David Cochran, M.D., who has spent decades in patient care and healthcare management, became president and CEO of Montpelier-based Vermont Information Technology Leaders (VITL) in July 2009. The organization’s mission is responsible for supporting the deployment of electronic health records throughout Vermont in support of the state’s ambitious healthcare reform and population health initiatives. Further, VITL manages Vermont’s statewide health information exchange (HIE). Cochran spoke recently with HCI Editor-in-Chief Mark Hagland about his work at VITL. Below are excerpts from that interview.
Healthcare Informatics: Your organization seems to be focused on several different, important objectives.
David Cochran, M.D.: The main thing to recognize about our HIE is that it’s about our overall health reform initiative. And what brought me up here last year was the understanding that the HIE and technology are really there to improve care. We have a statewide medical home initiative called the Blueprint for Health. When [U.S. Health and Human Services] Secretary [Kathleen] Sebelius announced that she was going to work at the state level, Gov. [Jim] Douglas was at her side. So we’ve established a statewide program that involves community-wide patient registries. And one of the major functions of the HIE is to provide the data infrastructure for that initiative, which was initiated in 2006, and built around the Wagner Chronic Care Model, and was focused around chronic care. In 2008, the concept was broadened to include preventive measures and wellness and disease measures, per the medical home. And it was done in three communities that get certified by the NCQA [the Washington, D.C.-based National Committee for Quality Assurance] for their medical home initiatives, and which get incremental fees from the Medicaid and private payers for their medical home work. Those three communities are St. Johnsbury, Burlington, and the Berlin-Barre area.
HCI: So, it began by facilitating work in those three communities?
Cochran: Yes, the state legislature approved pilot projects in those three communities, and then extended the medical home-based program statewide.
HCI: So VITL was first established to provide IT support for Blueprint for Health?
Cochran: That’s right. We’re a 501c3 public-private partnership, with active participation from the hospital association, state medical society, and other stakeholders; and we were initially identified in 2006 to support Blueprint. One of the learnings early on with the exchange was that not enough physicians had EMRs, so VITL did some initial work using funds from the state to help physician practices implement. In addition, we were designated as the regional extension center for Vermont.
HCI: What are the sources of your funding?
Cochran: We are primarily funded by federal and state grants. There is a very interesting state program here in Vermont, in which 0.2 percent of state claims levied on private insurers, go to fund programs like ours (and Medicaid makes a separate contribution), and that ends up being about $2 million per year; and we have other grants from the state as well. And then we are also the recipient of a regional extension center grant, and that’s about $5 million, out of federal healthcare reform, and that’s spread out over four years. We’re also the prime subcontractor for the state’s health information technology/health information exchange grant from the ARRA-HITECH program, and we’re one of the prime contractors for that, and that’s $4.8 million over four years.
HCI: Do you have a staff?
Cochran: We have a board of directors that is our primary governing body, and includes private stakeholders, the medical society, etc., as well as a staff. We have a staff of 14 to oversee and deploy the HIE work as well as the regional extension center, helping practices get up on EHRs. GE Healthcare is our vendor.
HCI: How many physician practices have you interacted with, with regard to EMR implementation?
Cochran: The program is pretty new; our target is to sign up 1,100 providers—physicians and allied health professionals. And we’ve signed up about 190 so far. In Vermont, the average practice size is very small—70 percent of our physicians work in practices of three or fewer.
HCI: What have your biggest learnings been so far?
Cochran: A couple. One is that, while there are standards that help guide the interactions and the building out of the interfaces among the practices and hospitals like our Blueprint Program, those standards are not at the point of plug-and-play; it’s more like plug-and-struggle. So it is real work to connect people and systems together, even in situations where they in fact have done a lot of work to get ready for connectivity. The other is that the agreements that govern the relationships among the practices and hospitals are actually much harder than technology to get one’s hands around. So all those agreements around privacy and security really need to be worked out in a way that makes everybody comfortable, recognizing that this is an evolving field, and those learnings need to continue to expand. So we certainly spend a lot more time on the policies and the agreements than on the technology itself, even as the technology itself isn’t all settled, either. The other piece is that when I’m talking with praes, it’s great to be able to have the discussions we’ve had in the context of Blueprint that involve changes in practice that result in changes in care, rather than just changes in technology. That leads to a more engaged set of conversations with the practitioners.
HCI: How would you context VITL in the landscape of HIEs nationwide?
Cochran: There are very few fully deployed HIEs outside of integrated delivery systems. Probably the closest thing we see is organizations like the Indiana Health Exchange. They’re probably the most mature. Cincinnati Health Bridge has really done a lot of excellent work, including operating in multiple states. I would say that there are a handful of truly mature ones; and then we’re one among the next tier, where we have an approach, are exchanging information, and have a roadmap for regional information exchange, though we’re still doing work. And a good part of the country is still in the mode of trying to figure out what to do and how to get it done. And there are two phases to that. Our organization went through that before I arrived; that was the discussion of what made sense for VITL and for the state of Vermont. And at the same time, hospitals have had to figure out their policies on privacy and on data exchange. So a good part of what we’ve been doing is working through those issues with the individual institutions. And as I’ve said, if every single hospital has a different set of policies, they’ll all have to individually negotiate with all the other organizations, and each negotiation has to be separate, it just won’t work, so we need to be a policy hub as well. And they understand that. And it’s not easy. But we have agreements with 11 or 12 of the 14 hospitals in the state, so we’re well along the path. But that’s a period of time during which the practices and legislators and others aren’t seeing a lot of what they want to see, which is information exchange.
HCI: So there’s a lot of hard work involved?
Cochran: Absolutely. But everyone recognizes that this will involve a lot of hard work, so the challenge is getting that hard work done quickly. But what’s really good about this is the tie-in between moving this information in support of healthcare reform, and engaging the physician practices, and I hope that that comes through.