Laying the Course for Coordinated Care

*Article from the VITL 2016 Annual Report

Anyone who is managing, or is helping a friend or loved-one manage complex medical conditions understands how difficult it can be to deal with these conditions in a health care system that is often fragmented.

The Agency for Healthcare Research and Quality states that “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.” (

In order to effectively coordinate care, providers must be able to reach across organizational boundaries. The services provided by VITL which utilize the VHIE and the HDM infrastructure are designed to help health care providers, accountable care organizations, the Blueprint for Health, and social service agencies give better care for their patients, by providing access to their medical information where and when they need it.

In 2016 VITL delivered or partnered with other companies to offer services that help providers better coordinate care, including:

  1. VITLAccess - gives access to a statewide health record for patients, so providers can make informed decisions.
  2. VITLDirect - allows direct, secure provider-to- provider exchange of clinical documents to expedite referrals and collaboration.
  3. PatientPing - notifies providers when their patients receive care at another facility, so they can follow up with the patient.
  4. OhMD - allows secure patient-to-provider messaging to reduce wait times and trips to the doctor.

Provider Access to Statewide Health Records

Pie chartIt is surprising to see how much patient information is generated outside of a local health care system. The graph shows that only 25 percent of the information in the VHIE for patients that received care at one of Vermont's regional hospitals originated at the hospital. Forty-seven percent of that data came from an academic medical center, 8.4 percent from the hospital's practices, and 19.6 percent from other community providers. While the percentages are different in each Health Service Area, the point remains the same: VITLAccess provides critical information from outside an organizations's own EHR.

Whether it’s a physical therapist wanting to review an orthopedic surgeon’s report, or a nursing home care coordinator planning for a resident’s discharge from an emergency department visit, VITLAccess helps to smooth transitions of care, which improves a patient’s experience, and may reduce costs and improve outcomes.

Secure Provider-to-Provider Communications

Counseling Service of Addison County (CSAC) recently became the latest user of VITLDirect, a secure messaging system that providers use to send patient information directly to one another. With VITLDirect, the medical staff can more effectively coordinate care by sharing care summaries with one another in a secure way.


VITLDirect has been used to securely transfer about 16,100 transition of care documents this year, and is now being used by the following organizations:

  • Burlington Health and Rehab
  • Counseling Service of Addison County
  • Green Mountain Nursing Home
  • Northeast Vermont Regional Hospital
  • Northwestern Medical Center
  • Southwestern Vermont Medical Center
  • The University of Vermont Medical Center
  • Vermont Department of Corrections
  • Wake Robin

Notifications of Admissions, Discharges and Transfers (ADT)

Under an accountable care delivery model, all members of a person’s medical care team need to be informed when changes occur in their medical status. PatientPing, in partnership with VITL and the State of Vermont, have established a statewide system so that all providers—no matter who they work for—can be informed of changes affecting their patients.

ADT imageVITL sends patient consent and patient encounter (admission, discharge and transfer) messages from all of the hospitals and five home health agencies across Vermont to PatientPing, which they use to generate notifications to providers across the state.

By joining the PatientPing community, providers are notified when their patients receive care elsewhere, and they are able to share care instructions with other providers. With PatientPing, providers can deliver higher quality and more cost effective care, which improves patient outcomes and experiences.

Launched in April 2016, PatientPing is in use or being implemented by the following organizations:

  • Community Health Accountable Care
  • OneCare Vermont
  • The Health Center
  • Mountain Health
  • Northern Tier Center for Health Support and Services at Home (SASH)
  • Middlebury Blueprint Community Health Team

On average, PatientPing is delivering between 8,000 and 9,000 notifications per month from medical encounters in Vermont.

Secure Communications Between Providers and Patients

In August, VITL and OhMD announced a partnership that brought a secure, HIPAA compliant text messaging service to Vermont health care providers and their patients. With smartphone use nearly universal, secure text messaging in health care makes sense as a fast and easy communications option, and offers patients more opportunities to engage in their own care.

According to a parent who participated in OhMD’s pilot program at a Middlebury pediatrics practice, “It really feels like we can get in touch when needed. Such a great service.” About a half dozen provider organizations in Vermont are currently using the secure messaging service provided by OhMD to communicate with their patients and colleagues.

OhMD is as simple to use as standard text messaging, and with built-in security and privacy to meet HIPAA standards, it offers an intuitive user experience. Texting can make care coordination with colleagues, staff and referring providers faster and easier, with the ability to quickly create channels for communicating with patients in their circle of care.

Consider a mother or father wanting to quickly send their doctor a secure text with an image of a rash their child just developed. Within the care coordination circle a clinician can forward the text to a specialist for assessment, receive a response and text the concerned parent with recommendations, without making an in-person appointment.

OhMD image