PROVIDENCE – With the frenetic pace that drives our world, in the midst of a coronavirus pandemic raging out of control and a tumultuous Presidential election that each day brings a cascading avalanche of stories – and where misinformation and distortion are rampant, it takes a steady hand on the helm to keep steering news content toward long-term understanding rather than give in to pushing short-term anxiety and click-bait.

Last week, ConvergenceRI published a four-part series on a new Health IT Strategic Roadmap and Implementation Plan, now underway at the direction of the R.I. Executive Office of Health and Human Services. To entice readers to dip their toes into the water, ConvergenceRI deployed a bit of click-bait: a photo of a chocolate layer cake from Gregg’s Restaurant as the primary illustration for the first story in the series.

To some extent it worked; the story was liked and retweeted by WPRO’s Steve Klamkin and Neil Steinberg, president and CEO of the Rhode Island Foundation.

But the mention of Dan McGowan’s Rhode Map in the lede sentence, saying that when folks heard about a new digital road map strategy in Rhode Island, that might be their immediate and mistaken point of reference, failed to draw a similar retweet from any members of the Boston Globe crew in Rhode Island. So it goes.

Other stakeholders, however, admitted to ConvergenceRI, even a week after the original stories had been published, that they still had not “found” the time to read the stories. Admittedly, deep dives into health IT were perhaps, like salmon fighting upstream to spawn, a difficult journey for readers, because they may have many stressful pre-existing conditions at play.

One important thread the story uncovered was the fact that many stakeholders who had been interviewed for the HIT Strategic Roadmap by the private contractor hired by the state, Briljent LLC, had been unaware of the final recommendations or even that a road map and implementation had been published.

As promised [at the risk of driving down potential clicks for a second week in a row], ConvergenceRI is publishing a story this week detailing responses from an important stakeholder, the Rhode Island Quality Institute, and its president and CEO, Neil Sarkar, Ph.D., who is also the founding director of the Brown University Center for Biomedical Informatics.

The responses are then followed by an in-depth interview with Sarkar, who occupies a key position in any effort to create a HIT Strategic Roadmap in Rhode Island. The Rhode Island Quality Institute, a quasi-public agency, is responsible for managing the state’s Health Information Exchange, known as CurrentCare.

Questions and answers
Sarkar apologized for the delay in responding to the initial questions that had been posed by ConvergenceRI, demonstrating a kind of humility so often missing from many top health care executives. Here are the responses:

ConvergenceRI: Have you officially endorsed the plan and are you happy with the description of the current work of RIQI and future challenges?
SARKAR: The Rhode Island Quality Institute was interviewed by Briljent during the process, and we were given presentations given about the HIT Roadmap. We do not have major issues with the description of RIQI or its future challenges, and hope that the implementation of the HIT Roadmap will provide better synergy across state agencies as well as partners like RIQI. I hope that RIQI is given the chance to address the suggested challenges from before my time at the organization.

ConvergenceRI: Will you be participating in the leadership governance of the road map and future entity?
SARKAR: I was a member of the HIT Governance Initiation Development Team, which made recommendations for whom should be members of the committee. The selection will be decided by Secretary [Womazetta] Jones’ office [at R.I. EOHHS]. The [suggested] nominees included individuals from:

• Consumer/patient organizations

• Community-based organizations focused on socially determinants of health

• Employers – including self-funding groups

• Health care providers

• Accountable care organizations and accountable entities

• Health improvement organizations

• Payers

• Privacy/security experts

• Key state agency directors or designees

• Chairs of the existing legislatively mandated committees

• Higher education

ConvergenceRI: Are you comfortable with the “data gaps” identified by Briljent in the changes to the proposed road map, which were added following the coronavirus pandemic?
SARKAR: The impact of SARS-CoV-2 [COVID-19] has continued to reveal data gaps, especially in public health infrastructure. I hope that we can focus on these acute issues in the short term, with an eye towards developing a sustainable solution.

ConvergenceRI: Where will the money come from to pay for the operation of the future entity envisioned by the road map?
SARKAR: The initiatives taken on by the HIT Roadmap would likely be funded by grants, most of which will require a 10 percent or a 25 percent state-funded/coordinated match.

ConvergenceRI: In my reading of the document, I did not find any discussion regarding the work of the data harvesting of the All Payer Claims Database regarding costs? Did I miss this? Or, is this an omission?
SARKAR: HealthFacts RI [the state’s rebranding of the All Payer Claims Database, or APCD] is included as one of the data assets that set the foundation for the HIT Roadmap.

There continue to be discussions on how guiding use cases can be developed from the APCD for enhancing or developing Health IT infrastructure. I would expect/hope that the Steering Committee [would] see the APCD as a key source of this important information – as you know, my view is that APCDs enable us to go from conjecture to fact, and furthermore, as we implement changes, we should see impacts in costs.

In search of sustainability
In the subsequent interview with ConvergenceRI, Sarkar stressed the need for sustainability and coordination around investments in health IT, given that the original federal funding to build the state’s health IT infrastructure was going to come to an end in the foreseeable future.

“Sustainability,” Sarkar stressed, “is the most important factor in any of these [discussions]. I can have the greatest idea, but if that can’t be sustained, the idea is worthless, unless it’s a one-shot kind of a thing.”

Sarkar continued: “We’re talking infrastructure. Infrastructure has to have a sustainability plan.”

The current reality, Sarkar explained, “is a lot of money that funded a lot of the health IT [infrastructure] nationally is going away. The HITECH Act [Health Information Technology for Economic and Clinical Health Act, enacted as part o the American Recovery and Reinvestment Act of 2009], will cease in its current form in the upcoming years.”

As a result, Sarkar said, “The funding model for supporting a lot of these activities going forward is going to change, so there has to be [better] coordination, with resources being more limited for the foreseeable future.”

Here is the ConvergenceRI interview with Neil Sarkar, Ph.D., the president and CEO of the Rhode Island Quality Institute, offering his feedback on the Health IT Strategic Roadmap and Implementation Plan.

ConvergenceRI: I’m sorry that we missed connections last week with my questions. I would have liked to been able to include your responses in my initial stories.
SARKAR: Yes. It’s been a crazy year, and currently, things are just very, very, very busy for all of us working in health IT, just trying to keep up.

ConvergenceRI: Let me start by asking: What did you think, overall, about the four-part series?
SARKAR: I think they were interesting. I think they do present some things that probably have been on people’s minds.

There were a lot of questions [asked]. I think that there are opportunities, hopefully, as the Roadmap activities take flight, that [the steering committee will be] made aware that these are some of the questions and challenges out there. And that the group, as they embark on it, know that these are some of the thoughts that are out there.

ConvergenceRI: I was surprised, in talking to a number of different stakeholders, many of whom were totally unaware of what was going on. They had been interviewed, but there had been no follow up with them.
Without revealing my sources, these were highly esteemed folks who have been very involved in the work around health IT. I was surprised that they were surprised.
SARKAR: We were part of the interview process. And, we were given some presentations. From our lens, we were just making sure what was being said about RIQI is fair.

I think there were challenges from before my time, so I cannot take complete responsibility. But we also, I think, need to be given the chance address some of those things.

Some of the questions that I did raise, and I believe that others who were interviewed from RIQI also raised them: How will RIQI [participate] in this? Who will we report to? Is this the creation of another government committee we are going to have to report in to?

Initially, it felt that way, and toward some of the later conversations, and presentations, it felt less that way. Activities have to be coordinated.

How this will all play out, honestly, I don’t know.

But I think this was a long time coming. There are a lot of places that probably need to have a health IT roadmap, that don’t, and I think it is about time that we had one [in Rhode Island], that pieces a lot of things together.

I’m not as well versed with some of the UHIP things as some others in the community are. Obviously, I have heard of it, aware of it, I know that is some of what this is hopefully going to address, so that that situation doesn’t occur again,

Your guess is as good as mine as whether this will solve that.

Mine, and RIQI’s view on this, is: we need to make sure the role that RIQI in health IT is maintained and, in fact, needs to be made stronger,

Many folks don’t understand how complicated some of these things actually are. Asking even one organization to do everything is asking for the impossible.

We as an organization are pivoting, we’re putting a lot more focus on certain things that we know we can do really well. And, we’re making sure that we’re doing that, first and foremost, before we take contracts just to cover the bills.

ConvergenceRI: One of the fundamental questions, moving forward, it seems to me, is that there are a lack of resources. The work on health IT often seems constrained because you’ve got to keep your operation running. From what I understand, your operation is very lean. Yet, at the same time, you keep being asked to do more and more tasks. Is that a fair analysis?
SARKAR: That is very fair. Some of what I do hope – and I did try and make these comments during whenever I had the opportunity to – is: We need to not have three of the same things being developed in three different places.

We should just say: This group will develop that. And, we all just have to know what that is. And we all have to work together around that.

Because, what ends up happening is that we end up wanting to create something, and then two groups, or three groups, are working on essentially the same thing, and, this is no surprise. We are a small state. We have a limited number of resources. So, we should be pooling, rather than dividing [our scant resources]. We have a very robust history of competition where it isn’t necessarily needed.

We need to just get the job done. This isn’t the time for coming up with something innovative or new, we are in charted territory.

There are constant challenges with people wanting things; everyone wants the shiniest and the fanciest tools. But you can’t do that unless you have the fundamentals working.

And, when you [focus] on the fancy new things, and then it turns out that they can’t do it because the basics weren’t worked out, it is wasting a lot of time, money and resources, in my opinion.

ConvergenceRI: And, that is a good opinion.
SARKAR: [laughing] Thank you.

ConvergenceRI: When Sen. Joshua Miller was holding hearings as part of his commission on health insurance reimbursement rates, you did of series of provocative data-mining exercises using the APCD which, I thought, were revealing: behavior health costs were a major driver of higher costs, as were women’s health care, and when you put the two of those together, and there was a real double whammy, in terms of how you address costs.

Where does that work go to now? It seems as if it is an orphan that nobody is really addressing, in terms of where do you go with this information that was developed as part of this commission.
SARKAR: I don’t know the answer to that. I know that in early March, all the members of the commission submitted recommendations as to what should be prioritized.

It is no surprise, given the COVID-19 situation, which has made things a little slower and a little unclear about where the work of the commission is going to go. I have not looked at the data since then, but my guess is that things are getting worse, not better.

And, I think that the disparities that we are going to see will be even more drastic as the result of health care really being stretched into places it hasn’t had to go before.

As you pointed out [in a recent article in ConvergenceRI], the merger of Lifespan and Care New England, this is something that has been long-time coming, we in the health care community have known this, but it took a pandemic for them to say, we really need to do this now, because it is the only way we’re going to survive. [See link below to ConvergenceRI, “In search of a sustainable business model.”]

My hope is that we learn a lot from the situation that we’ve all found ourselves in. Hopefully, you’ll definitely see me continuing to do those kinds of data analyses.

For me, I need to know; I need to have a target; the APCD is a valuable resource. Show me some data, and then show something that you want to fix, and show me something where you want to reduce theses costs.

From the health information exchange perspective, we’re going to be able to see some of those things, in real time. We will, for sure, at RIQI, be looking at signals that we can visualize from thing like APCD.

Another top priority for us is the burden on clinicians. If we thought that clinicians were overburdened before the pandemic struck, they are way more overburdened now. That’s not easily quantifiable through a database, per se, but we can hopefully start to address some of that.

I think that the HIT roadmap lays out the guardrails. There is a little bit of nebular nature to the Health IT Strategic Roadmap. It makes all of us a little uncomfortable, because it really didn’t share when it is [going to start]. Hopefully, with the stakeholders that are going to be pulled together to form the leadership [team], they’ll hopefully steer the ship in the right direction. That’s what I’m hoping for.

We at RIQI have our own alignment and internal vision and strategic planning for how we hope to being doing things. I am hoping that that aligns with what HIT roadmap is setting out to do.

But, I also think that we don’t have a choice. There has to be something.

ConvergenceRI: Some of the people involved with the cost analyses for the statewide compact to set a 3 percent annual cap on the growth of medical costs were not involved in the conversation.
SARKAR: I would argue that is troubling. My hope is that the HIT Roadmap steering committee, whomever they are, hear that and see that and say: OK, cost trends need to be part of this.

What are the things that we need to keep working, so that no matter where someone is getting care in our state, the basics of [health data] information are being met? From my perspective, the basics of information are: we know who’s coming in, for what reason, and that we know whatever treatment was offered, [whether] it worked. Very basic.

Everybody has many, many ideas. But if they are not sustainable, the ideas shouldn’t even be entertained, in my opinion.

And so, if you have to choose between resources that are cool and innovative ideas, versus just keeping the lights on, we want to keep the lights on, because all the other activities are for naught if you can’t do the basics.

ConvergenceRI: In my stories on the HIT Strategic Roadmap, did I ask the right questions? Are there other questions that I should be asking, that I’m not asking? I welcome your feedback.
SARKAR: Richard, I think you are asking all the right questions. And, I actually value your writing in this space greatly, because I think it offers an honest opinion. And, I think the work that you put into getting people’s opinions, putting them into, at least for me, a very palatable and acceptable form, that’s the key here.

I think that there always needs to be the other side of the story. And, I think, some of us, in full transparency, my funding, my organization’s funding, depends on the Health IT Roadmap doing things the way I think they should be, without a doubt.

That’s where we are a little nervous, without a doubt, about what the state is going to do. Especially in relation to the Health Information Exchange, and things that are should be in our court. We do not really have a clear picture as to how some of those decisions are going to be made.

I think an olive branch that was put out to me, [because] they let me sit on the group that made recommendations that now the Secretary and others will decide who is the steering committee going forward.

No surprise here, but I think RIQI should have a seat at that table. But they said: Let the secretary decide. We see how that all comes together.

But, I have always enjoyed your writing, as I said before, and I truly mean that with all sincerity. It’s important to me. It’s one of the few sources of honest writing I can get my hands on in this community to see what’s going on out there.