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Pondering the DeSalvo Era at ONC—And the Healthcare IT Policy Challenges That Lie Ahead: An Analysis

August 12, 2016
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A vast array of challenges faces Dr. Washington as this changing of the ONC guard takes place at a critical moment in U.S. healthcare

The announcement on Thursday, August 11 that Karen DeSalvo, M.D. was stepping down from her position as National Coordinator for Health IT, while not particularly surprising, was nonetheless both noteworthy and worth pondering. What does it say about where things are right now with federal healthcare IT policy? The meaningful use program? The healthcare IT zeitgeist in the United States? The announcement certainly comes at a moment of significance for healthcare IT policy.

Indeed, Dr. DeSalvo is leaving her position at a time of unparalleled uncertainty both at the Office of the National Coordinator for Health IT (ONC), and for U.S. healthcare IT and healthcare IT policy in general. Further down in this blog, I’ll have more to say about this—but it is an important element that puts yesterday’s announcement into a particular context.

Meanwhile, it is important to note that the post of National Coordinator for Health IT is of relatively recent vintage—the first National Coordinator, David Brailer, M.D., was appointed in May 2004 at the same time that President George W. Bush created the Office of the National Coordinator for Health IT. And, including Dr. Brailer (2004-2006), there have now been six National Coordinators up to Thursday: Brailer; Robert Kolodner, M.D. (2007-2009); David Blumenthal, M.D. (2009-2011); Farzad Mostashari, M.D. (2011-2013); Jacob Reider, M.D. (who was briefly Interim National Coordinator, October-December 2013); and DeSalvo (2014-2016). Vindell Washington, M.D. was named the new National Coordinator on Thursday, at the same time that Dr. DeSalvo’s departure was announced (she will now take on full-time her post as Acting Assistant Secretary for Health, a position she took on part-time in October 2014, in order to lead HHS’s Ebola response team during 2014’s Ebola crisis).

In that context, Dr. DeSalvo’s tenure as National Coordinator has actually been among the longest in terms of duration, lasting nearly three years, though with an asterisk, as she had already spent nearly two years splitting her time between the National Coordinator role and the Acting Assistant Secretary for Health role. Indeed, with the exception of Dr. Reider, who was Interim National Coordinator for less than three months during the gap between Dr. Mostashari and Dr. DeSalvo—all of the other National Coordinators have had tenures of two to two-and-a-half years. In that sense, Dr. DeSalvo’s full departure is “right on time,” as this position has proven from the start to be a rather short-lived one compared to many federal offices. And though some level of changeover might be expected in such federal agency leadership positions, one could legitimately question (and please count me in as someone who is questioning it) why such is the case here, given the centrality of the office to federal healthcare IT policy and the exceptionally rapid and constant pace of change in our industry. I’ll say it here: federal healthcare IT policy is in fact in certain ways rather exceptional; certainly, it is a key element in the federal government’s overall attempts, across political parties and presidential administrations, to help bend the cost curve on the United States’ $3.3 trillion, soon-to-be-$5.6-plus-trillion, annual healthcare expenditures. In that sense, healthcare and healthcare IT leaders nationwide, could not be fault for asking for exceptional management, including continuity of management, from ONC.

Still, the harsh Realpolitik of these positions is that, regardless of which candidate prevails in the November presidential elections, a new administration will come into place in January, and most of the officials in position’s like Dr. DeSalvo’s will be rotating off then. That being said, there is another very significant element here. Dr. DeSalvo’s departure also comes at a particularly delicate time for the ONC, as the agency struggles to guide the meaningful use process, already bifurcated by the passage of the MACRA legislation, which is replacing meaningful use for physicians with the MIPS program; and as hospital leaders strenuously advocate for a replacement of Stage 3 of meaningful use, with officials at ONC and CMS (the Center for Medicare & Medicaid Services, ONC’s sister agency within the Department of Health and Human Services). What’s more, the status of the drive towards interoperability, one of the issues that has resonated as something of a consensus cause among providers, remains unclear.

What is clear is that Dr. Washington will be stepping into the National Coordinator role at a time of unprecedented overall uncertainty at ONC, as providers push hard for ONC and CMS officials to step away from its role as the stern taskmaster of rigorous meaningful use requirements, and more towards something like that of a federal partner to providers in pursuit of innovation along a number of dimensions.

Regardless of whether Dr. Washington will be able to help reshape ONC in that way (one very good sign is that he has served as a multi-hospital system CMIO and CEO, so he at least has practitioner and patient care organization executive experience), healthcare and healthcare IT leaders are clamoring for change at the agency. Many—perhaps even most—leaders of patient care organizations have been dissatisfied with their interactions with ONC and CMS officials, particularly around the contentious issues embedded in the transition into Stage 3 of meaningful use. And it happened to be Dr. DeSalvo’s bad luck of the draw that she came into her role just as things were becoming dicey—and rather contentious—in the evolution of the meaningful use program. In certain ways, DeSalvo’s cautiousness and diplomacy ended up working to her disadvantage, as her reluctance to create news headlines also led to an absence of engagement at key moments, on key topics, with key healthcare and healthcare IT leaders.





You continue to be truly remarkable.  Capturing a well prioritized picture of the ONC's relevant history as well as challenges, you summarized a situation that is so complex, 99% are challenged to contemplate what it all means.

As you know, I was a medical director under Dr Reider at the ONC in 2013, so I had an insiders view, as well as front row seat, and occasionally a seat at the table.  One of the most interesting tables, by the way, was the Federal Advisory Committee meeting tables, meetings which are open, and are publicaly available (all presentations and an audio of the presentations and discussions.)

I'd like to briefly emphasize two points that you made, directly and indirectly.  First, human resources management is an incredibly important and challenging profession. It requires a lot of energy in both the public and private sector employers.  The keys, of course, are to get decision rights in the right place (RACI - who is responsible, accountable, consulted and informed, and when), that ensure that information is flowing, and that individuals strengths and motivations are recognized and exploited.  The talent management at ONC is hampered by the office's youth, structure (i.e. being a staff-division as opposed to an operating division), changes in leadership, and budgeting process that ensures non-sustainability.  Several past national coordinators have spoken up about this being arguably the biggest structural problem for the ONC.  There are, of course, other options.

Second and last for this comment, there has been grossly inadequate recognition of the valuable work that has been done.  For example, multiple grant and contract awardees, as well as the FFRDCs in general have done phenomenally important thought work, research, proof-of-concepts, and advocacy.  The extent to which work like TwinList has either been exploited by industry, or ignored in terms of impacting EPs and EHs should be studied.  Why?  Because safety and usability, especially in the context of Medication Reconciliation is a top three issue in our national HIT strategy.  The same could be said of other significant acccomplishments like the Yale Guideline tools, e.g. GEM Cutter.  There are many other examples.

And on the internal-to-ONC side, I have personally witnessed people making tremendous contributions that have gone completely unrecognized.  Some essential people with strong, proven track records are on year-to-year contracts, are paid well below "felt-fare" standards established in the marketplace, and are routinely humiliated in terms of having their training and travel scrutinized and often denied.  That includes denying training that has no travel and no fees, owing to unfortunate policies (not uncaring managers).  There are both options to improve the situation, as well as practices that need to be eliminated.  For example, and especially given the turn-over your mentioned, the on-boarding process for the ONC should be created and informed by the experiences those who committed to the office over recent years.  Again, there is a lot to be learned from industry regarding effective practices.

Mark, thanks for proposing that we ponder in the spirit of improvement.  And for getting us kicked off!