After a track record of success since it was founded decade ago – including a crucial five years in which it helped the federal EHR incentive program effect huge advances in the IT infrastructure of the U.S. healthcare system – the Office of the National Coordinator for Health Information Technology seemed to find itself at a crossroads in 2014.

With stacks of hefty incentive checks already mailed out for Stage 1 meaningful use – $23.7 billion as of June – but providers clearly struggling with the measures of State 2, ONC appeared to be at a bit of an impasse. 

Money earmarked for health IT by the American Recovery and Reinvestment Act in 2009 was never going to last forever, of course. And so, this spring, DeSalvo announced plans for a rethinking of the agency's hierarchy as it starts to "pivot" away from its first, more well-funded task – helping foster electronic health record adoption – and moves toward the tricky "next chapter" of interoperability.

"The HITECH Act's health IT infrastructure and program investments are ending and it is our responsibility to take this opportunity to reshape our agency to be as efficient and effective as possible," she said. "Now it is time to begin the next chapter to promote interoperable health IT solutions that support the ultimate goal of better health for all."

In May, DeSalvo unveiled a "flatter and more accountable reporting structure" that she hoped would be more conducive to priorities such as patient safety, consumer engagement and interoperability. She announced 10 new offices within ONC that would help steer the way toward the agency's next phase.

Even as she was doing this, Congress was asking questions. In June, DeSalvo received a letter from the House Energy and Commerce Committee, asking her to explain "what statutory authority" ONC has to regulate health IT and EHRs, and what role it envisions itself playing, in the near future, "on issues including, but not limited to, health IT safety and EHR certification requirements." among others.

In July, the Senate Appropriations Committee, in laying out a potential 2015 for the Department of Health and Human Services, suggested earmarking just $61 million for ONC – less than the $75 million that had been requested.

Moreover, it did so with proverbial strings attached. The committee averred that ONC should name and shame the vendors that stand in the way of interoperability, and "take steps to decertify products that proactively block the sharing of information."

DeSalvo has put interoperability front and center since she took the reins, most notably with the framework put out by ONC in June: "Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure."

"We have heard loudly and clearly that interoperability is a national priority," DeSalvo wrote at the time. "We also see that there is a tremendous opportunity to move swiftly now." 

But that momentum was threatened within a few months with announcement that the much-respected Doug Fridsma, MD, would be stepping down from his post as ONC's chief scientist – a position responsible for "all programs that are focused on providing a foundation for interoperable health information exchange," according to his ONC bio.

Fridsma’s leave-taking – to become CEO of the American Medical Informatics Association – came on the heels of other high-profile departures, including Office of Consumer e-Health Director Lygeia Ricciardi and Chief Privacy Officer Joy Pritts.

Soon, more moves followed. Judy Murphy, RN, who served in multiple key roles at ONC including chief nursing officer, left the agency in October to become chief nursing officer at IBM Healthcare Global Business Services. Murphy gave "passionately and tirelessly to the entire health community," DeSalvo wrote of her tenure.

But the big news came later that month, when DeSalvo herself was appointed by the Department of Health and Human Services to take on a new role, acting assistant secretary for health, to help HHS coordinate its Ebola response team.

ONC announced that Chief Operating Officer Lisa Lewis will serve as the acting national coordinator, and that “DeSalvo will continue to support the work of ONC," in her new role.

But doubt about the agency's staffing peaked that same day when word came down that Deputy National Coordinator Jacob Reider, MD – in a move apparently long in the works – would be leaving ONC in November.

The fact that such a critical brain drain was occurring at ONC, at such a pivotal time, raised a number of questions: Who will champion its interoperability roadmap and strategic plan? What does all this mean for meaningful use? Will HHS Secretary Sylvia Mathews Burwell appoint a new permanent national coordinator in the near future?

We weren't the only ones asking those questions. In the wake of DeSalvo's role change and Reider's departure, the American Medical Association put out a statement expressing concern that the "leadership gap" at ONC might hinder interoperability and meaningful use

As DeSalvo wrote in a post on HealthIT.gov, "ONC is far more than one or two leaders." Rather, its team "is personified in each and every individual – all part of a steady ship and a strong and important part of HHS' path toward delivery system reform and overall health improvement."