Q&A with OneCare Vermont's Director of Informatics

Editor’s Note: This is the third in a series of blog posts by Vermont Information Technology Leaders published during Vermont and National Health IT Week, September 26 – 30, 2016.

Today’s post is a Q&A session with Leah Fullem, MHCDS, the director of informatics at OneCare Vermont.

VITL: Tell us a little about OneCare and its analytics strategy.

Fullem: OneCare Vermont is a statewide accountable care organization (ACO) working with Medicare, Vermont Medicaid and the Commercial Exchange Shared Saving Programs. OneCare Vermont comprises an extensive network of providers, including several 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 110,000 combined Medicare, Medicaid and Commercial Exchange Vermont beneficiaries. We are working directly with the Vermont Health Care Reform team, which includes the Department of Vermont Health Access (DHVA), the Green Mountain Care Board, commercial payers, and stakeholders across Vermont to change provider payment incentives and streamline coordination of care in order to create a sustainable health care delivery system that is focused on quality improvement and excellent experience of care for patients.

The ability to provide comprehensive and real-time clinical information to every health care provider is an essential requirement as part of a system designed to provide better care and reduce costs. Additionally, sophisticated financial modeling to support the development of alternate payment models is critical to the work required for economic and payment reform. We at OneCare are building an informatics infrastructure to support these requirements and to address the following core strategies:

  • Align health informatics with the provider network, optimizing technology to manage provider, performance, outcomes, accountability, and transparency of data.
  • Identify and prioritize care gaps, assessing utilization and risk stratification data to identify at-risk patients in greatest need of point-of-care intervention.
  • Provide an efficient care coordination platform, supporting information continuity across settings and caregivers to enable seamless, scalable care management activities across the delivery network.
  • Monitor and learn from results, providing contract-specific performance data to track utilization and outcomes for each defined population a provider manages.

The integration of disparate data sets, including payer claims data and clinical data from EMR systems via the Vermont Health Information Exchange (VHIE), into our analytics platform is critical to the execution of these strategies.

VITL: Why is the clinical data mart that VITL is providing important to OCV?

Fullem: HIEs have traditionally functioned as a mechanism to transmit individual messages about a patient between providers and/or hospitals to support decision making at the point of care. The data captured in those messages can be very valuable for analyzing quality and outcomes for a population of patients. VITL’s clinical data mart aggregates those individual messages and allows us to combine the data with other data sources and systems to give us a more comprehensive picture of our attributed population and the patients our providers care for.

Additionally, we are required to measure and report performance on 26 quality measures that use clinical data for our 3 payer programs. Over the past 3 years, this has been done through a manual, very labor-intensive chart abstraction process focused on a sample of patients selected by the payers. Our goal is to make the quality measurement process more efficient by reducing manual chart abstraction as much as possible by using electronic data being transmitted from source EMRs through VITL to our analytics and reporting platform. This will also allow us to monitor performance on measures for a majority of our population rather than just a small sample.

VITL: How does OneCare Vermont use the information to better manage patient care?

Fullem: OneCare is just in the beginning stages of using clinical data from EMRs to better manage patient care. We have been using claims data to provide information to our practices for years, including providing information on high-risk patients that might benefit from care coordination or higher intensity services. Adding clinical data from VITL will enhance the picture of these patients for providers and care coordinators, by providing information such as last HbA1C results, immunizations, etc. These data will be integrated into our Care Coordination platform and used throughout our network to inform shared care plans and help better manage transitions and coordination of care.

VITL: What are some of the challenges in getting good quality data for analysis?

Fullem: We have had significant challenges getting useable clinical data for analysis, which is why we are still in the early stages of using those data in population health management. Factors that create challenges for us are (1) the lack of a unique patient identifier that can be used for matching patient data between disparate data sets, (2) the lack of consistency between content and format of messages transmitted from different EMR systems across the state, (3) the inadequate amount of funding available to providers to support the costs and human resources required to install and update EMR systems and interfaces to the VHIE (which is a root cause of many of our data gaps), and (4) the amount of human resources required to procure and clean the data for analysis. This is an extraordinarily complex process. We need an all-hands-on-deck approach to improving the quality of health care data in Vermont so that we can move forward with data-driven approaches to improving care for patients.

VITL: How are you using the data quality reports provided by VITL?

Fullem: OneCare produces our own data quality reporting from our analytics platform in order to identify where we are missing key data elements required to measure performance on quality measures for our programs. The data quality reports provided by VITL provide us with baseline information to help us identify where we expect to have data, or alternatively where no interface currently exists with the data we need. We work closely with the top-notch team members at VITL to identify and resolve data quality issues in order to improve our analytics.

Contact Info:

Leah K. Fullem, MHCDS
Director of Informatics
OneCare Vermont Accountable Care Organization, LLC.
356 Mountain View Drive
Colchester, VT  05446
Phone: (802) 847-6251