Building the Digital Infrastructure for Vermont’s Learning Health System

1. Building the Digital Infrastructure for Vermont’s Learning Health System ONC HIT Policy Committee Testimony September 14, 2011 Hunt Blair, Deputy CommissionerDivision of Health ReformDepartment of Vermont Health Access (Medicaid)

3. Building a Paradigm for “Systemness” • We do not distinguish between HIT/HIE and health reform; we have an integrated strategy to support a foundation of Advanced Primary Care and Community Health Teams known as The Vermont Blueprint for Health – and which we’ll next expand to include Accountable Care Partnerships. • The Blueprint’s design principles: • All Vermonters should have a Blueprint for Health primary care provider • All Blueprint for Health providers are supported by Community Health Teams that have nurses and specialists in nutrition, exercise, counseling and more to support individuals to lead healthier lives. • Specialty care is fully integrated with the patient’s Blueprint Providers and Community Health Team. • Blueprint Providers and Community Health Teams are able to address the population health needs of their communities. • Fragmentation of care should be a “never event.”

4. “Systemness” Extends to the State Enterprise • Extending that logic: fragmentation of state-sponsored health and human services for adults and children should be a “never event” and HIE is the vehicle to ensure that. • Better together, or the Vermont “Ben & Jerry’s factor” to mix in lots of yummy ingredients in tasty combinations: we haven’t met systems we can’t integrate & improve • SOA framework supports technical integration that helps model programmatic integration • Building a distributed networkultra-large scale system of systems where the State supports and helps to provide the system structure / framework for better integrated health care and human services

5. VT Blueprint Continuum of Care – General Health Services Higher Acuity & Complexity Targeted Services for Complex Cases Community Health Teams Augmented by SASH Teams & Medicaid Care Coordinators • Specialty Care • Advanced Assessments • Advanced Treatments • Advanced Case Management • Social Services • Economic Services • Community Programs • Self Management Support • Public Health Programs • Support Patients & Families • Support Practices • Coordinate Care • Coordinate Services • Referrals & Transitions • Case Management • Medicaid Care Coordinators • Senior Services Coordinators • Self Management Support • Counseling • Population Management Advanced Primary Care Practice Medical Homes Level of Need • Health Maintenance • Prevention • Access • Communication • Self Management Support • Guideline Based Care • Coordinate Referrals • Coordinate Assessments • Panel Management Lower Acuity & Complexity Locus of Service & Support

6. Blueprint Supported by an HIT “neural network” Specialized & Targeted Services Community Health Teams Including SASH Teams & Medicaid Care Coordinators Advanced Primary Care Practice Medical Homes Covisint / DocSite Clinical Repository, VT HIE Network & AHS Enterprise Architecture Connectivity across the continuum

7. Building on Core SOA Enterprise Components