, that any issues with 2014-certified product availability etc. don't get in the way of that.

We want to understand if the flexibility in that makes sense, and we do want people to know that we do want to progress, and that there is an opportunity for this country to continue pressing forward.

Some of the things in Stage 2, for example, around transitions of care and the opportunity for patients to be a part of the access to the data, are an important policy goal, and this is something we want to see advance.

HLM: At Datapalooza, Atul Gawande was talking about the number of faxes he still processes a week. That's the issue. Some physicians don't want to work that hard on modernization. On the other hand, the current status quo is unacceptable.

DeSalvo: And most providers, once converted to an EHR, want to stay on it. It's a much better way to get your data, especially if they have systems that are Web-based. They can access [data] after hours when they are on call or they are offsite.

It's really enabling, but you're touching on what is the important next chapter of work for everyone, whether it's ONC's thinking, CMS, vendors, [or] the innovation community. How do we make the systems such that they're enabling and supporting workflow and better workflow, instead of just having the fax system become electronic.

There are better ways that it can be done—ways to present data that actually can really support care. That is the exciting next chapter, because the technology is allowing for it more now that the data is in the EHR.

We want it to come out in such a way that it is more user-friendly, that it enhances safety, enhances quality, and makes the workflow really something's that better, more efficient.

HLM: Your predecessor kicked off a big conversation about usability, but I imagine that really continues under your watch. How will usability of EHRs get better, soon?

DeSalvo: There are a couple of things working in our favor. One is there's a lot of pull about the data, meaning that whether it's consumers who want to understand their own health, or whether it is innovators who want data to come out in such a way that they can produce applications that are interesting and useful to consumers or providers or others.

There are also technological advances—the potential of technology like FHIR to really make it lighter, faster, smarter, cheaper, to take the heavy data and turn it into something that is useful. So the technology and the pull—the desire for it—is changing.

The reality also is that because we have been capturing all this standard data for some time, people know it's there, and so we have this responsibility to have it surface in such a way that it really makes care better and safer.

It is a priority for me, because it's a reality that to keep this momentum, we have to show that the technology isn't just replicating paper charts in an electronic fashion.

It's like your phone, that we used to think was a thing that you dialed to call someone else, and now we realize is a way that measures sleep. It's a new way of thinking.

The innovators and technology are really ready for that. Our goal with our certification programs and our regulations is to make sure we're setting the right floor for standards, but not getting in the way of innovation.

HLM: You held a series of listening sessions last month. What did you learn about meaningful use?

DeSalvo: What we're hearing is that people want to see that we're advancing with meaningful use, meaning that it's not going to be a static program, but that we are going to continue to progress.

This is particularly important for consumers and public health, that the opportunity to enhance individual care and population-level care continues. A lot of comment and interest is in the space of interoperability and seeing that we're standardizing standards to allow for the systems to talk to each other and for the data to follow patients across the continuum.

There's concern about the complexity and making sure that the rule meets the technology ability, so that when a rule is published, technology can do the things that were asked of it.

There's desire to simplify some of the sets of expectations, maybe quality for example… so that instead of there being a defined line between success and failure, there's incremental improvement recognized for providers, so we heard some interesting ideas, which we're taking in and listening to.

HLM: How does your newly announced ONC restructuring work? I heard the phrase that you were moving from healthcare to health. What is this restructuring about, and how does that relate to that concept?

DeSalvo: A couple things. First of all, the timing is important for us to think about a more efficient organization. We're reshaping based upon resources available and thinking about how we can be more efficient and effective with the resources we have, so that pivot into the next decade is part of this new chapter.

The second thing is, we're really focused and tuned into the notion that health IT is more than electronic health records, and more than meaningful use. It is about building a robust health IT infrastructure that can support again not just healthcare, but health.

What does that mean? That means for our country, we have a national priority of better health, lower cost, better care, that three-part aim. To get there, it's much more than just the healthcare system. It's a part of it, but we want to build the right kind of robust health IT infrastructure that is inclusive beyond meaningful use, so beyond providers that are part of the meaningful use program – that's one piece.

So behavioral health, long-term post-acute care—it's expanding that. And then expanding the platform of interoperability, such that there is a chance for data, whether it's big data like genomics… all the way to patient-generated outcomes, to be a part of that overall thinking, but then a whole host of other sources.

For example, [data may include] information about those aging populations, and social services programs that might serve them, or for populations for feeding programs, like WIC and SNAP, to be included, so this is a broader view on the kinds of data that might come in, and the opportunity to put it to good use.

HLM: And part of the restructuring is a move towards care transformations? I guess you now have an office of chief scientist. Why did you do those things?

DeSalvo: We've had a few name changes, putting some structure on work we were doing, so care transformation is a great example. We have been partnering with CMS through both the innovation portfolio, the Medicare work, and Medicaid work, to help drive the movement towards value-based purchasing, price transparency, quality measurement.

[These are] things that can enable and support payment and other reform, but at the same time, this is also an opportunity for technology to in and of itself transform care, so an obvious example is telehealth, which is a different way to deliver care, or e-consults.

And technology can do that, but it has to work in tandem with the payment system. It has to be wanted and understood by the private sector, whether that's payers or employers or providers. So there is enough work and focus that we wanted to make sure that there was a small team of people who were thinking about that every day, even though we already had been, but just to define it.

We also have innovation responsibilities, not to necessarily lead always, but to be thinking and innovating with others in the private sector.

But we have in our standards portfolio a lot of work to implement that we want to make sure leads to a defined roadmap to implement around interoperability, so the data's not just in one system, but following patients where they need it, available for providers when they need it, and then able to roll up into other uses.

HLM: I read a report that the ONC office of consumer health is going away. Is that true?

DeSalvo: It's absolutely not going away. It still exists where it has been. It's been in policy and programs. Policy and programs split apart, so it's still with programs. It's an incredibly important part of our portfolio. No change to the resources. No change to the interest. No change to the focus.

As I wrote in my note to the team, we get up every day, well I'll speak for myself, I get up every day to work for the people of this country. That is the reason that I am in this job. It is who I serve. It is how we want to build health IT, to serve their needs as individuals for health, to help them take care of their families, and to see that we're doing a better job at public health and population health. So it is absolutely not lost, and it's a critically central part of what we do every day.