Ep. 18: How Technology is Improving Public Health
with Karen B. DeSalvo, M.D., MPH, MSc

July 15, 2021


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Part 1
Part 2
Karen B. DeSalvo, M.D., MPH, MSc
Chief Health Officer, Google

Dr. Karen DeSalvo is a physician executive working at the intersection of medicine, public health, and information technology whose career has focused on improving health and eliminating disparities. She leads a team of health professionals at Google who provide clinical guidance for the development of inclusive research, products and services. 

Prior to joining Google, Dr. DeSalvo was National Coordinator for Health Information Technology and acted as the Assistant Secretary for Health in the Obama Administration. During her time at the U.S. Department of Health and Human Services, Dr. DeSalvo focused on creating a more consumer-oriented, transparent and value-based health system. 

Dr. DeSalvo served as the New Orleans Health Commissioner following Hurricane Katrina. Prior to that she was Vice Dean for Community Affairs and Health Policy at the Tulane School of Medicine where she was a practicing internal medicine physician, educator, researcher and leader. She serves on the Council of the National Academy of Medicine.



I would like to see that this country makes an intentional effort to resource the public health infrastructure to protect and promote people's health every day, no matter where they live.

Karen B. DeSalvo, M.D., MPH, MSc Tweet



Part 1

Gary Bisbee 00:51

Early on, Dr. Karen DeSalvo considered a career in ballet until she thought about the time living away from her family. She then embarked upon a career in medicine, public health, federal government service, and she is now the Chief Health Officer at Google.

We divided this engaging interview into two parts. Part 1 includes Karen’s formative years and how they influenced her professional decisions.

We will discuss why she chose a career in medicine, her years on the Tulane medical school faculty, and the joy of being Commissioner of Health for New Orleans.

Karen is a self-described reluctant leader and we will learn how she overcame reservations to excel at leadership in multiple settings.

Well, good afternoon, Karen. And welcome.

Karen DeSalvo 01:42

Thank you, Gary. It’s so good to be here. Thank you for having me.

Gary Bisbee 01:46

We’re pleased to have you at the microphone today, as we’ve discussed, this show is about leadership. And you’ve certainly had a distinguished career as a leader. So we can’t wait to get into some questions here. Why don’t we kick it off? If you just think about your career, Karen, what are the prominent leadership lessons that you’ve learned?

Karen DeSalvo 02:10

Well, I have had, as you say, a really what some people think of as it is a different kind of career journey for physicians. But I think, for me all along the way, it’s been thinking about serving people. And in that service, it’s the lessons are about listening and not being assumptive. A mom taught me a lot about not assuming, but apparently I didn’t learn it as well until I was really in service. So it’s really I think, recognizing that though, I’m learned if you will get you know, I’ve had a lot of opportunity for education, there’s so much that you gain and learn when you just open your heart mind, especially to the people that you’re there to serve patients all the way to the world.

Gary Bisbee 02:57

What would the young Karen think about leadership compared to now, after you’ve held several leadership jobs? Did you recognize leadership early on is something that you felt you wanted to become part of?

Karen DeSalvo 03:09

I’m one of those reluctant leaders, Gary, I’m one of those people that I’m always surprised when I find myself in a position of leadership. There’s really, definitely one exception to that. And that was after Hurricane Katrina, when I very intentionally stepped into the void, because I felt that it was a responsibility that I had to my patients and to the community. But I find sometimes that I’m surprised when I’m asked to be on the board or run for an office or, you know, be that, you know, be the student council president or whatever that is. And I don’t, you’d think that by now, I would be accustomed to it. But I always, maybe it’s just because when I look around the room, I see so much talent. And I have to say, Gary is probably a lot of this is just I’m a hard worker, and I’m pretty tenacious, so I don’t give up when something’s important to me. And probably people recognize that and I get asked to take on responsibility and leadership across the way so but I will tell you this, young Karen, whatever way you define young Karen, how young is she? Oh, he asked you that question.

Gary Bisbee 04:17

I was thinking, you know, around medical school time, that’s that timeframe.

Karen DeSalvo 04:23

Young Karen, medical school, would not recognize this Karen. I think was really, she was thinking that she was going to be on a pathway that was definitely much more in the vein of a traditional clinician, and, and really, and practicing medicine as the bulk of what she did. So I think that the terms that I’ve taken in my career would be surprising, but I don’t think she would be surprised by the fact that she’s been asked to lead.

Gary Bisbee 04:48

Have you had mentors or others that you maybe have modeled your approach to leadership after?

Karen DeSalvo 04:57

I’ve had a lot,you know, one of the things I learned to do early in my career was to ask people I admired for their CV or their resume, and use that as a way to, to see what their journey had been like across their career. What was the first paper they published? What was the first role that they had that was significant enough to add to a CV and that way, sometimes I just learned about them. This is before Google, of course, that when you could Google someone’s name, I learned about them in the background. But I would say since I was very young, I’ve had people I’ve been able to look up to to learn from, and who have helped me through direct mentorship or sponsorship all along. I’m super grateful for that. I had one mentor, I’ll call out. A fella named John Peabody, a physician who was a formal mentor of mine for a career development award I had from the Robert Wood Johnson Foundation. One of the most powerful things John taught me was to say no, and you know, as a as a leader, We’re often asked to say yes, and be available and to step up to the plate. JOHN helped me realize that it was it was okay and sometimes necessary to say no, so that I could give my attention to the things that really matter to me. So, yeah, what a great example of how Somebody guided and steered and took the time to help me understand that there was going to be a lot of opportunity. I didn’t have to take them all at once.

Gary Bisbee 06:32

What was the first leadership role that you had that you definitely recognized? Hey, I am in a leadership role here.

Karen DeSalvo 06:40

It probably goes all the way back to high school, but I don’t think anybody wants me to go back that far.

Gary Bisbee 06:46

Oh, that’s fine, that’s fine.

Karen DeSalvo 06:48

I’ll pick one a little more relevant to medicine, which is being Chief Resident. That was a role I very much loved, being Chief Resident. I’m an internist by training and love, love, love, clinical medicine and richness of what you learn from not only medicine, but from patients and sort of the caring for them. And being Chief Resident, you have the opportunity to not only lead in a managerial sense, setting the schedules and understanding the needs and wants and wishes of all the residents and trainees, you do a ton of teaching, I spent a lot of time again, I’m dating myself, but in a library, looking things up to make sure I was up to the minute you know, and what the literature was, but also going back in time to understand the origins of why we practice medicine the way that we did, and I had in that role, also, not only opportunity for management and for role model leadership, that’s the teaching part. But also for good, this higher order administrative strategic work. And it was at a time when our residency training program was needing to undergo some improvements. And we were tasked by the new chairman of the department, he and the other chief residents to build a new curriculum, one that would really meet the needs of the time, that would really build the next generation of really high quality physicians. And so all mixed into that one role, I learned how delightful it is to be able to not only manage and be a mentor/role model, but also that strategic part of my brain that I would love to exercise and begin to think about building the future.

Gary Bisbee 08:25

For the younger, up and comer, leaders that listen to this show, what advice would you give to them?

Karen DeSalvo 08:35

You know, I always tell people to pace themselves, which Gary is not my best quality. As much as,John Peabody taught me to say no, and I’ve gotten better with each year. I also am a very passionate person, and I get excited, and like many folks, I want to take things on. And I want to do a lot of good in the world. And that sounds so silly when I say it aloud, but it matters to me. And it’s hard when you have that kind of a passionate drive to not only say no, but to know that you don’t have to solve everything right away. So I want them to realize that the journey is so important. The people that you’ll get to know on the journey will make you better, smarter, it’ll enrich your life and that you have to take time to build those relationships and experiences to hone your skills. Because you never know when that big thing is going to come. But if you’re racing towards solving that one goal and not really thinking about other opportunities, or not really giving yourself the downtime to reflect, and make sure that you’re making yourself better for the next turn of the crank, I think you don’t do yourself or others a service.

Gary Bisbee 09:53

Have you found that you’re better able to reflect now than you were when you were younger? I know I fall into that category.

Karen DeSalvo 10:00

I think I’m getting better at it, I certainly want to continue to be better. Like many people who are busy and engaged in work they care a lot about, you have to force to make that time and, when I was 40, I started running. It’s maybe a late age, so people would think to start running but it turned out to be and this still is my time that I reflect it’s the time that it’s just me and whatever the trail the street and my thoughts and I can just get out there and let the ideas begin to formulate in my head and put the pieces together. That reflection for me isn’t just about what happened. It’s about what could be and how what I’ve been seeing and know can fit together into a new opportunity, a new way for the work that we have to get done. So, I guess it’s my meditation Gary, but it’s running for me.

Gary Bisbee 10:58

Yeah, that makes good sense. Well, as a highly successful woman, if I asked you that same question, which is what advice would you have for up and coming leaders, would you modify that at all for up and coming women leaders?


Karen DeSalvo 11:15

Oh, you know, I might. And I’m in this really interesting generation where we started to learn that we didn’t need to be perfect at everything and nor could we be. And I think even as a kid I was raised that you can be successful professionally and personally and have great work life balance and take good care of your health and well being. And the reality is, it’s not quite that easy. And as we know, from the data, women do take on a lot of the family responsibilities, not only for their kids, but for extended family members, for their parents. And so, I think it’s expectation setting for them to know, again, pace yourself, you don’t have to achieve everything in the first 10 to 20 years of your career. It’s okay to prioritize family, it’s okay to be a human, I think is what I definitely want to say. So that’s sort of the pacing of being a human and acknowledging that you don’t have to be Superwoman to be successful. The second thing for women is this difficulty that we have of deciding whether we’re going to fit into a male dominated industry by becoming more like men in the male dominated industry, or if we’re going to change the industry to be one that’s more inclusive, I guess you could probably get a sense of where my head is about that. But I have this example I think of sometimes, when I was early in my medical career, I was the only woman in leadership in the Department of Medicine. I was the Section Chief of General Medicine, I was very early in my career, when I was asked to step into that role. And I was encouraged by some to wear like a scarf, the way that men wore a tie, so that I would dress the part basically, and I have always been a pretty conservative dresser. So that way, the issue of it was it was literally to add to my suit, something that would look more like a tie. And I thought that was such an odd comment, because I was much more interested in adding manuscripts and grants, peer reviewed grants to my armamentarium, than the outfit, and I think it was just so many lessons there. But one was I needed them to understand that I came with substance, that it wasn’t just the way I was going to show up physically and also try to assimilate into that world, I was going to assimilate from the standpoint of, I knew it was important to have peer reviewed grant funding, I knew it was important to publish peer reviewed quality manuscripts. But they also needed to understand that having a woman might mean that we’re going to have a different kind of culture that we’re going to have an inclusive one that would allow not just the Karens to show up, but all the women that I would help develop or help recruit to come into the environment, and we did. Tulane has become much more diverse in that frame. That’s where I was early in my career. And I think that the guys were super open to it. It was just kind of a knee jerk reaction, like you need to assimilate as opposed to, we should create a new way.

Gary Bisbee 14:24

What about you and your background allowed you to kind of be independent and just take that position? Because a lot of women, I don’t think, did at that point. Hopefully, life is more diverse now and more inclusive now. But what about you made you feel that you just wanted to go right ahead.


Karen DeSalvo 14:44

I wish I knew. And I’ll tell you a little bit about my background, Gary. My parents married pretty young and had a pretty unhappy marriage. My dad left when I was five. And my mom had three kids, including a newborn infant, my little sister, and I was the middle child. So she had her hands full raising the three of us alone, we were poor. And she didn’t have family to go to, so we were on our own as a unit like pretty early on with a pretty young mom. I mean, my mom was was only in her mid to late 20s at that time. So, she would scrape the seeds out of the cantaloupe, the first cantaloupe she’d buy in the season and dry them out and plant them in the side garden of the rental house that we had to grow our food. But she would do that with tomatoes and everything else. She sewed our clothes, we only shopped at Goodwill. I think the word I’m looking for is we were resourceful. We learned that super early and I learned that you could be scrappy and resourceful and still make it and also still get ahead. So that was instilled in me at an early age. And I think that gave me probably a sense of confidence that I could build things, do things where there hadn’t been something before and that was certainly true about what I needed to forge for myself professionally. No one had been to college or med school in my family, this was like a new thing I needed to build. I will say this other thing. So, that was very young Karen, I think younger Karen as a doctor, I hope this doesn’t sound egotistical, but I was a really good doctor. And so I was really confident about my abilities in that setting of a medical school as a really good doctor, a really good teacher, and I had a good understanding of the kinds of things that would make a difference in their world. So, I felt I was coming from a place of not just passion, but of certainty that my North Star and my abilities to get there were lined up. And that probably, when I walked in the room, gave me a sense of confidence that I wouldn’t have otherwise had. So what is it, confidence plus scrappiness equals successful leadership? I don’t know, that might be a new equation.

Gary Bisbee 17:10

Well, it certainly worked in your case, what At what point? Karen, did you think about medicine as a career?

Karen DeSalvo 17:18

I was young. I was about 13. And one of the things that my mom did with us after school since she was working was we went to the Austin recreation center, I grew up in Austin, Texas, and they had basically free after school programs, it was a place for us to go, that was safe. So in that environment, I took to dancing and acting, and definitely ballet and would spend hours there after school and into the evening. So I really thought I was going to go into ballet as a profession. And for a variety of reasons, certainly probably not in my head at the time, but in reality now, I probably wasn’t good enough. But I was being asked to audition, to go away to schools. And I realized I just didn’t want that life, I didn’t want to be away from my family at that time, I didn’t want to have that kind of a career as a ballerina that was really difficult and financially insecure relative to other careers. And growing up poor, it was really important to me that I have financial certainty. So that caused me to do a little thinking, maybe create a little table with some pros and cons and things. And I was at the same time doing a book report for a science class that I had. And I did it on radiation oncology because my mom was a clerk in an office of a radiation oncologist at the time. So I went there, spent an afternoon following him around and thought, well, this is cool. It’s science and helping people. And it seems like a very stable career, I should be a doctor. And that is pretty much the story. It happened over a very short period of time, I was pretty thoughtful about it at such a young age. And then, on the good, man, as soon as I stepped into it, born for it, like just yeah, that’s what I was meant to do. It’s really pretty great.

Gary Bisbee 19:21

That’s very cool. Now, what about policy and politics? Because that’s kind of intertwined with medicine throughout your career, when did you become interested?


Karen DeSalvo 19:35

You know, I think I had an inkling that I was interested in policy, even early in my academic career when I was doing health services research, because the gist of it is that I went from taking care of individual patients, and I did continue to do that for decades, but taking care of an individual with, say, diabetes, and began to understand from them and my relationship with them that their disease happened in the context I saw most acutely was the other doctors who care for them or the health system in which they worked. And that caused me to want to be a teacher, to teach other doctors to do great quality care, too. And then the next layer was, how can I make the hospital system higher quality? How can I make the ambulatory environment more accessible? That’s that layer of the system around them. And I think as I began to do that work, I realized that there were also payer systems, and community context, and these other concentric rings that were causing differential health outcomes, especially in the patients that I was caring for, which were largely from communities of color, or low income, or uninsured. So, when Katrina happened in 2005, Hurricane Katrina, and I was in the midst of teaching research, clinical care, and leadership roles in the medical school at the time. Something had to give, right, so the things that you care about. But though some things started to give, I actually ended up adding because I thought, well, I can make a bigger difference in the lives of my community, if I’m thinking about the policy context that’s shaping the way our health system is set up, or how transportation systems are set up, and that, for me, was just a sort of stepping back and reflecting at the time of that disaster that the poor health that I was helping my patients navigate, maybe this was our chance to shape policy so that then, not only for them, but the next generations to come would have access to healthy food, and green space, and public transportation that could get them to jobs and/or jobs that would give them meaningful economic opportunity, all those things leading to better health, in addition to great access to great care, including great primary care. So, it was very driven by my interest in helping my patients, honestly, I mean, it was just like, well, this will work. But, it’ll be better if we keep adding things. I think the politics piece, I’ll just make a comment about that, is one of the most interesting jobs I’ve had, it was when I was in the Obama administration. And I served as the Assistant Secretary for Health. And that is a job that very much lives at the nexus of science, policy and politics. And it was the first time I saw how crisply, not only are they intersectional,but how you can see data differently depending on where you sit and how important it is to have people who know community and know science and, you know, know medicine, to be in those seats and are thinking about all those things, contemporaneously. So they can balance them and make a good judgment. But I say over time, policy is a place where I just feel like there’s so much opportunity to do good. And it’s the place I always navigate back to. Politics, less interesting to me. Science, always interesting, but it has to be science-based policy.

Gary Bisbee 23:04

What were the circumstances that led to your becoming Commissioner of Health in New Orleans? And particularly, given how good a clinician you are, and seems like that was really a key part of your kind of professional being, at least for a while, did you have to give that up when you became the Commissioner of Health in New Orleans?

Karen DeSalvo 23:24

I had to scale back, but I still was able to practice while I was there. In fact, I still practiced a little bit when I was in Washington. But, I had already been scaling back, Gary, because after Katrina, my role increasingly became creating the environments in which people could deliver care. People just need to remember that everything was shut down, essentially. We had some emergency services at three hospitals in the area, but all of the safety net was shuttered. And so we had to build it back from scratch. And it was our chance then to build back something from scratch that was patient centered in neighborhood, that was really great primary care and mental health that we built up with these community organizations across the city that still is there and is serving, hundreds of thousands of people, really proud of that work. So, that was very much where my energy was being spent. And I was caring for patients in those clinics, but really wanting more to make sure that we were building up that environment and the policy environment to support it. So when Mitch Landrieu was running for mayor and I served on his health transition team, he asked if I would look at being held Health Commissioner for New Orleans and I gently said, “No, thank you. I’m the Vice Dean of the medical school and I’m on my academic track to being a dean one day. That’s what leaders do. That’s the leadership track that I was on, but I’ll help you find a really good health commissioner.” So, I spent a few months trying to help him find someone. We made an offer to a candidate, and she turned it down. And I was so relieved that she did, because I wanted the job. And I didn’t know until that moment. I remember the moment, I was driving back from Baton Rouge, I’d been doing some work there – Baton Rouge, the capital of Louisiana – and I heard that she had declined and I thought, “Oh, I’m so happy.” And when I got home, I called him and said “I want to do the job, but I’m gonna have to take a leave from Tulane because I’m still on an academic leadership path. I’ll be a dean.” So you know, whatever. Like, I still had that in my head. But, I said I want to come over and help. And I’ll tell you why I said “yes” to him. There are many reasons, phenomenal leader. But he also said to me along this process, “it’s great that we’re going to rebuild better quality health care in New Orleans and look at coverage, expansion and all this”, he said, “but I also want a Health Commissioner who’s going to think about all the drivers of all the kinds of health. So, health is physical, and mental, and social, and the drivers are physical, mental and social. And so, how can we be thinking about that broader view, widen the aperture”, as we would say out here. And I just thought, “oh man, to have a politician who gets that”. And he totally gets it. And I was there, I mean, a few hours the first day, Gary, I walked two blocks from, the medical school was two blocks from City Hall. And my life changed in that two block walk that morning when I went to my first day at City Hall, and I sat in the cabinet meeting, and listened to the people talking about transportation, and housing, and the criminal justice system. And it was all the stuff my patients had been telling me for years about what was interfering with their health. And it’s like, oh my God, everyone’s around this table that can help us build a healthier New Orleans. And this is where I should be. And so I struggled with that for a little while and kept thinking I was gonna go back to academics, but eventually I had to say, sabbatical probably over, I’m not going to come back to being Vice Dean or Section Chief, I’m going to step over into public service and see what I can do in this world. And I kept my faculty appointment there for a while, I guess probably somewhere in the back of my head kept thinking, I’m going to go back to that world. But, I was definitely built for public service. I will tell you that I love, love, love, love serving the community. I love that idea that when I get up in the morning, every decision I have to make is how will this improve the health of my community. It was a very wonderful job. The Federal Service was like that too for me.

Gary Bisbee 26:33

Looking forward, Part 2 will explore Dr. DeSalvo’s federal government service as Assistant Secretary for Health and National Coordinator for Health Information Technology.

She will share with us why she accepted the offer to join Google as Chief Health Officer and the opportunity that Google has to influence health care.


Gary Bisbee 00:51

This is Part 2 of an engaging interview with Dr. Karen DeSalvo.

In Part 1, we covered her consideration of ballet as a profession to deciding upon medicine and the joy in leading public health as Commissioner of Health in New Orleans.

In this episode, Karen explores her federal government service as Assistant Secretary of Health and National Coordinator for Health Information Technology, where she studied the importance of the HITECH Act in accelerating the digitization of medicine.

Karen will share why she accepted the offer to join Google. She reviews the role that Google played during the COVID crisis, which is not generally known. She describes how it drew on her experiences and understanding of public health.

We wrap up the conversation with Dr. DeSalvo by discussing her bucket list and the movement toward public health 3.0.

Well, what led to go into Washington then, how did that come about?

Karen DeSalvo 01:57

It’s all Mitchell’s fault. No, it’s the work that we had done in New Orleans that was on the radar of the people who were in the administration, not only working building great primary care that Kathleen Sebelius had been tracking and knowing about, but I’d been very involved in a lot of the health information technology work for the state of Louisiana and for New Orleans after Katrina. It was a time, you might remember, when there was a lot of money coming out of Washington to support the digitization of the care experience. And I was involved in all three of the grants, I was either on the governing group or our organization was leading the execution of it, or we were a part of that. That was for two of them. And the other ones, so there’s a beacon grant, which was population health, and there was one about the last mile of implementing EHR, and then there was one about the Health Information Exchange. So I got to know all the ONC people, basically, the Office of National Coordinator. And when they needed a new national coordinator, they called and said, We think that you’re just what we need, because you know how to implement technology in medicine, and public health, and community health. Would you come to Washington and be a part of the team? I said, “Thank you. No, not at all. I’m not interested in, I’m not a technology person. I’m a community and public health person. But, thank you.” And you know, then they call back and they said, “Just come talk to us.” And so I did. And then they said, “the Secretary wants to talk to you.” And I said, “I don’t want her to call me because I don’t want to have to say no to her.” And she called me on a like a Saturday, it was this Kansas phone number. And I thought it was a sales call. So I didn’t answer it. And then I listened to the voice message. It was Kathleen. And I was like, “Oh, now I got to call her back.” And she’s so smart. She said, she said, “Don’t say no, don’t say anything, just listen.” And then she explained, like, how she was thinking about, it’s kind of like Mitch, you know, had this same view of the world. She had a view of the world that aligned with mine, that technology wasn’t the end game. The end game was equity and health and these things I care a lot about, and that she needed. She needed that kind of experience on the team. So I joined. And I said yes, like a few days before healthcare.gov went south, by the way. So that was also an interesting, interesting window. I wasn’t in the administration at the time, but I thought, oh, that doesn’t look like they’re having fun. Anyway, it was wonderful. And I loved working for her. And I loved working for Sylvia, who’s the secretary that followed. Different women with different ways of working and seeing the world. And it was a wonderful experience to kind of be in that work. So yeah, it’s that reluctant leadership thing. I’m the worst example of it. Although it was not like that for Google. I can tell you, they called I said, “when do I show up?”

Gary Bisbee 04:03

Yeah, that’s an entirely different opportunity, isn’t that? Before we get to that, though, a bit, but it’s kind of related in that, you know, if you think about the HITECH ACT, which fundamentally digitize medical care, broadly, I would say, and then the ONC position, which really allowed you to see that. How important was the HITECH ACT, you think, to medicine and this decade and next decade, and the Google position is kind of right in the middle of all of that, I think.

Karen DeSalvo 05:20

That was pretty obviously transforming for the way that we think about health as not just a one-off experience that people have when they’re sick and not something that’s owned and controlled by physicians and healthcare systems, but that democratizes that disparate experience for people. It sounds super lofty, but that’s the way I always saw it, I saw it as, yeah, this isn’t data that’s going to live in a paper chart in the back of someone’s office, this is now going to be your data as a consumer that you can share, that you can make available for efforts like precision medicine, so for science to advance that work that you could make available for public health, that you can make available to other providers to your family. It’s a really empowering thing for consumers if done properly. And for clinicians. I mean, as difficult as it was for us, just even being able to look someone up when you’re on call after hours for your group and know that they were started on a drug that day. And that’s probably why they’re coughing or having this new symptom, it’s pretty dramatically life changing. And that was the first kind of taste certainly for me, when you’re doing group call, to be able to have that information. But then there’s so much more that that’s expanded. And I think we’re only obviously just beginning to understand it. You know, Gary, you asked me earlier about words that I think of in leadership and ONC is reminding me of something that has been a hallmark of my career, which is turnarounds, turnaround/building. And I love that kind of stuff. And ONC was an example of a turnaround, and so was the health department in New Orleans, and a lot of my work at the medical school. But when I arrived at ONC, it was a place where they had gotten really laser focused on Meaningful Use, which was this government program, that for people who don’t know, to incentivize electronic health records by paying basically for their adoption. But the program was overreaching and creating so much friction with doctors and others that it was causing people to not want to move forward with modernization. And that the team had kind of gotten so heavily focused on it, they’d lost sight of all the other important work that we needed to get done. And my thing was put down your pencils and let’s figure out, what are the authorities and responsibilities that we have to the public? And how should consumers have better access to data? But when I say turnaround, I also stepped in at a time when that HITECH money from that act was at the cliff. That’s right, we got it, we got an infusion of a couple of billion dollars into this tiny little office of 60 people, it had been only about 12 people, it ballooned to 60, you had a lot of contractors, and the budget was ending. And it wasn’t really known to the team and, honestly, wasn’t known to me until I understood and I realized we were going to have to go from being a grant making organization to being a policymaking organization in the span of like six months. Thank goodness, we had a lot of good policy chops from the original people who have been policy oriented. But it also meant people who were good at giving out multi-million dollar grants needed to work in other parts of the government or somewhere else that did that work because we weren’t going to do it anymore. And it was such a great experience for me to think about doing that. I’d done it at the local level, I’d done it at the city level. Doing it at the national level helped me understand some of the change management components, but also just like how even how important it is to ask, maybe it’s about asking the right questions to make sure that you’re understanding what your remit is going to be when you step into the org. I think the other thing about the turnarounds in all of those cases also was the turnaround of the trust that the community had in those organizations. Trust was certainly weakened in our health department in New Orleans in ONC when I arrived at those organizations, and it was super important to me that, when I walked out the door, that those were trusted organizations because I felt both of them were really important as part of the ecosystem going forward.

Gary Bisbee 09:50

What would you advise, or you probably already have, Micky Tripathi, who’s the current ONCE leader, what advice would you give to him?

Karen DeSalvo 10:00

Yeah, you know Micky’s terrific, and I think he’s just the right person at the right time for this job. And part of that is because Mickey understands that the responsibility and the opportunity for the National Coordinator is more than just EHR is in the healthcare environment. But, that EHR, he understands it’s a source of data, not the source of data. There’s this opportunity to tell the story of someone’s health by understanding their social context and pulling in data from not just medical devices, but social determinants and other sources. And he understands that there are multiple use cases, not just healthcare, but public health and science. It’s where we were going. And I think, it’s not that Don Rucker didn’t understand it, but Don definitely had more of an interest in understanding the medical context, I think, towards the end began to see that there’s a real need for the National Coordinator, to ensure that they’re understanding the responsibility that they have to coordinate across government and with the private sector, for a lot of reasons. One of them is the coordination is about giving certainty to the marketplace, so that there’s a nonpartisan, pragmatic approach to how we’re going to digitize not just the health care experience, but the health experience of Americans and use that to inform daily health work. And as we’ve seen in the pandemic, it needs to be able to inform public health and forecast future health challenges. So when I told Micky that, he was already there. And I know that he really understands, technically as well as from a relationship standpoint, the important things that are going to have to get done going forward, especially in partnership with the CDC. I’m excited about it. And he’s got a fabulous team. And Don did too. And Don was really good. Don Rucker was the last national coordinator. Some of the people who work there have been there since the origins of the office of National Coordinator, and there’s some serious talent in that office.

Gary Bisbee 12:11

Well, it’s much needed, that’s for sure. And it’s good to hear you kind of express your confidence in the group. Well, thinking about Google, which in many ways, it seems like you’re ideally suited for that job. But, what was the opportunity you saw in going to Google?

Karen DeSalvo 12:31

You know, when I left government, I had been working at the intersection, to use a kitschy phrase of public health and technology and medicine. But I literally was doing that, because I was National Coordinator at the same time that I was Secretary for Health, and was co-leading the delivery system reform work. So I was in all of those spaces in any given day, you know, or hour of the day-

Gary Bisbee 12:54

That’s in the category, Karen, if I can interrupt, that’s in a category of just taking on too much responsibility. You’re maybe learning, but I don’t know.

Karen DeSalvo 13:06

Most definitely. I mean, in the framework of giving advice to yourself, I totally failed at that. You know, I was National Coordinator. And I was in the middle of finishing that turnaround, and we weren’t quite done. And I hadn’t rebuilt the leadership team. Ebola got very hot, and there was not an ASH. And the ASH, this is the Assistant Secretary for Health, oversees the Surgeon General and the Public Health Service Commissioned Corps. And is the director of blood safety for the country and has some other roles. And so they needed an acting assistant secretary, because, in particular, the Commissioned Corps was going to stand up a hospital in West Africa for Ebola, but there were a series of other things that would be happening, and we had an acting Surgeon General. So there were some reasons why they needed some additional leadership there. So they said, “Would you step out”, it was literally down the hall, like the two offices were down the hall from each other. I was like, sure, whatever. It’s just down the hall. So, I took that on, thinking that I would phase out of being National Coordinator. There was, you know, there was a need for me, though, to stay on as National Coordinator for a while, and then it became, well, we’ve kind of figured out how to do it. And let’s just keep going for a bit. And I did until Vindell Washington joined and then he, for the last few months of the administration, was the National Coordinator. So, we could tell stories all day about that, but I’ll tell you a couple quick things, which is that the delivery system reform work was another really fantastic effort of Patrick Conway, but it became less and less of my time than it had been when I first stepped in. So it wasn’t as three full time jobs. It was really towards the end mostly two, but those were two principal roles. So, I wouldn’t have known this before I went into government, but those are two externally facing principals that are expected to do a lot of stakeholder management, to give a lot of speeches, to be out in the country, I had 10 offices as the ASH. So I was, you know, visiting those as well. And so my calendar was pretty full. I was really, and God bless my team, like my Comms team and everyone else were like, “I’m sorry, which Karen is this”? But yeah, so what happened is that it became so clear to me and everyone else that there’s wonderful things about public health that could inform what technology needed to do, this, you know, understanding about, there’s some appreciation of population health and ethics and equity. There were also things about technology that needed to be informing public health. So increasingly bringing those worlds together and this report that we did, Public Health 3.0, is a very crisp example of how those worlds got married for me and in a future vision of where the public health infrastructure should go. So yeah, I wouldn’t do it again, necessarily, but I think the outputs have been good. And it led me to Google, quite honestly. And so, when they called and said, “Are you interested in coming here?” I was not being flippant earlier when, I said, “Oh, yes. When do I show up?” Because to me, it’s a place where not only do I have the scale of the world, but you have the world’s attention in this really promising way where the community wants information, they want knowledge, they want help. And, you know, whether I was a doctor or a public health person or a public servant, that’s what I’d get up in the morning to do, right, how am I going to help? How am I going to help this person when they have questions? Now, what’s the world asking us on Search, on Maps, and YouTube. And so, that was sort of one piece as a direct connection to the consumers in this really scaled way. And I’ve always felt like we’ve not figured that out well on health. We talk to doctors and debt payers and health system leaders, but there’s not an not a true B to C, business to consumer, way of giving them the information they need at scale, to really take the reins of their health. And so, that was one really attractive piece. The other thing is we’re like missing this chance, I think, in this century, to leverage AI and sophisticated methodologic approaches to augment work of medicine or the doctor or the nurse or public health writ large. And it’s essentially a new way of ingesting complex data, which we’re overwhelmed with, right, of trying to get to be horizon-al in our strategically thinking about improving the health of a person, or community. And it’s just, I think when we figure it out, we’ve got to make those models fair, and equitable. We’ve got to think about how they’re most useful in a workflow. You can’t just throw AI into the clinical environment or the public health environment. And that’s how you get, we’ve had this incredible journey, the last, you know, whatever, 15 months of the pandemic, of learning, of now learning as a company, not only, here’s all of our tools that we can have, but how can we be useful and just accelerated the conversation with all of those actors that I mentioned, consumers, public health medicine. So it’s, coming here is just working with brilliant people who have amazing talent to do good. And we have a reach, and people are knocking on our door every day wanting that kind of help. And I mean, how could you say no to that?

Gary Bisbee 18:40

No, I don’t think you can. I’m glad you didn’t. It also strikes me that, now that you’re there, you probably see even more opportunity than you thought when you went there. Is that true?

Karen DeSalvo 18:53

Most definitely. You know, when I came, it was to be the Chief Health Officer in Google Health, which I still am, which is a group that does research and builds products that are for clinicians and consumers, broadly, to think about how we can apply AI to give superpowers to both of them. But the pandemic taught me very fast about all the rest of the company, you know, sort of what are the ways that we can think about YouTube as a way to mass-customize content for high risk communities in whatever area? What are the ways that we think about leveraging ads in partnership with community based organizations to help people know what kind of resources are available to them at the local level to get transportation to food banks? There are just a lot of ways that you can do the public health good. I think what I definitely am learning here is that we have some novel signals that will be useful to medicine and public health, and to community health. And we’re just beginning to exercise those muscles. You know, we’ve put out work in climate change, for example, that’s looked at flooding and really important impactors of health. We’ve been doing this with search data that we’ve made available to academics and to the public health community and to healthcare systems to do some forecasting. So I think the novel signals piece, I’m just beginning to understand the power of the data inputs, I guess that the AI is the methodology of that data, and then the audience and sort of the partnerships and the use that we might do. I’ll be here 10 years, and I’ll still be trying to figure out all the amazing ways that we can be helpful, but it’s a pretty incredible place.

Gary Bisbee 20:45

What about thinking back when you were Commissioner of Health in New Orleans? I mean, do you see health departments being able to work directly with Google to help the fact that, you know, a lot of these health departments just aren’t well resourced and they really do need help? Is there some connection there that you’re thinking about?

Karen DeSalvo 21:07

Oh, we’re doing that. Yeah, I mean, the expression I always have for when I was Health Commissioner is that we did it with two nickels and some friends, and it is not that far off, you know. And the New Orleans Health Department is small and super under-resourced, and it’s, you know, in much better shape because the people there have just done amazing work, my team when I was there and they’ve continued that on. So it’s in better shape, but it’s still incredibly under-resourced, and doesn’t have, you know, teams that can ingest big data and analyze it and create data visualization tools. And just as an example, especially local health departments are that way, but some state, and so as we thought in during the pandemic, about how we could be helpful, those are some of the kinds of tools that we’ve offered. So, let me use the search symptoms trends as the example but I’ll give you two, that’s the first one I want to use. Because one of the first things that I said to our researchers here when I got here was when I was Health Commissioner, to get information about the pulse of my community, of what they needed, I could look at very stale EpiData that had been collected two years prior. So that was a rearview mirror look, then I would sit in church halls and community centers and drink stale coffee that we brought, whatever, to talk to the community and figure out what was on their mind. I often say that what I learned in those first few weeks as Health Commissioner is that what the data said was people were dying of cardiovascular disease and cancer. And what people told me when I talked to them was that people were dying of violence and lack of economic opportunity. And those things actually do relate to each other. The allostatic load from those issues relates to developing cardiovascular disease, there’s biologic plausibility there, that I wouldn’t have seen if I hadn’t been able to talk to them. So I said to the teams, is there a way to get just cross-sectional data from Search that would tell a local health commissioner what their community is thinking about. And that’s what search symptoms trends is, that’s what they felt. It’s much more sophisticated than I could have ever imagined. But it’s that idea that can we create an anonymized set of data that would tell a local health officer in the last day, and then comparing the last three years, these are the kinds of things on the top of the mind of your community. So that is a tool available, but we also knew that it would need to be, we need to create the data visualization tools, and we’d have to support and help. So we’ve done that as well. Now, the more concrete way that we’ve been working locally during the pandemic is, there are so many examples, but I’ll use the exposure notifications as the example. And that’s definitely more at the state level than local. But what we heard from Local Health Officers was we need to do contact tracing, we need to scale it, people are not answering their phones when we call them, can you help us. And so working with Apple, we created this digital contact tracing tool that augments the work of regular contact tracing, augment being the operative word, it doesn’t replace, and longer, lots of story about that. But it’s this idea of these brilliant engineers realizing that Bluetooth Low Energy is a really pretty good way to see who’s been within six feet for more than 15 minutes of another, which phone has been close to another phone. And you could use that as an anonymous way to notify people of exposure. So it would protect privacy, it would give information to public health. And it would be a technology that public health would know. In fact, when the engineer said, would Bluetooth Low Energy be an option, I said, I don’t even understand what you’re talking about. Like, you have to help explain this to me. And they said, well, we’re just gonna build this API around us. Okay, well, we’re gonna have to back up and really get the glossary out and make sure everyone understands. We did. I lost count honestly, Gary, but we talked to dozens and dozens of local health leaders, including at the county and the city level and at the state level, and national associations, over the course of months to explain to them what we could do, how it could be helpful, to get their feedback to keep iterating. And we’ve been doing that still, of course, across the pandemic. What that builds is not just a tool called exposure notification, but it has built relationships. So now our company has first name in the trenches experiences with Health Officers, and with public health, trade associations like ASTO, and NATO, these, you know, the alphabet soup of the really important groups that represent those health board health officers that we can build on for the future. And that coming out of the pandemic is what I’m super excited about because we did help. We want to keep helping, but we need to do that with them is the point, like we can’t just build it in a vacuum. And now we’ve got these really strong relationships forged. And as we speak, we’re speaking a similar language. And I’m excited to see what we can do next.

Gary Bisbee 26:20

Yeah, it’s very cool. We’ll look forward to continuing progress there. Can I also ask about Google, maybe as Google Cloud has a relationship with some of the larger health systems Mayo, Ascension, and recently signed some kind of partnership arrangement with HCA. Can you just give us a real quick thumbnail sketch of what the purpose of those partnerships is?

Karen DeSalvo 26:47

Oh definitely, yeah, we already had stronger partnerships with the healthcare ecosystem before. It’s kind of typical, right, for tech and healthcare to be partnered up. So I emphasize a lot the new public health piece, but we’ve continued to progress. And our work in Google Health, in partnership with Cloud, with those partners that you mentioned, the product and services work, there is a mix of things. It’s spanning what we call, a tool we call Care Studio, which is a tool we’re developing right now with a subject that is user interface for the electronic health record that makes that data intuitive and useful in the way that we’ve made the world’s information intuitive and useful through search. I’m overplaying it. But that’s the vision. We’re not all to that place right now. But what we’re trying to get is something that feels familiar, light, airy, intuitive, and helps with the experience of retrieving and documenting an EHR. And we have other partners interested in doing that with us, Beyond, Ascension. We’re also with Cloud and trying to understand how we can help our partners with analytics and with prediction models, so leveraging some of the AI and other tools to help them do some forecasting work. There are some good examples of how that’s happened during the pandemic, particularly around COVID. But there’s other work that we’ve worked with that we’ve done in that space. And then the other big bucket I should mention is work of applying AI particularly to diagnostics and therapeutics, again, with all those partners. The example in the NHS is we’ve been working with them on mammography readings, so can AI augment the reading of a human radiologist to give a second read and accelerate the time till the woman gets her results? In the UK,the NHS requires two reads and having enough radiologists to keep up with that causes some delays in the system. We’re doing Mema work with Northwestern Medicine right now in some other places. Also, we’re doing work with Mayo and therapeutics with radiotherapy in particular. So is there a way that we can accelerate the work of radiation therapy for head and neck cancer to identify what’s the right field to radiate? And these and other examples, and diabetic retinopathy, and our work in pathology in general, I think speak to not only the power of AI, but also the importance of computer vision, which are related tools that just, when you take an image, right, can we help advance the diagnosis of that condition, and accelerate the pathway for the patient? And can we also help when in the space of treatment? So those are some examples of the ways that we’re thinking of being helpful with those healthcare partners.

Gary Bisbee 29:40

Karen, we’re gonna have to land not, because I’d like to, but you need to get back to what you’re doing. But, this has been an exceptionally interesting and engaging interview. I do have one last question if I could, and that’s the bucket list question which is, given all that you’ve done in your career, is there any professional, kind of, on your list that you have yet to do?

Karen DeSalvo 30:08

I think I’d say it more like, there are things that I’d like to see resolved. And I don’t know if they’ll get resolved in my lifetime. But one of them is, I would like to see that this country makes a real intentional and significant effort to resource the public health infrastructure, to give it the tools and resources it needs to protect and promote people’s health every day, no matter where they live. And that’s the Public Health 3.0 work and some efforts that have grown out of it, I think we’re making some progress. But, I just think it’s such an important part of the ecosystem, health care is so important, you know, the payer space important, everybody, there’s a lot of parts of the actors in the sector, but public health is the only one that has the statutory responsibility and accountability to protect everyone’s health who lives learns, works and plays in their jurisdiction. And they’re an important partner to the important work that that medicine does. And I would very much like to continue to be able to support public health, but do it in a way that’s not just projects, but see that we respect and acknowledge that we have to bring them back into the family. So that’s on my bucket list still.

Gary Bisbee 31:30

Well, my position on that is we need you back in Washington, Karen. So when you wrap up at Google, why don’t you head back, we need you there.

Karen DeSalvo 31:40

I’m very happy where I am, but thank you for saying so. There’s a lot of great talent that I’m really excited about there that I think is doing really important work.

Gary Bisbee 31:46

Once again, thank you so much for your time. Terrific interview. Thank you again.

Karen DeSalvo 31:50

Thank you, Gary, it was great chatting with you. I really appreciate it. Thanks everybody for listening.

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