National Coordinator for Health IT Karen DeSalvo: Focusing on Listening to Provider Concerns

Sept. 10, 2014
Just over two weeks after she officially began her duties as the new National Coordinator for Health IT, Karen DeSalvo, M.D. sat down for a phone interview with HCI Editor-in-Chief Mark Hagland, to discuss the meaningful use process—and much, much more.

On January 13, Karen DeSalvo, M.D., formerly City of New Orleans Health Commissioner and Senior Health Policy Advisor to Mayor Mitch Landrieu, joined the Office of the National Coordinator for Health IT (ONC) as the National Coordinator for Health IT, in the most important public policy role in healthcare IT in the United States. Now that she is in the National Coordinator position, how does the landscape look to her? Dr. DeSalvo sat down on Feb. 5 for a phone interview with HCI Editor-in-Chief Mark Hagland, to discuss meaningful use Stages 2 and 3, physician struggles, vendor capabilities, and the role of the trade press, among other topics. Below are excerpts from that interview.

I know that you’re facing a welter of immediate priorities, but could you name the top three priorities, from your own perspective, right now, in the first six months  to year of your tenure?

Not necessarily in order, there are several. They include some organizational assessments, to make sure that our form and structure as an agency meet the needs and fit the funding, and as we begin to focus more on the coordination function at ONC, and our role on facilitating, implementing and leveraging goals. It’s the meaningful use, lower-case sense, of health information technology that I’m speaking about there. What do we have in place that is leveraging the needs we have in the country to improve the delivery of care, in such a way that we improve care and lower costs? Also, we’re  looking at how we can do a much better job of enabling health information exchange, both as a noun and a verb, so what needs to happen to get to the goal of true inoperability. And I might need to do some restructuring of the agency in order to make sure that that happens.

But also, there are so many technical components that go into interoperability—into not only standards, but also governance and business issues. Those need to be looked at. And also, we have two major regulatory obligations—meaningful use Stage 2 and meaningful use Stage 3, and always, in that context, thinking about how that [process] advances the health of the nation. We had a discussion in our policy committee of the latest elements of MU3. So it’s an immediate need, to make sure we’re addressing meaningful use Stages 2 and 3 appropriately, to get to the [broader] goals.

We’re hearing considerable concern in the industry among physicians. Hospitals may be struggling with meaningful use, but physicians are struggling even more, as a group. Are you also hearing about physicians falling behind hospitals in the meaningful use process, and if so, what are your thoughts on what might be done in that regard?

We have definitely heard from physicians that not all eligible providers will be able to achieve Stage 2. Certainly, some are well underway; but we’re hearing that there may be some challenges, so we’re listening to that. And there may be some lessons learned as we move towards Stage 3—not only the broader goals, but also the quality measures. I have heard that. And also, we’re hearing from physicians that there are needs beyond the technical elements, having to do with the usability and friendliness of [information] systems. And that matters because if you really want health information technology to enhance safety, the electronic health record [EHR] needs to be “usable” in such a way so that when that doc opens that record, the information needed comes right at them, right? And there’s some opportunity to really enhance that at the point of care, in the clinical environment.

Also, what we all want to see is to have systems that are usable in that clinical environment, so that docs and patients are interacting with each other. There’s some real opportunity there; the vendors are interested in that, the doctors are interested in that. And sometimes, clinicians still have to pull out the information instead of getting it pushed. And to me, that’s related to health information exchange needs, too. We’ve already had a lot of listening sessions in those areas. And in terms of the lower-case m, lower-case u, the meaningful use of all this, doctors do want to be a part of integrated system, and we need to try to help them get there.

Another big concern we’ve been hearing across the industry is regarding the usability, functionality, and interoperability, of vendor products right now, particularly EHRs. What is your response to provider concerns over vendor products?

It gets back to what the role of is, of the Office of the National Coordinator for Health IT—and that is as a coordinator for health information technology. This is a role that requires us, as an agency, and me as National Coordinator, to do a bit of what you’re describing, honestly, which is to listen to the concerns [of providers], and to look for opportunities to use whatever authority we have to try to help make the electronic health record more of an enabling tool. And that means we need to make sure to do an internal look to see what we’re doing as an agency to enable innovation. I’ve heard what you’re sharing, and I’ve asked the team to think about that, because what we really want to do is to be a force for advancing the field.

And there are some real challenges on the part of everyone. For example, we’re trying to do our job to help educate hospitals and vendors to help build good contracts that require vendors to change things if there’s dissatisfaction. And that kind of work might help facilitate the ability to create more useful products. It’s complicated, and I’m not trying to brush off the question. I think everyone’s got a hand in it, and our job is to set a table around which everyone can talk.

Is there any flexibility on timeframes, per the pleas of the leaders at CHIME, in particular, to extend Stage 2 and Stage 3 deadlines? Or are you locked into current timeframes by the way the enabling law was written?

CHIME [the Ann Arbor, Mich.-based College of Healthcare Information Management Executives] came to the policy committee meeting yesterday and raised that issue. We are working with CMS [the Centers for Medicare & Medicaid Services] to look at the information available, to see where the provider community is, and trying to get a sense from vendors about their rollouts and timelines. There are realities in the regs that would make it seem that we have to proceed, but we’re certainly listening to people’s concerns.

On his blog, John Halamka offered you some unsolicited advice as the new national coordinator. One of the things he suggested is that ONC should focus on Stage 3 incentives that drive better outcomes, rather than penalizing providers for not checking more attestation boxes. In other words, Stage 3 should focus on enabling organizations to qualify for incentives rather than on penalties for non-compliance with Stage 3 requirements. What are your thoughts on that advice?

John’s the vice-chair of our standards committee, one of our federal advisory committees. And I know he can weigh in there and also write about this. He’s a smart man who has his finger on the pulse, and also has developed his own systems that are somewhat advanced, so there’s a lot of good perspective there, and I appreciate it. As we said yesterday in the policy committee meeting, the ONC perspective is that we do indeed need to stay focused on outcomes, which is one of the goals of MU3, and we’re continuing to look at how interoperability can be advanced, not just for doctors and hospitals, but also across the continuum of care.

A goal will be that we continue to bring folks along, and the system along, so that we have electronic quality measures and some areas around safety, in the context of this learning system idea. So the goal is not just to capture data from the EHR, but also to use data from health information exchange to help with decision support at the point of care, and to have that lead to improved outcomes. I think we’re all in keeping with those ideas. The big challenge will be to make sure that what we select as measures for meaningful use 3 is a stretch yet achievable, so that we continue to push providers, but also do it in such a way that we keep as many folks in as possible and don’t end up with a digital divide.

Do you have any reassurance to offer providers, or hints, on the Stage 3 requirements?

Yesterday, the policy committee presented their findings; we had a very robust dialogue about it. We didn’t take a vote; I didn’t think we were ready to do that. I felt we need to continue to get feedback, for meaningful use in all senses.  We want [Stage 3 requirements] to be a stretch, but we also want to make sure we’re not overburdening [providers]. It’s about achievement, and the rewards system is meant to move us all forward.

What can we in the trade press do to help the industry move forward, broadly speaking?

That’s a great question. I just came from public health, and one of the things about public health is that it’s hard to get to the press. And health IT has its own set of press, which is great, with a lot of potential for messaging and sharing. What I would say is that I think we’re all doing a pretty good job in the HIT field of informing each other. There are a lot of channels to communicate. What I really want to help the community to get a handle on is that there are multiple perspectives. And that there are some true success stories in the country—places like Minnesota or Rochester, New York, where HIT is being meaningfully used, not just within organizations, but inter-organizationally, and that’s pretty exciting.

And there are physicians who really love their electronic health record; and there are places where it’s informing public health and public policy, so there are some good stories out there, and those aspirational stories can help keep people excited and motivated. And I would say this, too, the Office of the National Coordinator was established ten years ago, and our role is to coordinate national policy around HIT, and it’s an opportunity to be a convener, and to facilitate links, and to leverage connections, especially between the public and private sectors. And that’s  really nice opportunity for this office to make sure we help healthcare systems become as seamless as possible.

I think it’s also a real opportunity for us as a country. And think about ten years hence, what 2024 looks like, and the systems are working really well. There are so many really important policy questions to consider. But there’s much more at play here than the meaningful use program, and the more we can look up and look down the road and keep in mind that this is improving the health of the people, and not get stuck too much in some of the frustrating bumps along the way… we’ll hit those bumps, and we’ll solve them together. I remember back in New Orleans when I was Health Commissioner, Mayor [Mitch] Landrieu would say, look up from time to time—and though you have to keep an eye on what you’re doing every day, he would remind us to look up from time to time and get the bigger picture. So that aspirational aspect is very important.

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