OneCare Vermont (OneCare), LLC and Vermont Information Technology Leaders, Inc. (VITL) announce a collaboration to provide OneCare Vermont with comprehensive population health data in a system designed to improve data collection and clinical analytics capabilities. To accomplish this, clinical data from the Vermont Health Information Exchange (VHIE) – operated by VITL – will be filtered and transmitted into OneCare's enterprise informatics platforms. The VHIE collects and indexes clinical data from different electronic health record (EHR) systems across the state. This data is then analyzed by OneCare for the purposes of managing care and meeting its wellness and patient satisfaction objectives. OneCare Vermont is Vermont's largest accountable care organization and manages care for the more than 100,000 patients attributed to its Medicare, Medicaid, and commercial shared savings programs.

Analytics—the science of analyzing data for trends and insights—is moving beyond the analysis of past events, to a predictive phase where at-risk patients are identified early and interventions can be made before diseases progress to critical states. OneCare Vermont Chief Medical Officer Norman Ward, M.D. said, "The analytics capability of this system will allow us to engage with patients in new and exciting ways. In order to improve patient outcomes, we must get to the point where we engage people as early as possible."


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OneCare Vermont tracks 34 clinical quality measures for their patients—data such as blood pressure readings, blood glucose (A1C) levels and smoking status—to identify chronic disease trends, determine the need for new clinical interventions, and to monitor the success of current interventions. The challenge OneCare Vermont faced was collecting this clinical data from the many different EHR systems at participating provider's offices. That's where VITL—the operator of the VHIE—offered a solution. The VHIE already collects patient data from Vermont hospitals, Dartmouth-Hitchcock Medical Center, Federally Qualified Health Centers (FQHCs), primary and secondary care practices, home health associations and commercial laboratories, for use by Vermont providers at the point of care.

Through this cooperative project, VITL was able to establish a data warehouse that captures all clinical data coming to the VHIE in a structured format for analytical purposes. Each month, OneCare Vermont provides a list of its patients, and VITL tags OneCare patient information with a special identifier to be extracted into a OneCare data mart (a subset of the full data warehouse). The data mart is refreshed on a daily basis, ensuring that OneCare is always operating on timely data.

Where gaps in data collection exist, VITL works with sending organizations to ensure data is being collected in their EHRs, and to create any new interfaces (connections) that will send data to the VHIE. As part of this project VITL added 116 new interfaces to capture data from 68 new organizations in 2015. This work is continual and ongoing.

VITL President and Chief Executive Officer John K. Evans said, "The technology partnership with OneCare Vermont made sense from the very beginning. Over the past 10 years VITL has established interface connections with all of Vermont's hospitals, as well as Dartmouth-Hitchcock Medical Center and most of the primary and specialty care practices around the state, to bring data into the VHIE. We're now leveraging this infrastructure to improve data quality and provide OneCare with data they need to improve patient outcomes. The work with OneCare places VITL at the forefront of exchanging health information in support of health care reform initiatives."

Funding for the development of this project was provided through the Centers for Medicare and Medicaid Services (CMS) Innovation Center State Innovation Models (SIM) Initiative grant that was awarded to Vermont in 2013, and administered by the Vermont Health Care Innovation Project (VHCIP) office. Ongoing funding for maintenance and operation of this system is provided through a commercial agreement between OneCare Vermont and VITL. OneCare Vermont Chief Executive Officer Todd Moore said "Data is the fuel for the engine of coordinated care. As an ACO, we have to understand what happens to our patients across a connected health care system, to make sure we meet all their needs and see opportunities for improved care."

About VITL

Vermont Information Technology Leaders, Inc. (VITL) is a nonprofit organization that assists Vermont health care providers with adopting and using health information technology, to improve the quality of care delivery, to enhance patient safety and to reduce the cost of care. VITL is legislatively designated to operate the Vermont Health Information Exchange (VHIE), and is governed by a collaborative group of stakeholders including health plans, hospitals, physicians, other health care providers, state government, employers and consumers. For more information, please visit www.vitl.net

About OneCare Vermont

OneCare Vermont is a statewide Accountable Care Organization (ACO) that participates in Medicare, Vermont Medicaid and the Commercial Exchange Shared Saving Programs. OneCare Vermont is an extensive network of providers that includes most of Vermont's hospitals, two New Hampshire hospitals, hundreds of primary and specialty care physicians and Advance Practice Providers, federally qualified health centers, and several rural health clinics, to coordinate the health care of approximately 95,000 combined Medicare, Medicaid and Commercial Exchange Vermont beneficiaries. For more information, please visit www.onecarevt.org