Public Health 3.0 describes an innovative model of public health that integrates social determinants of health with health IT and public health informatics. The architect of this plan, former Acting Assistant Secretary for Health and Human Services and the former director of the ONC, Dr. Karen DeSalvo, joined “Inform Me, Informatics” recently to reflect on the legacy of Public Health 3.0 and to share her vision for the future of public health informatics. During the course of our conversation, she also shared stories from her time as Health Commissioner in New Orleans and some great advice for the next generation of informaticians. Dr. DeSalvo recently left the public and academic sectors to become the first Chief Health Officer at Google.

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Dr. Karen DeSalvo

INTRO

PIPER

Hi, this is Piper Hale, and you’re listening to Inform Me, Informatics!

I’m so excited this time around to be bringing you an interview with a public health informatics and health IT superstar: Dr. Karen DeSalvo. Her bio is a staggering list of accomplishments, but I’ll do my best to summarize them for those not already familiar with her work: Dr. DeSalvo served as the Acting Assistant Secretary for Health in President Obama’s administration, where she was also the former National Coordinator for Health IT. In this role, she created and pioneered the innovative Public Health 3.0 plan. Earlier in her career, she served as the New Orleans Health Commissioner, where, among many other accomplishments, she helped the city scale up its emergency health response to natural disasters. Over the course of her career, she has worked in medicine, public health and academia. As of last fall, she is also now the very first Chief Health Officer at Google.

Shortly before her big transition last year to this new role of bringing public health expertise into the cutting-edge world of Silicon Valley, I spoke to Dr. DeSalvo about her personal perspectives on the current and future public health landscape. I started out by asking her about her biggest legacy from her time in the Department of Health and Human Services.

PIPER

So I wanted to kick off our talk by referencing Public Health 3.0, which was your exciting vision that really integrated social determinants of health with health IT and public health informatics. And I was wondering if you could give our listeners the broad strokes of what that initiative entails.

KAREN

Oh, definitely. Thanks for starting there because it’s really meant to be a reflection of what’s happening on the front line to public health all across the country. It certainly grew out of my own experience as a health commissioner in New Orleans of us working to modernize our health department to be able to address the broad challenges facing our community, which were though, you know, always gonna relate to chronic disease and communicable disease, there is this growing need to have the infrastructure and the resources and the relationships so that we could address the broad social determinants of health that were driving for health in our community, things like community violence or challenges around housing.

And so when I was at HHS, serving as assistant secretary for health, we took the opportunity to do listening sessions across the country and learn from local health departments about how they were modernizing themselves into a 21st-century version. And through those listening sessions and other means of input, we arrived at this vision of Public Health 3.0 that has 5 major areas that we saw advancement in modernizing to a 21st-century public health department.

One was around leadership, that leaders at the top, but really across the organization, were performing like chief health strategists, working outside of the walls of their health department and building relationships and bridges with other sector leaders to have opportunity to collectively address broad challenges. The second area was about accountability and infrastructure of health departments to help these health departments that were modernizing or moving towards accreditation, because this was a way that they could really do a check on structure to make certain that they had all the right pieces in place to play on any field to participate with partners across the board.

The third area that we saw commonly had to do with finding ways to have more flexible funding so that they either could develop new initiatives that could look over the horizon of challenges in the community and/or be more flexible to partner with others, which brings us to the fourth big area which was about strategic partnerships.

We found a lot of these health departments, similar to my own experience in New Orleans, where working with maybe what you might call unusual partners, you know, those in tech or in the business sector rather than kind of the more traditional partners of public health, which would be maybe medicine. As an example, there are some of these social service organizations, so they’re adding to their strategic partnerships. And then the final area was about really leveraging data and technology in new and innovative ways given that, you know, in the 21st century, this is essential to the way anybody does business, much less public health, and some very exciting ways that local public health is thinking about and leveraging public health informatics and data and technology to really meet the needs of the population.

So 3.0, a reflection of what’s happening in the field, meant to articulate that in a way that gives people a 5-pronged pathway to moving ahead. And I’ll just say this one thing, Piper, which is every community we visited, and still to this day when I go around the country, talking about 3.0, informatics and data are a top, top priority for not only the health departments but their partners. Public health is seen as a source of good true data, a source of information, and a real great partner in trying to get to the understanding of the needs of the community through the great vex that public health is known to curate. So it’s an important place for us in public health, but it’s also a priority that needs to be modernized.

You know, I thought when I left government that Public Health 3.0 would go on a shelf somewhere and not continue forward, but I should not be surprised that it has, because it is really not the vision of a person or of a federal government, it’s a reflection of the organic growth that’s happening in the field.

It’s the way public health departments are innovating and modernizing themselves

But I think more significantly, we’re getting some momentum around clarity of how to train chief health strategists. The de Beaumont Foundation, as an example, has been a leader in creating opportunities for leaders who want to be more of a 3.0 mindset. There’s been good progress in understanding what the financing gap would look like, thinking through how to improve the accreditation process through PHAB so that it reflects the modern 21st-century public health department and then also some advancements in the opportunities around data and infrastructure, including some legislation in Congress to start to shore up the data infrastructure for health departments.

So the movement continues. It’s being really pulled by the front line who know that they need to modernize and I think being helped and assisted by the work that’s happening at the national level to carry forward some of the recommendations that we made in the report.

PIPER

When you look around at the current state of health IT and public health informatics in the U.S., how would you characterize that landscape, and what would you describe as the biggest barriers to creating, you know, fully interoperable systems that exchange data that’s timely and meaningful?

KAREN

I think we have ways to go, especially in public health informatics, but in health informatics more broadly, you know, where we made the major investment as a country through the HITECH Act, was into health care infrastructure. And even more narrowly than just health care, hospitals, doctor’s offices, we did not include in that major investment, that legislation, opportunity to modernize the IT infrastructure for the mental health system or the post-acute care environment like nursing homes. Public health did not receive resources to modernize and be a partner to health care in improving health.

So in the ecosystem where we need all of the partners to have a strong foundation of their own IT infrastructure so they can collect standardized data that can be shared. We have a bunch of weak spots, and public health is one of them. And again, I’m not pointing a finger at the teams in public health or at the willingness even, it’s just a lack of resources and it’s something the country is gonna need to come to terms with.

I mentioned a little earlier that there’s some legislation brewing in congress to do just that, to begin to provide resources to the public health IT infrastructure so that it can be a better partner in work around things like surveillance and epidemiology needs, also things like emergency preparedness.

Where I’m going with this is that part of our problem in today’s world of striving to improve health is all the parties don’t have a strong IT foundation at their core, much less the opportunity to have interoperability.

Now, we’ve made a lot of advancement in the technology space for health care to be interoperable. And I think we’re moving in a good direction around standards and modernization in some corners of public health, but there is a fair amount of work that still needs to be done.

Mostly what I find, particularly in the health care sector, is that the challenge around interoperability is less technology and more about business and culture. We moved in an asynchronous fashion as a country to push the technology in health care without really driving a business case for why data should be shared. We are getting there with the value-based care momentum. It’s a place that we press really hard when I was the national coordinator, was to align the value-based care agenda of the technology, agenda for health care. We need to do something very similar for public health. What is the business case that makes sense for states and local governments and the federal government to invest in the health IT infrastructure and keep it modern, not just do a one-off investment, but maintain that?

And the last thing I would mention is there’s technology, business, and culture. People have some views, and maybe they’re right that data is valuable, and so they wanna hoard it. We call that data blocking. It’s now against the law for health care and probably the 21st-century cure that calls it so is broad enough to start to incorporate other kinds of consumer data that relates to their health. But this cultural shift about who owns and controls that data has got to change in this country, because it’s really the data about consumers and the community and who should be able to control how it’s used. So those are three big areas where we’ve got to make advancement. We can’t just focus on the technology. We’re gonna have to, as a country, make sure we get the business case right and also change the culture around data sharing.

PIPER

That’s such a great insight. You hear so many people talking about technology is really the key to unlock this greater interoperability, but yeah, culture and business cases, that really is such a big piece of it. So thank you for sharing that perspective. I did also want to ask you, are there any innovations in public health informatics or health IT right now that you’re particularly excited about or that you think could be good models for other practitioners to point to?

KAREN

It is true that there has been some pretty significant innovation, even with the technology and the business case and the culture at hand, you know. And I think that, you know, some of these models are examples of bridging the health care IT infrastructure such as the data that we get from electronic health records or from claims information to inform public health practice and needs. I always like to point to the work that they’ve done in New York City called Macroscope where they’ve used data for the electronic health record to serve as a proxy for surveillance for chronic disease. There are examples of that in states like Massachusetts as well.

I have another one though that I wanna use that’s more personal that relates to preparedness. And you know, back to the business and cultural piece of it is in preparedness in the throes of, say, a hurricane coming ashore and people needing to evacuate from a community. We have seen time and time again, whether it was storms in Florida or North Carolina or in Texas, we have seen that the IT systems, the health information exchanges across datelines were able to connect almost overnight, where they had been struggling for years to find a way to share information across datelines to get to the data necessary to care for people who are gonna land in the shelter, people who you don’t wanna have gaps in their care plan or their medications.

You see examples of how suddenly the technology works because there is a reason to do it. People feel a drive in disaster to be collaborative and to connect, say, in health information exchange.

We had a similar kind of drive in our experience in New Orleans around health IT that is a little bit of a longer story from paper to hotspotting, but I think speaks also to this business case around preparedness, which I always felt is an opportunity for common ground across many sectors and really a place where public health informaticists can show value in a very near term.

So in the case I mentioned around places like storms, like Harvey, where we’re able to connect the data very quickly for information exchange, we also, in New Orleans, were able to get a little ahead of that and create a system called emPOWER.

So the story essentially for us in New Orleans of an example of how public health informatics really advanced and modernized our ability to be prepared and then support communities that when I became health commissioner in New Orleans in 2011 and asked for special needs registry, what I got was a metal cart with a bunch of pieces of paper jotting down who had called in to be a part of the medical special needs registry, and it wasn’t in any order, it wasn’t even in alphabetical order. And we had to systematize that, put it in an Excel Spreadsheet. My deputy director worked nights and weekends to get that done, leading into the hurricane season.

So we went from paper to Excel spreadsheet, that was our first step forward. Maybe that was our 2.0 version. But then we had a significant storm, Isaac, where we lost power for days and had a lot of people with special needs, they were on oxygen or wheelchair-bound, that we learned about because we eventually, after days of power outage, door to door, knocking on doors, and especially in high-rises, to figure out who’s in trouble and figure out who we couldn’t reach on the special needs registry and maybe there were other folks as well.

And it became clear to me as health commissioner that even the Excel spreadsheet that I had which was better than the paper was not gonna cut it, because it relied on people calling us, right. And I needed a much better way to cast a net of who was gonna be at risk. So we worked with the federal government to access Medicare claims data and pull out who was oxygen-dependent, that was our first pilot pass, and now it’s much broader. But the pilot was, “Can we pull for the New Orleans community Medicare beneficiaries who are oxygen-dependent?”

And we did a test where we went door to door in the community, went in the field and knocked on the door, and when they answered, I said, “Hi, I’m from the government. I’m here to help.” I actually said that to people, switching to break the ice a little bit and ask them, “We’re from the public health department. I usually had FHIR with me. And we understand that you’re on home oxygen, and we wanna make sure that the data we have is right and see if you wanna be registered for the special needs registry. In case power goes out, we’ll know how to find and help you.”

We published this data. It was a very accurate database, and we’re able to do the search using, you know, traditional kinda search and rescue quadrant approach. That pilot, now, has been scaled. It’s a system called emPOWER. People can find it at the HHS website. Data is available to any public health department across the country, not just about oxygen dependency, but other dependencies. So those that may be wheelchair-bound is an example.

So our local health department can get a hotspot map in event of impending disaster to know where they have the people with most need and how to reach them, because it’ll have their name and address and other information. It’s also—we found it useful in New Orleans to do some prework, right, to go to hotspot places where maybe there was a high-rise and we knew maybe there were 20 or 30 people living in that building, and we could do events on the ground floor to get people registered for special needs and also to do any other support that may be relevant for those individuals to get them connected to the right services.

So it’s a personal story about how we went from paper to using a big data to do some hotspotting that would not only allow us to help people in the event of disaster but to get ahead of it, and it frankly was one of the reasons that I was so inspired to write about 3.0 later in my time in government, because I saw firsthand that leveraging data, you can do more for people in your community, and the business case doesn’t have to be, you know, paying for something in a way that sometimes we think about a business case of a contract, but really the business case for us was saving lives. And the feds and the local government really got that, and the people on the ground, our community received it very well.

PIPER

In the course of our conversation, I mentioned to Dr. DeSalvo that many of our listeners are public health students and early career informatics professionals, and asked if she could share some wisdom with you, the listener.

KAREN

Well, I’d start by saying they picked the right field.

You know, Piper, I’m not an informaticist, and I’m an example of a health care and public health leader that learned the digital world so that I could help leverage it to do the work that I found was important for my patient base or my community. And I think that these students will find there are a lot of people like me in leadership positions across the country, and what that means for them is, the students or the informaticists, is they were gonna have a lot of educating to do about leadership, because there’s no health leader in any chair, whether you’re in governmental public health or a health plan or a health care system or even in some of the partner organizations that doesn’t need to understand digital and data and technology in the 21st century.

It is the currency of today, so it is the way that all businesses have built-in strategy. It’s no longer…at least if you’re gonna be successful, it’s not a side department, it has to be integral to the core work that you, as a leader or as an institution, do to improve health.

PIPER

In the course of giving this advice, Dr. DeSalvo plugged one of my favorite resources from the Public Health Informatics Institute, and I swear, listeners, that this plug was entirely unprompted!

KAREN

I wanted to mention, the de Beaumont Foundation has, along with the Public Health Informatics Institute, some nice little short video clips that kinda get to that point, and maybe if you have a chance, we could share that with leaders. They can probably find it by Googling. Just some quick tips on how to communicate across and vertically in the organization to make sure that the work of informatics is understood but that it also stays core to the important strategic priorities for public health.

PIPER

So you can find these videos by Googling them, or you can go straight to them at phii.org/informaticsforeveryone. At this point, as we were wrapping up our conversation, I asked Dr. DeSalvo the question that I ask all guest on this show: how do you define public health informatics?

KAREN

I like this catchy definition that the de Beaumont Foundation used actually on that website, so I’m gonna borrow that, because it’s not quite as long as some of the other ones, which is simply to say that information is what you need and informatics is how you get it. I think that’s a nice way to explain that, say for example, to your colleagues in epidemiology, you know, “You need information about, informatics is how you’re gonna get it, and let’s work together to see how we can get the most timely granular relevant data from the sources that will be the most accurate for you in the near term.”

And there are so many great examples, I think, of how public health informatics is leading the way to show that they can get that information, that useful information importantly, that could be actionable, you know, not just from more traditional sources like surveys in field or even electronic health record. I think we’re seeing some exciting work about using things like Google searches or Twitter information, and I mentioned some working claims data that is gonna help see that our partners get the information they need in a more timely fashion so they can take action and drive really good policy.

PIPER

Many, many thanks to Dr. Karen DeSalvo for coming on the show to share her valuable insights on the national public health landscape! It was such a treat to get to talk to one of my personal public health heroes, and I’m glad I got to share that conversation with all of you. Thanks also go to Angie McPherson at NACCHO for connecting me with Dr. DeSalvo to set up the interview.

This podcast is a project of the Public Health Informatics Institute, which is a program of The Task Force for Global Health. Visit phii.org to learn more about all of our informatics work! You can also find us on Facebook and follow us on Twitter @PHInformatics. The music used in this episode was composed by Kevin MacLeod.

I also wanted to let you know about another public health podcast that I’ve been binge-listening to lately. It’s a podcast hosted by two very funny and entertaining disease ecologists that delves into the biology, etiology and social history of diseases ranging from plague and Ebola to genetic disorders. It’s called This Podcast Will Kill You, and it’s very interesting and genuinely funny. I’ve recently been annoying all of my friends with fun facts I’ve learned on one of their episodes. And just to clear, that’s not a paid promotion or cross-promotion; I just—really have been enjoying that podcast.

As always, if you know of an innovative or interesting public health informatics project or story you think would be a good fit for the show (or just a podcast you think I might like listening to!), let us know on PHII’s social media or email us at podcast@phii.org! Thanks for listening.

I’m Piper Hale, and you’ve been informed.

BUTTON

KAREN

Piper, did I lose you?

PIPER

Sorry, I realized I was on mute. Sorry about that.

KAREN

Okay. It’s okay.

PIPER

I realized as I was speaking I was like, “There’s not a response. I might be on mute.”

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