Data and Analytics

OneCare measures health care cost, quality, and utilization to help providers identify which Vermonters need outreach and which areas of care delivery to improve.

Providers who participate benefit from OneCare’s data about their practice, their region, the state, and how they compare. Using this data, health care providers can look at the health of the Vermonters they care for as well as their community in order to develop strategies to help everyone in their care become and stay healthy.

OneCare focuses on compiling and analyzing health data providers need. We bring data together from different parts of health care: health care visits, insurance claims, medical records, pharmacies, and hospital visits. Then, we help providers use the insights gleaned from these data to quickly adapt to and meet evolving health needs in their communities.

Data also help providers examine a critical aspect of health care: cost. OneCare supports health care for all Vermonters by making investments in preventative care: checkups, screenings, and community health initiatives. Using these data, we can help lower costs for care that is both unnecessary and expensive by avoiding duplicate tests, or waiving a requirement that patients spend days in the hospital before transitioning to skilled nursing care when the hospital stay is not needed.

Examples of Health Data to Act On

Looking at data provided by OneCare, Brattleboro Memorial Hospital discovered that their colorectal cancer screening rates were low compared to other areas in the state, and began targeted outreach to patients who had been missing this screening, resulting in improved screening rates.

OneCare creates innovative tools in rapid response to emerging situations. These applications use data from across the health care system to help providers address emerging public health situations.

By partnering with OneCare, we were able to use data that helped us shape how we deliver care. Our diabetic community had A1C levels [a type of blood sugar measure] that were not well controlled. The data showed to us that we needed to do something different. Together, our team decided the best approach would be to embed a nurse practitioner who was focused on diabetes and lifestyle medicine, within BMH, to serve as a resource for our primary care practices. As a result, we have seen A1C levels go down dramatically. It’s important that we continue with this work.

Eilidh J. Pederson, MPH

Chief Operating Officer, Brattleboro Memorial Hospital


Quality measures ensure providers are monitoring, and striving to improve, health outcomes. Health care organizations with high scores on standardized measures of quality earn funding for innovative programs and health promotion efforts. Because participating organizations had excellent quality measure scores, they earned $6.3 million in quality payments in 2019. Participating organizations showed improvement key quality measures, including controlling high blood pressure.

Spotlight Quality Measure: Hypertension: Controlling High Blood Pressure

Essential Hypertension, also referred to as Primary Hypertension, is high blood pressure that doesn’t have a known secondary cause. Controlling high blood pressure significantly reduces the risks of cardiovascular disease mortality and lead to better outcomes including reduction in heart attacks, stroke, and kidney disease.

Factors that can assist patients in their care of high blood pressure include, medication management, adherence to a blood pressure plan, routinely monitor their blood pressure, reducing sodium in their diet, and increasing physical activity.

Hypertension: Controlling High Blood Pressure quality measure looks at patients within a specific age cohort with an active diagnosis of Hypertension based on claims billed using specific diagnostic coding. Measure compliance is obtained for those patients who have a blood pressure below the recommended BP reading 140/90 (mmHg).

Spotlight Quality Measure: Diabetes HbA1c Poor Control >9%

Diabetes is a long-lasting disease which affects the body’s ability to produce insulin, which is a hormone allowing your body to turn glucose into energy. Patients with diabetes are at a greater risk of health complications such as, vision loss, heart disease, stroke, kidney failure or potential amputation of lower extremities.

This condition can be treated with diet, life style changes and medications such as insulin or other oral medications. Long term control of blood glucose levels helps reduce complications from diabetes.

Diabetes HbA1c Poor Control >9% looks at patients within a specific age cohort who have an active diagnosis of Diabetes Type 1 or Type 2 whose A1c levels are above 9, indicating poor control. This particular measure does not include patients who have a secondary diagnosis of diabetes due to another condition.