Delivery of Care

Neil Sarkar presents his recipe to change health care in RI

‘If we can truly enact change in Rhode Island, the rest of the nation will follow’

Photo by Richard Asinof

Neil Sarkar, president and CEO of the Rhode Island Quality Institute, the home of Rhode Island's health information exchange, CurrentCare, spoke at length with ConvergenceRI about the integration of data and AI in health care delivery in Rhode Island.

By Richard Asinof
Posted 6/24/24
Neil Sarkar, president and CEO of the RI Quality Institute, believes that Rhode Island is he place to solve the national health care crisis.
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PROVIDENCE – Neil Sarkar, president and CEO of the Rhode Island Quality Institute, the home of CurrentCare, the state’s health information exchange, occupies a unique position in the delivery of health care in Rhode Island.

Sarkar is in charge of the flow of data across the numerous platforms used by health care providers in sharing electronic medical records. His job is to ensure the quality and reliability of the data.

As ConvergenceRI described it in an interview with Sarkar in October of 2023, talking about data with Sarkar is much like “participating in a therapy session with a skilled practitioner of the science of data.” Sarkar is also the founding director of the Brown Center for Biomedical Information.

CurrentCare is in the midst of a major operational change – moving from an opt-in system to an opt-out system; currently [pun intended], only about 50 percent of Rhode Islanders are enrolled in the health information exchange that allows patients and providers to share data across systems.

The state of Rhode Island recently concluded a procurement, selecting a new vendor to provide the underlying technology stack for the health information exchange, deciding to move from Intersystems to CRISP, a firm located in Maryland.

As a result, Sarkar told ConvergenceRI, it was difficult to talk about timelines regarding the rollout of the opt-out system, which will result in roughly 90 percent of Rhode Islanders participating in the data exchange program.

“I can talk about the procurement because it is now public,” Sarkar explained. “The technology stack that the state originally had selected was a company called Intersystems, which is the underlying technology stack for the majority of health care around the globe. They underpin large medical record systems like Epic. They also have a portion of health information exchanges in the country.”

The state, Sarkar continued, “went through a procurement process and decided to go with a different vendor and transition to another entity that is an outfit out of Maryland, called CRISP.”

As a result, Sarkar said, the Rhode Island Quality Institute is “going to be transitioning from Intersystems into this new technology platform in the next year. The contracts were literally just signed last week.”

ConvergenceRI responded with an attempt at humor, a kind of dad joke: “Are news reporters beating down your door to get this information? I think not.” Was it better to work under the radar screen, rather than have a lot of media attention, ConvergenceRI wondered.

Sarkar replied: “From our perspective, it’s a technology; it’s changing from one computer system to another computer system. There is always a transition cost. It’s no different than a hospital system or a health care entity changing from one electronic medical record system to another. The day-to-day shouldn’t change.”

When culture eats strategy for breakfast.  
The challenge in all of health care, Sarkar  told ConvergenceRI, attempting to frame the difficulties of building a collaborative framework around sharing health data, is that “it comes right back to the famous Peter Drucker quote – that ‘culture will eat strategy for breakfast.’ The challenge in all of health care is that the culture of health oftentimes gets in the way of strategy, especially in the IT space,” adding: “Where even if there is an IT solution that makes sense, if the culture isn’t ready for it, it’s a non-starter.”

Here is the ConvergenceRI interview with Neil Sarkar, one of the more astute participants within Rhode Island’s innovation ecosystem, at a time when Rhode Island is experiencing a major crisis in health care delivery.

Sarkar was blunt in his assessment: “I think there are a lot of complex pieces in health care. And I don’t think there is a magic wand that anyone can wave and, all of a sudden, all we have are solutions. I think we have to be honest about how health care currently functions. I think that there are a lot of challenges. I think we will get there. I think we will need to get there. Otherwise, health care as an enterprise will go completely bankrupt. And worse, patients, will feel the brunt of that.”

ConvergenceRI: Did you get a chance to read the story in today’s edition, “Bang the gavel slowly?”    
SARKAR: I just finished it.

ConvergenceRI: What did you think?    
SARKAR: I think it was a good summary of the event [the health care summit].

ConvergenceRI: Were you there?    
SARKAR: Oh, yeah

ConvergenceRI: Did the story hang together?    
SARKAR: I thought it did, yes.

ConvergenceRI: It was not a “he said this, she said that” kind of story. I chose to focus on what I saw as being problematic with Optum.    

ConvergenceRI: …which is legally part of the effort to move toward accountable care organizations. Yet they are just a really bad actor across the board, in my opinion, in everything that they do in health care. And there appears to be no real consciousness or awareness of what they do or the role that they play – and no reporting on it. Here we have this big health summit, and they are not part of the conversation.    
SARKAR: I have no insight into why or why not they were not included in the conversation.

ConvergenceRI: I guess I look at it and say: That is why ConvergenceRI is so important. Because no one else is going to be covering these things to that degree. Or, if they are, you don’t get the insight. I’m not trying to pat myself on the back; it was a difficult story to write, and I wrestled with it for a long time.    
SARKAR: I think that it is important to have multiple perspectives right now. I think that across the spectrum with media, I don’t think there is one absolute, complete truth. I think that there needs to be multiple, complemetary sources of where we get our news from.

ConvergenceRI: I’ve been looking forward to our conversation. In our last interview, you talked a bit about the problems related to AI, health care and story telling. About understanding the differences between the storytelling that occurs between the patient and the provider, and the story created by AI technology, and understanding what the differences were.    
SARKAR: …And, to really have appreciation for why there is a lot of the excitement around the influence of AI in health care. It has been around for more than 60 years.

I think it is very popular now, with things like ChatGPT and the like, but the use of AI has been in health care from the moment we began using computers in the 1950s and the 1960s. It is embedded in almost every clinical workflow, and has been for more than 40 years, for sure.

There are questions now of the more capabilities that we simply weren’t technically capable to do with the limitations of computational power and accessibility that entities like OpenAI and the big tech players who are in the game are now actually able to unleash.

ConverenceRI: Can you elaborate on what that means?    
SARKAR: The [new technology] is nothing more than large language models.

They are language models; they have perfect grammar. They are very well tuned to statistical machines that work based on previous examples.

And they are excellent at that, without a doubt. They are able to go through reams and reams of data and develop these very cogent syntheses that would take a human a long time, simply put. But they are fundamentally not new. They’ve been around conceptually since the 1940s, in terms of what people now refer to as neural networks and the like.

ConvergenceRI: How does that impact your work, in terms of the health information exchange, and the way you process data?    
SARKAR: We are not looking at AI modalities for supporting the health information exchange. We are focused exclusively on the exchange of data. It’s up to the provider organizations about how they will leverage AI and the various ways of interpreting the data that we provide. But our first and formal charge is to ensure the fidelity of data as it goes from one health care provider to the other.

I don’t see us, in the near future, modifying or changing data or using AI or any such technology to provide potential diagnoses or even summarization – those things are really up to the provider to do.

We have always built into our systems the ability to standardize and normalize using a variety of computational and normalization techniques. So that when a medication is reported by one entity, that medication can be translated into a form that the receiving entity can understand it.

ConvergenceRI:  Where do you stand today? When we last talked , about 50 percent of the Rhode Island population were members of CurrentCare. Has that number increased at all in the last few months?    
SARKAR: We’re still holding steady. Our plan in the next year or so, but I think it will be at least a year, maybe more, as we convert from our opt-in consent model to opt-out. And as we shift to opt-out, based on what other states have found, we expect that 90 percent of the state’s population will be in the exchange. The delay, and why it is hard to put out timelines, is the state has re-procured the technology that we used for the health information exchange.

ConvergenceRI: In terms of your collaborative work with other states, I know that you have engaged, I believe, with Vermont, and Maine, and Connecticut, to develop a collaborative platform around sharing of health information. Is that still proceeding? Are there new players as part of that collaboration?    
SARKAR: This is a New England-specific collaboration. The states with health information exchanges are regularly sharing concepts, ideas, and best practices.

ConvergenceRI: Where does Massachusetts fit into all of this?    
SARKAR: Neither Massachusetts nor New Hampshire have a health information exchange.

ConvergenceRI: Has the mood improved in the delivery of health care? When we talked last time, there were serious qualms about many people entering the field about whether delivering health care services was actually what they wanted to do, because the rewards were so negligible. Has there been any shift in the culture.  
SARKAR: The good news, Richard, is that we talk often enough, that if there were things changing, we would know. But the bad news is that change in health care does not happen that quickly.

ConvergenceRI: Why is change not happening quickly?    
SARKAR: I think there are a lot of complex pieces in health care. And I don’t think there is a magic wand that anyone can wave and, all of a sudden, all we have are solutions.

I think we have to be honest about how health care currently functions. And, I, along with many in health care leadership positions across our state, really do want more and more [invested] in accountable care. And taking care of populations and ensuring that we have the best preventive care services available.

Those are nice words to say. I can stand up and give a wonderful speech about it, but it is really hard to enact. I think that there are a lot of challenges. I think we will get there. I think we will need to get there.

Otherwise, health care as an enterprise will go completely bankrupt. And worse, patients will feel the brunt of that.

One of the things I am proud of in Rhode Island is that the payers, the health systems, entities like mine that are somewhere in the middle are all working together to try to wrestle with this.

ConvergenceRI: Did you feel like my article in this week’s edition was too hard on accountable care?    
SARKAR: No, I think the reality is that accountable care is really hard.  And I think that, it’s really hard to enact. I think there is a challenge that health systems in particular face when they get into an accountable care organization business. There are so many issues in health care right now. Starting with the true lack of a primary care workforce to support what we want to see as a community for accountable care.

In order for that to really work, Richard, I think the honest truth is that we need to have more primary care providers, and we just don’t. Simply put.

But primary care physicians are hard to find. And, ultimately, they are the ones we need more of.  In the little time I have spent at the medical school here, I can tell you that most of the next generation of practitioners do not want to go into primary care. It’s not just about the money, and everyone makes it about the salary, but it’s not just about that.

If you talk to an average primary care provider, in our state, and this is not just in Rhode Island, it’s a national problem. It’s a crisis, and we are definitely feeling it here.

It’s not a part of medicine that you go into and expect to be well treated, expect not to be abused by the system, and honestly, practitioners are just trying to get their job done. The electronic health record is just one part of that. There are so many pieces that make the primary care practitioner’s job so heart-breaking.

ConvergenceRI: And it’s often harder for the patient to try and navigate the system.    
SARKAR: And, you’re special, Richard, because you are engaged. Probably one of the most challenging parts of health care is that most patients aren’t engaged.

ConvergenceRI: What needs to change? In health care, the people who are pushing the boundaries probably won’t get any recognition for doing so.    
SARKAR: The personality types that get attracted to health are, I think most of us honestly are trying to make the world a better place. It’s not about ego. It’s not about myself, it’s not about my agenda. It’s about how can I best weave data to support a partient whom I probably will never meet. I know that in the deepest part of my heart, at least one patient is getting the benefits. And that makes me happy.

For most of all of us who work in health care, it’s not about ourselves; it’s about the community we serve, which may be a character flaw.

I think we need to emphasize that there is a huge opportunity in front of us now in health care in our state. People are listening; people are aware of the crisis. It’s now or never, folks. I think we really need to come together as a community.

Because, I view what we do here in Rhode Island as the future of our country. We just happen to see it all because we’re a small community. But let’s be honest. Health care in our country is absolutely broken. Everywhere, no matter where you go.

We are one very scalable place where this is observable. I think we have an opportunity. If we can truly enact change, and show how to do health care right, I think the rest of the nation will follow suit. This is our home. This is Rhode Island, working together.

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