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Audit Questions Health Information Exchange Oversight in VT

An audit of health information exchange activities in Vermont has yielded more questions than answers about healthcare interoperability in the state.

- Officials at the Department of Vermont Health Access (DVHA) tasked with overseeing the development of a statewide health information exchange have drawn criticism from the state's auditor for their oversight of millions of dollars in grants and contracts.

Health information exchange in Vermont

In a report released late last month, State Auditor Douglas R. Hoffer found DVHA to have fallen short in two areas: evaluating the actions taken by Vermont Information Technology Leaders, Inc. (VITL) — the exclusive operator of the statewide HIE network — and measuring the latter's performance over the previous two fiscal years, FY 2015 and 2016.

According to the report, the state department issued $12.3 million during that time, representing close to one-third of total funding ($38 million) paid to VITL since 2005. Oversight of the VITL HIE contracts and grants fell to both DVHA and the Agency of Administration (AOA).

Deficiencies in oversight have raised doubts about the development of a clinical data warehouse to be used for health data analysis and reporting.

"Although the State assented to VITL building the warehouse, it was not explicitly included in any agreement as a deliverable, nor did the State define its functional and performance requirements. Without such requirements, the State is not in a position to know whether the clinical data warehouse is functioning as it intends," the report states.

Upon closer inspection, the building of a clinical data warehouse casts doubt on the state's handling of agreements with VITL, which according to the state's audit cited unclear language as authorization for the system.

"Even if we accept that this language authorizes the construction of a clinical data warehouse, which we believe is unclear, no evidence was provided to indicate that the State defined the functional and performance requirements of the warehouse," the report reads. "Without such requirements, the State is not in a position to know whether the clinical data warehouse is functioning as it intends."

Uncertainly also extends to the ownership and use of the clinical data warehouse as a lack of explicit language appears to indicate that the state is the licensee of the software used but its ability to make use of the data is restricted by the healthcare organizations providing the information comprising the system.

" Accordingly, VITL contends that the agreements do not currently permit VITL to disclose the personal health information in the warehouse to the State and, therefore, the State does not have any rights to access, use, or disclose this data," the report states.

As it turns out, the case of the clinical data warehouse was a microcosm of a much larger issue of poor programmatic and financial oversight of VITL. DVHA often failed to finalize agreements with VITL prior to project start dates — in five of six agreements. These delays had several consequences:

First, having VITL perform work without a signed agreement inhibited the State’s ability to hold VITL accountable to desired standards because they had not been formally documented and agreed upon. Second, the Green Mountain Care Board reported that delays in finalizing VITL’s contracts resulted in uncertainty about what terms would ultimately be agreed to or omitted, what work should be prioritized, and if and how to allocate staff, contractors, and other resources to various projects. Third, because of the four-month delay in signing contract #30205, VITL and the State agreed to eliminate two required deliverables (connecting the Cancer Registry and the Vermont Prescription Monitoring System to the VHIE). VITL also reported that the delays in signing other agreements resulted in a reduction in the number of completed activities (e.g., fewer interfaces were developed) and certain projects being completed later than expected (e.g., the event notification system was delayed four months).

State officials chalked up the delays to difficulties in receiving federal approval.

As for measuring DVHA's measuring of VITL's performance over the previous two fiscal years, the State Auditor concluded that agreements "contained few performance measures" to assess quality or impact.

"While DVHA’s agreements with VITL did contain quantity measures (how much), there were very few quality measures (how well), and no impact measures (is anyone better off). Further, the state’s current Vermont Health Information Technology Plan (VHITP) does not specify any performance measures for gauging the performance of the VHIE," the report states.

The state's audit reveals that state officials have taken steps to address these deficiencies, including requiring more detailed invoices from VITL which prompted an investigation into the allowability of some costs (conclusion still pending) and the decision by DVHA to fund an impact assessment of VITL's work

Ultimately, the audit concludes that the states is in no position to determine the functioning of the clinical data warehouse nor measure the performance of VITL in developing HIE services that have a positive impact on improving care quality and reducing care costs.

"Without quantifiable performance measures, the State’s ability to judge VITL’s efforts and gauge success is significantly inhibited," it closed.

Given the uncertainty surrounding health information exchange activities, the state of healthcare interoperability in Vermont remains problematic.

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