Q&A: Dell Med’s DeSalvo Talks Social Health Startups, Data Ownership
Karen DeSalvo has experience working in the public sector, but she’s hardly what you’d call a government bureaucrat.
DeSalvo, who is trained as a physician, served as the National Coordinator for Health Information Technology from 2014 to 2016 under President Barack Obama. During some of the time she headed the ONC, as the office is known, DeSalvo was also Assistant U.S. Secretary for Health, a position within the Department of Health and Human Services (HHS). Before that, she was vice dean for community affairs and health policy at Tulane University School of Medicine in New Orleans.
Earlier this month, DeSalvo joined the faculty at the Dell Medical School at The University of Texas at Austin, where she’ll serve as a professor in the Division of Primary Care and Value-Based Health. For DeSalvo, joining Dell Med marks a return to her roots—she grew up in Austin, TX—and to working in academia.
DeSalvo recently spoke with Xconomy by phone about the upside of working at a still-new institution (Dell Med enrolled its first class of students in 2016), why your ZIP code may be a better predictor of health than your genetic code, how artificial intelligence and other new technologies are influencing the education of doctors, the impact Amazon and CVS might have on healthcare, and more. Our interview has been condensed and edited for clarity.
Xconomy: What do you bring to Dell Med and what are you hoping to accomplish as part of the school’s faculty?
Karen DeSalvo: Part of the mission of the school is to improve health in the community. Developing a workforce, doing research, and creating a healthcare infrastructure that can support community health is a really exciting opportunity.
I bring my experience in not only medical education but also in public health practice, pubic health research, and then health IT. All those tools will be necessary to really bring great health to the community.
X: As medical schools go, Dell Med is still very young. Do leaders at the school feel they have latitude to create programs that focus on pressing issues in health and medicine today (for example, Dell Med has an entire department dedicated to population health)?
KD: The leadership has this idea to really create health in partnership with the community. It [requires] some rethinking about the traditional infrastructure. We’re going to iterate and learn over time.
The idea of having population health as a visible and active focus of the work matters a lot because populations are who we’re there to serve. But it’s also a different way of thinking. It’s about learning to attend to the person in front of you, and to do that in the context of the rest of the community in which they live and learn and have relationships. It’s not just what happens in the doctor’s office.
X: Has the school intentionally included more of a technology focus in its curriculum?
KD: The education that doctors need to not only be in [medical] practice now, but certainly in the years to come, is different than the way I was trained.
We have to teach skill sets that have to do with digital health and technology more broadly. At Dell, it’s helping physicians in training feel more comfortable with looking at data.
Increasingly, patients are collecting their own information about themselves … things like wearables that count steps, or people who have chronic disease like heart failure and have scales at home and are weighing themselves into the record. Doctors need skills about how to find signal from that noise, how to make good use of that data on behalf of their patients and populations.
This is a whole new world that we’re living in. But we haven’t really allowed technology to support and enable physicians and the rest of the care team using things like A.I. or machine learning, in a way that we have in other sectors. Helping physicians feel comfortable with that—to know what are the ways that data is an enabler and not a barrier—is such an important future for us. We want to make sure that we’re building a workforce that is taking the best of technology to do the best for their patients.
X: When it comes to optimizing how health data flows and follows patients as they receive care, some of the key stakeholders are healthcare providers, software companies, government, and academia. What’s one example of a situation where the interests of all of those parties are aligned?
KD: I would think the area where everybody’s interests are aligned for data flow and sharing is in disasters. We saw that recently in Texas. There was a rallying cry and then action on making sure that individuals who were needing care in the shelters from the Houston hurricanes, from Harvey, were able to access their health information. Disasters always remind us that information not only saves lives but can [also] reduce suffering.
X: What’s an example where some stakeholders’ interests are in conflict?
KD: I think the place where interests are not yet aligned is in the everyday practice of medicine.
We have made some progress but patients’ information—even though now digitized, and even though they should control it—is still thought of as an asset that’s owned by a practice or a hospital, in the way that an old paper medical chart was considered an asset of a physician’s practice.
As a healthcare system, we haven’t quite got to the place where we recognize, “It’s not about the chart, it’s about the data; and more importantly, it’s about the patient.” The work that I did at HHS as national coordinator was about freeing that data on behalf of consumers so that they could access it when and where it mattered to them.
Congress actually passed a law to say that it’s not ok to block someone’s data. The healthcare system needs carrots and sticks … to make sure that we’re putting people first, and not [guarding] data too closely, because then it’s not there to help them.
X: The stimulus package Congress and President Obama approved in 2009 included $29 billion in incentives for U.S. hospitals and clinics to adopt electronic health records systems. Do you feel offering these incentives to healthcare providers turned out to be an effective strategy?
KD: The quick answer is “yes.” The encouragement model of adoption didn’t accept that physicians and hospitals needed some encouragement [in the form of] funds to offset the cost of adoption.
In hindsight, what [government leaders] were trying to do was push the adoption of electronic health records, because that made sense at the time. Think about the world in 2009. There was barely an iPhone. Everything was about hardware and software. Now we understand the currency is data. It’s not this digital health record.
Ten years ago, there was a need to infuse and push. We did that. But I think in that journey, it became really clear that a cloud-based and more data-focused environment was going to be needed that required updating the authorities and the approach of the Office of the National Coordinator. It [also] requires the private sector to really lean in and make that a reality, because technology is less of the issue. [It’s] more about culture and incentives.
I think we are a few stitches away. I think of it like a fabric: weaving together the various interoperability platforms from the public and private sectors to have a “network of networks” model. You don’t have to recreate an IT infrastructure. Let’s weave together what’s already there.
X: One term that seems to be on the lips of many healthtech investors and entrepreneurs today is “social determinants” of health. Can you provide a definition and some examples of social determinants, and discuss why the concept seems to be so in vogue?
KD: The social determinants of health are reflective of where we live, learn, work, and play, and the environment in which we do these things. Examples would be the built environment—including housing and sidewalks and public transportation—or economic opportunity, or educational systems.
Data, [both] historically more recently, is telling us over and over again that the bulk of influence on your health and your life expectancy is your ZIP code, and not your genetic code. It’s about where you’re going to school and living and the relationships that you have. The healthcare system has a role to play in addressing the broad determinants of health. But it’s not the only actor.
I want to give you a historical example about social determinants and health. We think about tuberculosis as a terrible disease that was finally cured by great drugs that were able to treat people and reduce transmission. But in reality, housing policy made the biggest difference in reducing tuberculosis transmission rates. As we spaced people out and had better ventilation, and particularly tenements, that was the way we really tackled an important public health challenge. The idea that there’s a social determinant like housing that’s more influential on somebody’s health than, say, a drug for tuberculosis, is true in almost every disease.
The world is reawakening to the importance of this. For many in the healthcare system, it has to do with the bottom line. Healthcare systems and [insurers] are seeing that some 5 percent of patients account for half of their [total] costs. When you really begin to understand those patients, you see that it’s not just that they have a lot of medical needs, but they have a lot of social needs. They’re low-income. They may not have good housing. They may not have access to food at all, much less healthy food.
The healthcare system is now reaching out to social services, the business community, elected officials, and urban planners to say, “Let’s create a healthy environment, give people an opportunity to make healthy choices, and to mitigate not only the impact on health in today’s world but try to do more in prevention.”
This is spurring all kinds of activity in the payment world and models of care delivery, but also in technology. The VC community is really on fire about how to not only collect but [also] better use information about social determinants so that we can target high-risk folks and get them help that they need.
X: What are some of the venture-backed startups developing tools that could improve the status quo?
If you’re a health system and you have thousands of patients, you’ve got to eat the elephant one bite at a time. How do you prioritize the people that you care for and also prioritize the social needs that should be addressed that help them come back into wellness?
[Startup] Socially Determined has an interesting approach [of] trying to create an index to not just say, “60 percent of your clients have food insecurity,” but rather to say, “If you address food insecurity, we think you can improve health outcomes and reduce costs by X amount.” That puts a value proposition on addressing social determinants for the health system because it reduces re-hospitalization or unnecessary hospitalization.
X: Has healthcare lagged other industries when it comes to making cutting-edge technologies part of professionals’ daily lives? Is your view that the past 10 years have largely been about getting hospitals and clinics to implement new electronic health records systems—in part by having the government offset part of the cost of the new software—and that the next decade is when we’re likely to see people in the industry really harness those tools to improve care and lower costs?
KD: Yes and yes. We’ve been embarrassingly slow. We still, to a large degree, are just thinking about how to improve efficiencies in our supply chain, rather than really rethinking the model.
This is why what we have the chance to do in Austin [at Dell Med] is exciting. It’s also why we’re seeing a lot of “side disruption,” people might call it—the possibility that there’s going to be some significant disintermediation of the healthcare infrastructure.
This CVS-Aetna merger, as an example, is the beginning of what I think are going to be some very interesting alignments between retail and digital platform companies, like the Amazons of the world. [Those alignments] will really disrupt healthcare in a way that I think can accelerate change.
And as long as it’s done on behalf of—and to the benefit of—patients, I think we’re in great shape. We’ve just got to make sure that we’re putting them front and center.