- Jeb Wallace-brodeur
- John Evans
Most Vermonters know about the 2013 online health insurance exchange, in part because it launched without functioning technology. Even today it remains a crippled operation. But what about the state's first health care exchange? The one that was going to comprehensively track patients' electronic medical records and enable providers to share and access information?
A decade ago, an independent nonprofit organization set out to create the Vermont Health Information Exchange — its operators prefer to call it the VHIE network to avoid confusion with the beleaguered insurance exchange. But like the latter, it was built with federal and state dollars: $32 million.
The network opened to seven test sites last October and has been ramping up toward statewide access for the past two months. Statistics provided to Seven Days last week show VHIE's still-fledgling status: It has just 631 authorized medical professional users, and only 15,010 patients have given consent for their doctors to access their medical information through the online system.
"We should be further along than we are," said Lawrence Miller, chief of health care reform for Gov. Peter Shumlin's administration.
In 2005, the legislature made the nonprofit Vermont Information Technology Leaders, or VITL, responsible for developing and operating the network. It also established a fund into which insurance companies pay an assessment fee every time one of their customers files a claim. To date, those assessment fees have provided the organization with $18 million. And yet, Miller said, "They haven't finished the core of what they were set up to do."
That's why, in January, Shumlin asked the legislature to authorize the Green Mountain Care Board to review and approve VITL's budget. "If we are going to fund them," Miller said, "we need to have better oversight of what they are doing."
Shumlin isn't the only one who has grown impatient over VHIE's slow pace of development. A top official in then-governor Jim Douglas' administration and three legislative leaders complained to VITL officials in a May 2008 letter. "It wasn't moving fast enough," recalled Mike Smith, former secretary of administration for Douglas. "I urged them to get going, and if they weren't going to get going I didn't see the reason for VITL to exist."
Smith hasn't monitored VITL's progress since he left state government, but he said he hasn't seen evidence that it achieved its mission. "I think I would write my letter again," he said.
Started as a project of the Vermont Association of Hospitals and Health Systems, VITL morphed into a freestanding nonprofit organization in 2005. Its main office is in Montpelier, but two-thirds of the 33 staff members work in an old mill building overlooking the Winooski River in Burlington.
VITL has a 12-member board that includes a state legislator, a member of the Shumlin administration, a consumer, and reps for doctors, hospitals and insurance companies. Although it's not a government agency, almost all of its money — $6.5 million of its $6.6 million in revenues in 2014 — comes from government sources.
Despite the delays, many policy makers still support VHIE's goals of creating a secure electronic health data superhighway to help doctors improve care and reduce costs. More recently, the VHIE databank is seen as a resource for monitoring and managing care for patient groups under the state's Blueprint for Health, a chronic-disease management initiative, and for identifying population trends and best practices.
John Evans was a founding VITL board member in 2005. After nine years consulting on health-information technology across the country, he came back to the organization two years ago to become its president and CEO. "Health care as an industry has been woefully behind most industries that are increasingly technology dependent," he said. "We are sort of in version one of this transformation."
Evans defends the pace of the data exchange's development.
First, doctors had to switch from paper to electronic medical records, a process that "comes with frustrations," Evans said. A common one from doctors: Typing at a laptop interferes with their interactions with patients.
Next, VITL was faced with the challenge of creating a system that can accept data from at least 70 different electronic-medical-record systems used by 174 health care locations connected to VHIE. Those include: doctors' offices; all 14 Vermont hospitals; Dartmouth-Hitchcock Medical Center and Cottage Hospital in New Hampshire; Samaritan Hospital in Troy, N.Y.; three commercial labs; two nursing homes; four mental health agencies; and five home health organizations.
It wasn't until last year that the state — through the Green Mountain Care Board — adopted interoperability requirements that should standardize electronic medical record systems.
Evans also said it was important to have enough data banked to make the exchange useful to doctors when they started to use it. Data — mainly from hospitals — first started being entered in 2011 and now contains information on 1.5 million patients, with about 4.5 million pieces of data arriving monthly.
Then, on the cusp of rolling out the exchange, VITL stumbled. It launched a public awareness campaign that debuted with a $10,800 ad that aired during the Super Bowl. Shumlin and others criticized it as a lavish expense, and now some lawmakers want to ban VITL from spending money on advertising.
"The Super Bowl ad was a one-time opportunity to reach a very broad audience," Evans said. "Even if people didn't like it, it did increase hits to our website by 200 percent in one week." He said it was an example of VITL's efforts to reach the public and providers. The organization also hosted three recent community forums. "We are seeking awareness of our services so they get used," he said.
"Why should the public know or care about VITL?" Senate Finance chair Tim Ashe (D/P-Chittenden) asked Evans last week during a discussion of proposed provisions in the Senate's health care bill. The focus, Ashe said, should be on educating doctors about VITL's offerings.
"The impact ultimately benefits the patient," Evans countered, citing the potential to avoid duplicative tests and extra costs and to receive more informed care. He also told the Senate Finance Committee that he approved of the Green Mountain Care Board reviewing VITL's spending plan and approving its use of state dollars. VITL has also received federal dollars and some fees for special projects, such as providing clinical-care data to OneCare Vermont, an accountable-care organization.
This year, for example, VITL has $4.5 million in state funding and $3.6 million in federal funds.
Evans stressed the need to limit the board's oversight to state dollars. "We are an independent organization. We need to be entrepreneurial. We need to be able to innovate," he argued, referencing the clinical data gateway VITL developed and operates for OneCare Vermont, which sends information to a northern New England collaborative. It is also developing a notification system to let providers in the accountable-care organization know when their patients are admitted, discharged or transferred from hospitals. "If I become something that looks like state government, I don't believe we will be able to achieve the health-reform goals that everyone desires," Evans said.
But the Shumlin administration wants the Green Mountain Care Board to approve all of VITL's spending. "We want them to be able to look at not just the state funding but the totality of their efforts," Miller said, suggesting that VITL's entrepreneurial projects distract from the core mission.
Al Gobeille, chair of the Green Mountain Care Board, agrees with the governor, although he admitted he was surprised by Shumlin's proposal that the board oversee VITL's budget. "I never had thought of it," Gobeille said, adding, "You are creating a utility — is the performance of that utility being monitored properly by state folks? The answer to that is 'no.'
"We have to make sure it works and that they don't have their priorities all mixed up. Getting this working in a vibrant way is very, very important."
Dr. Robert Emmons, a psychiatrist with a solo practice in Burlington, worries about giving the Green Mountain Care Board this new authority. "It is more regulatory power being concentrated in one place," he said. The board already approves hospital budgets and health insurance rates.
Emmons also questions the fundamental value of the health-information exchange. "I'm not aware of scientific evidence that collecting big data and mining it improves health care and reduces costs," he said.
He also noted that patient data has been uploaded to the system even though most Vermonters haven't given consent. "Is the patient controlling the information if data is being sent automatically?" Emmons asked.
American Civil Liberties Union of Vermont officials are also worried. Executive director Allen Gilbert noted that people's records have been forwarded to VHIE "without too many people knowing about it. That already probably makes them less secure than you thought they were."
Specifically, Gilbert objects to the consent procedure the Green Mountain Care Board approved last year: If patients say yes to one provider, it opens the door for all of their health care providers. Previously, each doctor had to secure permission from patients individually in order to view their records.
Supporters are focusing on the potential benefits. Rep. Tristan Toleno (D-Brattleboro), a chef and tech geek, has served on the VITL board for two years. "I don't think anyone thinks where we are now is where we want to end up," he said. "The move that the governor is proposing — recognizing that VITL is a core piece of infrastructure — isn't the end of the story. It is the beginning of an opportunity to see how this technology can help achieve health reforms and healthier outcomes."