Most of her peers will say that Karen DeSalvo, M.D., National Coordinator for Health IT for the last two-and-a-half years, accomplished a lot of good in a relatively short period of time when it came to advancing digital healthcare. Most recently, DeSalvo made clear that the Office of the National Coordinator for Health IT’s (ONC) priority moving forward would be to move away from focusing primarily on Meaningful Use and towards the creation of a healthcare system in which there would be a “person-centered path for improving health outcomes,” as Health and Human Services (HHS) Secretary Sylvia Burwell noted in her announcement of DeSalvo’s departure as ONC head last week.
However, DeSalvo’s journey as National Coordinator took an interesting turn in late 2014, when she took on a part-time role to lead HHS’ Ebola response team during the 2014 Ebola crisis. As such, rumors started swirling as to how long she would actually remain at her Acting Assistant Secretary for Health role while still overseeing ONC. But DeSalvo actually spent nearly two years juggling those two jobs, and for that many who have surrounded her during that time span have applauded both her work ethic and her multispecialty skillset. But it also meant that not many in the industry were in the least bit surprised when DeSalvo finally announced she should be stepping down from her role at ONC to be at HHS full time, giving way to Vindell Washington, M.D. It was not a question of if, but rather when.
Jeffrey Smith, vice president of public policy at the American Medical Informatics Association (AMIA), and formerly with the College of Healthcare Information Management Executives (CHIME) when DeSalvo started her ONC tenure, says that whenever there’s a shakeup at the top of ONC, there is an initial natural reaction to be concerned, but looking across federal agencies, one begins to realize that this is how business is done. “Look at the Departments of Energy and Transportation, and at HHS itself. You don’t see these executives and administrators stick around for more than a couple of years,” Smith says. “Those of us in health IT don’t have a 30-year history of working with the federal government. It’s a new area of policy, relatively. [The turnover] you see in ONC is actually consistent with how the executive branch is run.”
Jeffrey Smith
Arien Malec, vice president of data platform and acquisition tools for RelayHealth (an Alpharetta, Ga.-based McKesson business unit), and formerly of ONC, agrees that jobs of this ilk simply are not meant to last a lifetime, sharing an anecdote that shows how tough the job was. When Malec was working for the agency, the best time to get “instant emails” from ONC senior leadership would be at midnight on the East Coast, as they were still working at that time after putting their kids to sleep and before calling it a night themselves, he says. “It’s a hard job with a ton of political pressure and a tremendous amount of responsibility, and the average tenure of an ONC head over the course of the agency’s existence has been about two years. I think that tells you something about how hard that job is,” says Malec.
Indeed, neither Smith nor Malec were surprised in the least when hearing of DeSalvo’s departure last week, noting that that was always the eventual outcome when she took the Assistant Secretary position at HHS. In fact, Smith says that when Dr. Washington was brought on as a Principal Deputy in January, it was under the assumption that he would replace her and take over that head role when DeSalvo left.
Smith adds that what sticks to him most is how much listening and convening DeSalvo was advocating for and responsible for when it came to health IT policies and processes. “It’s not necessarily black and white when it comes to the differences between her and Farzad [Mostashari, M.D., former National Coordinator from 2011-2013] but I do think that she, as a function of coming into this conversation when she did, really did open up the doors of ONC and said ‘okay, let’s hear all the problems.’ And that was very helpful and fresh perspective when it came to trying to figure out what went right and wrong with Meaningful Use Stage 1 and Stage 2, and into Stage 3,” Smith says.
Taking a Look at Dr. Washington
In the announcement last week appointing Washington, who previously served as the president of the Baton Rouge, La.-based Franciscan Missionaries of Our Lady Health System (FMOLHS) Medical Group and as the health system’s CMIO, Burwell noted his involvement in key initiatives at ONC such as delivery system reform, the Precision Medicine Initiative, and the opioid crisis. “In his capacity as National Coordinator, Vindell will continue to lead the administration’s efforts to leverage health information technology to reform how we pay for and deliver care; transform health research and innovation to empower clinicians, individuals and communities to manage their health; and oversee implementation of the Federal Health IT Strategic Plan and the Nationwide Interoperability Roadmap to unlock digital health data and ensure it is widely accessible, usable, and transferable throughout the public and private sectors,” Burwell wrote.
Malec says that he only met Washington after he was appointed at ONC in January, but that he has been “very impressed by the depth of his understanding of healthcare and health IT, and by his calm and rational approach to the world." Malec says, “I have had a number of examples of explaining to him complicated topics, and he’s always listening, absorbing, calculating, and changing his position based on the facts. He’s going to be a fabulous National Coordinator.” Smith adds that what’s good about Washington is that “he is used to getting things done, as he has been in charge of multiple efforts that may have taken years, but they had a definitive beginning and end point. Having someone like that who can bring a project manager viewpoint to the things that need to be done can be very helpful,” Smith notes.
Arien Malec
Malec adds that past National Coordinators have had a strength of either policy or technology. David Blumenthal, M.D., and DeSalvo were both policy-oriented, meaning they were good at working with political stakeholders, and putting the mission at ONC into a broader context, Malec says. Mostashari, he says, was closer to the technology front, as he was “out there wiring up doctors in New York and knew the technology stuff really intimately. He had a lot of experience using EHRs [electronic health records] to improve the quality of care,” Malec says. As such, Malec senses that Washington is more like Mostashari in that he knows what’s it is like to implement technology on the ground and be a provider of care on the ground.
ONC’s Future
Smith says that culturally, ONC is different than the Center for Medicare & Medicaid Services, its sister agency. He calls it a “HITECH [Health Information Technology for Economic and Clinical Health Act] baby,” so they have a smaller office and a more innovative atmosphere, almost like a startup. “That affected how ONC views the world from a regulatory standpoint. The result of that is a lot of different initiatives and ideas that got created, some of which has closed up as a result of HITECH money going away, but many are still active and will continue to be,” Smith says.
Smith adds that ONC has the ability to be a “service shop” to the rest of the federal government when it comes to health IT-related matters. “Its certification program will continue to evolve, and there are things in of itself they can do to improve the program,” he says. “We talk about the need to do interoperability testing, something ONC has not engaged in historically.”
He also sees areas such as health IT safety and gaps in consumer-facing technologies as spaces in which ONC can play a critical role. He says health IT safety is an “active conversation” in Congress on whether or not ONC has the authority [to intervene]. “But if you look at some of the regulations that they have proposed in the last year or so, you do see that as being a fertile ground for ONC policymaking.” He also references a recent report from ONC, the Federal Trade Commission and the Office for Civil Rights, which found that there is basically a complete lack of oversight in terms of how mobile health companies handle patient health data from a privacy and security standpoint. “I would expect there will be numerous conversations on how you regulate things like Fitbit and other wearables,” he says.
What’s more, Malec notes the various policy initiatives currently making up the health IT landscape, from the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] legislation to the broader alternative payment accountable care organization (ACO) mission of CMS, the Cancer Moonshot, and the Precision Medicine Initiative, all of which should still go forward after the transition, and all of which require health IT in some form or another, Malec says.
“So ONC has a critical role to play in serving that connected tissue behind some of these large national endeavors,” he says. “I have been a good advocate of switching the focus of the tactics of Meaningful Use to serving a broader mission that includes standards, certification criteria, and some of the infrastructure components that we have on the technology sphere. We need someone who is thinking three to five years ahead. That’s not the federal government making stuff up or doing all the heavy lifting; it’s the National Coordinator for a reason, so it’s about partnering with the private sector to make sure we are all focusing on the key enabling technology bits that are vital to the mission.”
Another uncertainty at play is the upcoming November presidential election, though neither Smith nor Malec see ONC’s role changing a whole lot, regardless of which side wins. Malec says that he expects the transition to be a smooth one with strong continuity of mission, just like the government had when it transitioned from President Bush to President Obama in 2008. Smith adds that “ONC is not a very contentious wing of the executive branch.” Malec does say, however, that he himself “will not be around to see the transition if we don’t have someone sane and reasonable at the top of the government. And I think a lot of people will be in that position,” he says.
Malec says that in the new value-based payment world, with ACOs and bundled payment programs, ONC definitely has a different mission. “The private sector in that world is the one doing all of the implementation of interoperability, and ONC has a role as the folks looking five years out, clearing the playing field, and doing a lot of the research and coordinating. That’s a natural role for them, and I think it’s what they want,” he says.
