 The first item on today's agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. I just have some scheduling announcements. First, that next week, we will be potentially, that's on November 20th, voting on the HIE plan, which we're going to hear about today. We're also going to hear from our own team on the all-care model benchmark update. And then we had moved an item on the discussion on the ACO 2018 results from today to next week. So that will definitely be occurring next Wednesday. Also, next Wednesday, November 20th, we have the Primary Care Advisory Group, and that will take place at the public meeting at our office on 144th State Street, and that starts at 5 p.m. And then I don't want to put her on the spot, but on Thursday, November 21st, we, as a board, the board members will be attending the Rural Health Care Task Force, but as noted on the agenda, this is not a formal public meeting. And Robin, do you want to just give a few highlights of what's happening in St. John's Dairy? Yes, so November 21st from one to three at the, thank you. Oh, yeah. So on the DRH, the Rural Health Services Task Force will be having a listening session, which will consist of a very brief overview on what the task force is and what the charge is and the work that we're doing. And then we'll ask people to split up into small groups and talk about some discussion questions and then come back together as a big group to share the information. So that's, I think, gonna be a really interesting meeting and we'll learn a lot. Thank you. Thank you for that update. I'm sorry to put you on the slope. No, no problem, appreciate it. And then the next week is the week of Thanksgiving. So we are having a meeting that is scheduled on Monday, November 25th to, again, talk about the all-year model benchmark proposal with a potential vote. And then, again, that is Thanksgiving week. Happy Thanksgiving, everybody. I have nothing else to report unless there are any questions of November schedule. Thank you, Susan. Next item of minutes, Wednesday, October 30th, is our motion. So moved. Second. We moved and seconded to approve the minutes of Wednesday, October 30th, without any additions, solutions or corrections, a certain discussion. Seeing none, all those in favor, signify by saying aye. Aye. Any opposed? Okay. So we'll welcome our friends down front. And Sarah, are you going to tee this up or no? No. No. Okay. Who's going to start off? Okay, whenever you're ready, Jenny, take it away. Jenny Sanderson, the deputy commissioner of Department of Remote Health Access, and I'm joined here by my colleagues, Emily Richard, Maureen Gilbert, and Andrea, who is doing just fine. We're here today to go over the health information technology strategic plan, and what is encompassed in moving that forward. So just as a reminder to the group, the Title 18 calls for an annual update to the health information exchange plan. And then in every five-year cycle, asks the Department of Remote Health Access and the steering committee to do an overhaul of that strategic plan. Last year was the first time in many years that the strategic plan had been approved. And this plan is essentially an update. It doesn't change any of the vision, direction, or scope of the work that we do, but gives an update on the progress that we have been making towards the elements that are included in that tactical plan. It builds on and reflects, one of the line-ups that builds on and reflects the approved plan from last year. Take a step back as a reminder to the group. The goals that were laid out in that HIE plan last year included creating one health record for every person in Vermont, improving the healthcare operations, and using data to enable policy and decision-making. As we look at this year as an implementation year, you really will begin to see these goals lead into the projects that we have been working on, specifically as we look at the collaborative service project as an example. It will begin to see these three uses, or these three goals, driving the types of data that are coming into the health information. And just like a quick walk-down, I'm really, in 2017, the legislature asked us to do a compliment to the evaluation of HIE. And I think to sort of over-simple by the situation, things were okay, and people didn't understand the problem, but they knew that they weren't going to do the results that they wanted out of health information exchange. So, HealthX Solutions, their party came in here and showed us, or eliminated a number of different things for us, which can probably be summarized into, stakeholders need health information exchange, health data is needed for a lot of different reasons, and we weren't set up for success in achieving our health information exchange goals. So, shortly after that evaluation came out, we got moving very quickly on developing a stakeholder group called the Health Information Exchange Steering Committee, who formulated that first strategic plan, which she was referring to. And I think, Guesha, we clear on the fact that our goal really was to demystify the problem last year, to talk about the many more component parts of health information exchange, why it's important, and why it's hard, and why we've come up against so many challenges in the landscape, not just us, but nationwide, worldwide, in terms of getting the data that we need for the multitude of reasons that is necessary. So, I think that's an important sort of foundational thing to think about as we walk you through how we built upon that work that started, that in many ways, kicked off in 2017. This is a reminder in terms of demystifying health information exchange, there were a couple of key terms that were laid out in last year's plan, one related to the health information. The other also demystified in relationship as we go through to us talking about the health information exchange as a verb, the actual exchange of health information, and as the noun, which is the health information, the Vermont health information exchange, which is where we house and exchange the data through vital. In order for health information, in the evaluation that was conducted, in order for health information to be effect, health information exchange to be effected in Vermont, we identified that it needed a multifaceted environment in which health information is moved. And it really had kind of several key pillars, in addition to the technology which we typically think of as the health information exchange in Vermont. Those pillars included formalizing a governance structure, which we've done this year, and really worked on. It included policy, and this year as we think about our policy objectives and advancements, we really are talking about some of the consent policies that we have addressed. It included the financial goals and financial sustainability. And this year as we've looked at financial goals and financial sustainability, it's really been focused on ensuring that the resources that we have available are matched with the amount of effort and work that are being put into it. Each of the pillars of the ecosystem must evolve in order to achieve our goals. And in order to make that happen, underneath each of these pillars is a tactical objective that are included in the tactical plan in that we have for you. You know, when we take back a couple of years, our view of our information exchange really might help. We're very focused on Vermont. I know the leader of Vermont, excuse me, the Vermont Health Information Exchange, and not about component parts that might be leveraged with their success. So I think starting with this foundation is really important, and we're kind of illustrating here today through all of our sort of conversations about how the work is progressing. That without the policy, without the financial goals, without appropriate governance structure, that technology is never going to meet our needs because it's not going to be built in a way that's reflective of what the needs actually are. So we're just kind of always keeping this in mind. You know, we brought this year and today together not to think about just what Vital does, but all of those component parts that are going to be able to do that. And one of the foundational components to our success is also looking off at the technology components. And when we began to develop the health information technology plan last year, we really looked at the national guidelines like those coming out from the Office of the National Coordinator and assessed that against Vermont's key use cases. The steering committee identified components that must be in place in Vermont, and you can see those components here. Those are really falling to three areas. Foundational services, which are really the minimum and foundational things that we need to be in place for the exchange of information. The exchange services, which really are kind of some of the core technology that needs to be in place, and the end user services. As we go through today, and specifically when we begin to talk about investments, we begin, and through our technology roadmap this year, we really are looking at the foundational services as being core place for the public investments to be invested in as are the exchange services. The end user services are typically services that those two layers below need to support in terms of having the availability of the data, but typically maybe investments that are made outside of the health information technology investments, but are potentially made by additional organizations, for example, the accountable care organization. Sorry, just to underscore sort of why this is important, and to be sort of like a caveman about it, but it's really like you can't have step three without step one, and all we're saying here is that there are some basic things that have to be in place for us to get sort of the shiny fun tools that people talk about a lot like, how do we manage care using information and technology? How do we do analytics? How do we get real time notifications of where patients are? We can't do any of that kind of sort of shiny, important stuff without having identity and security and a consent protocol that works or interoperable systems. So those foundational layers are why we think about public investment there, because it enables data exchange and data use in a way that consumers and providers and patients are really making sure of. So what you saw in the 2018 and 2019 plan was really for the first time a way to potentially break down small digestible chunks, how to actually achieve and get to our goals and objectives, and especially in terms of supporting the environment that we laid out, but also the technology and the structure that was laid out. Specifically in 2018 and 2019, they established some key objectives. One of which was to ensure that we had a permanent governance model in place. And I think as we walk through today, we will connect this to our efforts and work, but really this begins to look like or begins to be the HID steering committee. The second is incremental progress on some of those core foundational services and the core exchange services. And you begin to see that come alive as we talk about Act 53 and the Consent Policy changes and you see that come into execution when we look at the collaborative services agreement that we will both talk about, but later we'll talk about in more detail. We're looking at implementing a long-term sustainability and financial planning. As we move through today, we really are trying to achieve that right now in terms of putting in our operational efficiencies and creating value for investments in the future and developing the technical roadmap. While the HID plan helped to establish some of the core things in the environment, we needed to take a look at what the technology needs were going forward and both what was happening at the national level, both from a policy standpoint and in terms of technology advancements and the roadmap will help us do that. So when we begin to think about, as we begin to think about our work this year in terms of the progress that we've made that tie back to the areas we really are looking at five specific areas or projects for the big advancements. Really we're looking at HID governance. We're looking at operational efficiencies and effectiveness by execution of the tactical plans and other elements such as the vital agreement, health information technology roadmap and the creation of that this year, the collaborative services project and moving from an opt-in to an opt-out consent policy. So when we began to look at the evaluation in 2017, it really highlighted the lack of an accountable party. So in this past year, in the plan last year, we really identified that there would need to be a permanent governance structure and that that governance structure needed to serve the needs of the HID users. It needed to strengthen relationship between authority and accountability and it needed to engage a broad range of stakeholders. This comes directly out of the plan from last year. In order to put that into execution the HID steering committee this year put in place its permanent members. They finalized a charter, finalized a charter in the last year to establish clarity on its vision and approve the approaches of the, approve and look at approaches like HID governance and also looked at how we could convene potentially subcommittees moving forward to move forward things like our developments of the tactical plan and elements such as the connectivity criteria. What we believe will happen in 2020 related to governance is that we will focus on prioritizing subcommittees and some of the current proposed areas may look at connectivity, data governance and HIE consent coming out of some of the priorities from this year. I mean, I don't know if it's worth saying but I will that, you know, when we think back over the last couple of years before we had the HID steering committee it was really not clear it was accountable for HID success. And Green Mountain Care Board and Viva sort of shared an oversight role over vital which was not clear. And so that didn't help vital, you know, accomplish their goals. It certainly did not help Viva stick in a strategic planning role or sort of a liaison role across the healthcare system. So we're hoping, I mean, obviously we're working towards perfection, but you know it's a process. We're hoping that the committee is reflective of the healthcare system in a way that we're building a strategic plan that helps vital accomplish goals that are real and meaningful and helps other stakeholders invest in health information technology in a way that's not definitive and it is building on sort of core services. So I think this slide helps, this slide you will find in the health information technology the health information exchange plan. And specifically the goal here is to outline clear authority and accountability across the system. So really looking at what the roles of the HIV Steering Committee is, what the ad hoc committees will do, the GreenMap Care Board, the V-CHI and other organizations who are using the V-CHI and their performance-based contracts. This gives us some structure for that level of accountability. The other thing that the HIV Steering Committee does is it helps create a link between the users of the health information exchange and the accountability for the health information exchange. So you will see that the makeup of the board represents key stakeholders that are particularly strong users or inputs for the health information exchange. Pause there. Any questions so far on kind of the governance structure or the governance activities this year? So one of the other areas of focus this year we're coming out of the evaluation plan coming out of the oversight from Act 187, we've seen significant progress of vital and health information exchange going on. We, in 2019, really worked to carry that forward through a couple of key areas. One of them was to create goals and accountability in the contract with vital. I think what we, the connectivity criteria which we'll talk about in just a second is an example of this. When we were able to establish the connectivity criteria which had been absent, the clarity on exactly what was necessary in the levels one, two and three have been absent in the past. We were able to establish that connectivity criteria in 2019 and in 2020 we'll see the contract begin to point us forward in terms of more practices and organizations moving from a tier one to a tier two and some level of accountability for that built into the contract. I think last year Mr. Pellanyu asked, so when you come back next year am I going to see the vital contract aligned with the HIE plan? So if you pick up the vital contract in its current form and it's soon to be the 2024, you will see the exact subject matter of the HIE plan reflected in the contracts and what is going to happen in that annual period to progress that area. So I think that's pretty substantial growth in terms of how the program operates. Another, I feel like we've made significant advancements in the HIE operations is continuing to apply for and receive federal funds for the HIE and matching that with our Health Information Technology Fund. What you will see as we go through the Collaborative Services Project we were approached by multiple different organizations to fund multiple different, the same thing multiple different times. And our goal this year is to say, how much revenue do we have coming in from our HIE fund? How can we leverage that and continue to leverage that for federal funds and line that up so that we're not exceeding the revenue from the HIE fund for the IAPPB? And so we see some operational efficiencies there. We also see that we've matched up the investments that are being made from those HIE funds with what is outlined in detail in the HIE plan. I think the other element that we're proud of is that we've made considerable progress on all of the tactical elements in the plan. And related to interfaces, we've begun to think about how we will leverage, prioritizing new interfaces and how we will move the current interfaces from tier one connectivity to tier two and potentially tier three connectivity. So let's talk a little bit about the advancements in the connectivity criteria. There were no significant or major changes in the overall framework for the connectivity criteria. But the HIE Steering Committee and the stakeholders that are involved in the HIE Steering Committee convened several times this year to review the data elements that are included in tier one, which are essentially, can we get information from an organization on the people that they are serving? So really the baseline information. Tier two, which was really the sharing of the essential clinical information. So what is it that we need for the sharing of that clinical information board to be useful for organizations like the ACO, state organizations like the Blueprint for Health, and also to be able to report on our all figure model measures. So they mashed up what is necessary for those organizations about what was available in the current electronic health records and created the tier two criteria. For those things that were not necessarily readily available and were kind of stretched goals for the first time they created the tier three criteria. This is the direction that we might be, that we would be going in the future. And we include things like the plan for mental health follow up as an example. And you can see how that might match up with the all figure model goals. So if you can't tell them like they'll watch that memory lane person, just what they give me, I'm going to carry it back from the journey for my best of what's happened. So, you know, connection criteria is born out of the Greenmont care board. It's existed since 2014 and it was a great concept to say, you know, how are we going to assure that the connections that are being made between electronic health records and our central repository, the health information exchange are actually of quality, you know, getting us what we want. And so in 2014, and I'm a little more not speaking for you, you all know this better than I do, you know, it started as this sort of concept. In the last couple of years, David and I all worked together to put a real structure around it. So to say, okay, so this concept is great, but like how are we actually plugging in more vital accountable and ask our electronic health record members to adhere to a certain standard. And so that's what we did last year. David and I all came together to create this three tiered structure. So the concept was great, but we didn't have enough time to have the stakeholders all around the table to say, here are the exact data elements that I would need to do, improve operations, to do point of care support, to do quality reporting. And so Vital now has engaged a stakeholder committee to start having those conversations and they were able to put together a much more comprehensive set of data elements for tier two. And so why that's important is because tier one's like, you know, with your name, your birthday, we know who you are, who you demographic data. But tier two are really, how are we going to start using the data elements? And then tier three is, no blueprint for health administrator, or I run the ACO, you know, as I wear different hats, what are my different data element needs and how can I guarantee that the connections that the state or private sector are paying for are yielding the results that I'm interested in. So it's a progression of things. We haven't gotten to tier three in totality yet and I'd say tier two is still in the works, but at least the structure gives us something to sort of work towards. And I think as Carolyn and Andrea would say, it gives them the authority to say, hey, the state of Vermont is asking for this, so you electronic health record gunner, you need to act on behalf of your provider organization. It gives them a lever to kind of call back on it. And it's the flow seamless from the modern moves from Medicaid to commercial or back again. Are they connectivity criteria? Yep. Yes, because the information is flowing from their healthcare provider. So when they change the, from one insurance product to another insurance product, it doesn't necessarily mean that they have to change healthcare providers. And so since this is information coming from their healthcare providers too vital, it shouldn't impact them. But your question perhaps goes into a topic area of what do we ask of insurance carriers in terms of obligating their providers, the providers that they have a business with to exchange data through the health information exchange. And that's probably a bigger topic than you want to delve into today, but it is something to consider and something that we can talk about at Medicaid. So in creation of the tier two data this year, they did look at the prevalence. So the data that was available to help make some of those decisions. As we look forward to 2020 and through this process this year, we've identified that this current connectivity criteria does not necessarily meet the needs of all different types of practices. And so these were the updates. As you look at these, the types of data that were updated in terms of the data elements this year, you will note that many of them are pretty healthcare specific. As we think about next year, and we begin to think about other types of data coming in, for example, as the designated agencies convert over to a new electronic medical records. And as we work through the connectivity criteria and may be able to take in additional types of data sets for those types of, for additional types of providers, you may need to look at segregating and creating additional types of connectivity criteria for them. So as an example, as you look at a designated agency, they're gonna have information on developmental services that may not necessarily be something that you would find in their traditional health record, or they may have more detailed information on mental health. We plan on using the work that's already been done by Vermont Care Partners as an example, where they are already aggregating data to potentially create that segregated connectivity criteria. Another example were women's health practices. While they collect a lot of the same health information that primary care practices do, there are additional types of tests and other results that they may have that are not found in a primary care worker. Questions on that connectivity criteria? The technical roadmap was a goal that we laid out to achieve in our tactical plan last year. The technical roadmap's purpose was to continue to advance the HIV plan by taking a look at the three core goals that were established and to evaluate the technical and policy landscape and engage stakeholders to provide guidance on future objectives and technical investments. So this really was the take and dive into the technology that we would look at. The technology roadmap was published late in September with only enough time for the steering committee to go through the high level objectives. They've been receiving feedback and provided feedback throughout the plan, but the actual full technology roadmap of this entirety was not available and so we've already had to evaluate and create this year's HIV plan. And so from that standpoint, they did look at the six overall goals and objectives in the technical roadmap, but we will spend 2020 really integrating what is in that roadmap into the tactical plan. So you will not see, while it is attached, you will not see a full integration of that roadmap into this year's HIV plan. So the technical roadmap, just so you know and have a concept for it if you do dig into it, it engaged a contractor, that contractor participated with 44 individuals and 16 organizations in order to develop it and it supports the key objectives that are laid out in the HIV plan. This is the collaborative services you've heard about several different times throughout the year through the vital. Diva and the HIV steering committee were being, as I mentioned before, were being asked multiple times to make investments, particularly three times by providers directly. They were also being asked to invest in it through the ACO was also contributing and getting data and the state government agencies were contributing and getting data. Our goals were to try to get to invest in the infrastructure, those foundational infrastructures one time and also to make sure that we were creating a modular infrastructure and that we were doing it in a phased and responsible way. So in that respect, the collaborative services project emerged in order to create phase one, which really put in place the master person index or the ability, national peace index, the ability to match different records from the same person coming from different organizations. The ability to collect additional types of data and through our terminology services. So to really be able to map data that wasn't necessarily in standardized format and pull out additional information and data for that and the ability to wrap in great data. It feels like a good time to stop and just talk about folks. So, you know, back to we, there are foundational elements that are required for success, right? And so lots of people who care about health information exchange or facilitating health information exchange or using health data, we're trying to invest in the same foundational components to get the same quality data at the back end, right? And so those are people that, those are groups and people that DEVIL works with. ACO, the blueprint, vital, the provider community, others we're asking for basically the same thing because the same thing was broken across the system. So instead of investing in it multiple times, Eva said, great. So we're going to create a comprehensive strategy where we invest one time and it benefits all of the stakeholders. And so these are foundational things that are going to make the data more usable, more exchangeable, more interoperable for all of the end users. Does that make sense? Okay. So an opportunity there, as we've looked at investing once as an example in terms of the financial sustainability of HIE is that we're not going to pay for things twice. So we're not going to pay for the data repository, which is the phase two at the HIE and the Vermont clinical registry. So at the clinical registry will actually sunset on December 31st and the efforts that were underway for that would be merged into this project. So now we're investing one time for two different purposes. In addition to increasing the data quality through the health information through the collaborative services project, we are also looking at how we can increase the availability of different types of data. So when we talk to organizations like the accountable care organization about their efforts, as they think about things like matching a person for different disparate data sets, they want to pay for that one time. Remember that making that investment once. So as we think about moving to phase two, which is really creating that data repository and we think about the value case for this, we do see ourselves, the HIE does see advancing into collecting additional types of data. For example, being able to collect the substance use and mental health data, as long as the part two solution is available in that data repository. Potentially also bringing in the claims data because the ACO is already getting the claims data and they want to be able to match the clinical data that they're getting in the claims data using that master person index. So again, investing one time for multiple different purposes. And the last type of data that we perceive may go in in place is looking at some of the AHS social determinants of health data to help advance the risk stratification as an example for the ACO. So now you're seeing the creation of those foundational services and you're seeing it being used as a data repository across multiple different types of data sets. We are on target as vital a report for getting phase one done in April of 2020. Phase two, which is really that foundational services, the NPI terminology and interface services by the end of that, that would be in place by April. And then the data repository we believe which is phase two will be in place by the end of 2020 with the additional data sets throughout 2021. Any questions on that? Yeah, can you give me an example of the terminology services? Yeah, so I'm gonna give you an example of what terminology services does. So it brings in potentially data that was not necessarily standardized in the past. So, Andrew, if you wanna use Diabetic as an example, they may have 30 different codes that would identify Diabetic consistency. And terminology services is an opportunity to normalize it and call it one thing. So you could have 20 different codes and it would still take it and convert it to an A1C. You know, I just think I always use the word translation instead of terminology services because that's really what it's doing. I can say like, here I'm gonna, the word tomato in 30 different languages, I need it to be tomato on the back end. So if it comes in in 30 different languages I need it to come in. I need the output to be in English. So it's translating a bunch of different ways to say the same thing. The one say tomato, I say tomato. Oh, that one. Exactly. In the past, a lot of that information would have been left on the cutting room floor. So it would, and so as you look at those foundational services and we're looking at data quality and data access, in the past, if it didn't say tomato, it was just cut. And so, this will allow more types of data to come through. And I think that's a whole set of great questions as well. Oh, I whispered to him. I was curious about what kind of savings, cost savings is gonna happen by sunsetting, you know, the clinical registry or do we share the palatory and sunsetting or the things, the big estimate of what's gonna be stated. We're still working on what those estimates are. What we do know is we're needing to make some additional investments and vital, but the current, the contract that we had for the Vermont clinical registry, some elements of that for data quality will move over to vital. But overall, we're seeing a reduction in the cost. I can't quantify that for you. What I can say is that as we've looked at the HIT, that the HIT fund budget this year and going into next year, in the past, we have typically expended about $7 million in the last couple of years of the HIT fund budget. The revenue into that has been about $4 million. And so with this project, as we look at the budget for this coming calendar year and the following calendar year, we have right size the agreements that we have to what is available in the HIT fund and through the IAPD. And so there have been actual, there have been savings. That's a small thing for some, you know, an investment made over the next couple of years to get the use of and running. So, but I'm not saving. But there isn't that savings. Absolutely. Thank you. You have a question? Yes, I have a question. So my recollection is that the clinical registry was the way that the blueprint provided information to the practices and then what's gonna happen between the time that that sun sets and the time that phase two is under running. Yeah, so we did, we took, we worked with the blueprints during the valuation and really at this point in time, they get two data feeds out of, on an annual basis, out of the clinical registry. One of those data feeds comes at the end of the year and we will be able to, when we will be able to get them their data feed this year and at the end of next year, invite them to lose that they may be able to also provide a data feed in the middle of the year. Either way, the middle of the year, the middle of the year data feed was not necessarily for major and core operations. The practice data was really what was happening at the end of the year. So one of the research should not be a gap in the data. Great, thank you. Yep. Other questions? Guess we're gonna move on to your impossible task. I'm gonna learn how you're gonna reach out to the reason why. I do have questions on the actual plan, but I've been holding that until the end. Okay. It's work, do you want me to do that now? Wait. Chairman, the big- Fire away. The big blip. I do think some of them are related to topics that you already talked about. Um, so I wanted to talk first about the financial model that's referenced in the strategic plan. And this I would say is more in the form of feedback than in the form of a question. But when I was looking through the key questions in the lens that you were looking at in terms of developing the financial model, I thought all the questions were great, but I felt like there were some missing. And that is in that the questions are really focused solely on the state investment and not looking at the total picture. So in the HIT evaluation, there was a discussion of the financing model in terms of particularly those end user services and connecting them to customers in order for the customer voice to be heard, which makes sense. In looking at the actual financing of it, I think you then also need to look at the impact of those dollars in the private side of the system as well. Because even if the state is not paying for it with a match state and federal dollar, somebody is paying for it probably in a private insurance premium dollar. And so I think we need to be looking at the total picture, not just the state side. So that would be my feedback on the financial model. And I think you already answered this question, which was when I was reading the strategic plan and looking at the summary of the tactical plan, I started to compare it to the technical roadmap, noticing then that the chart that you have on page 21 in the strategic plan is looks to me to be a condensed version of the larger chart that's in the technical roadmap, sorry. And it sounds like that you may have done kind of an initial first pass and pulled out some of those pieces, but that the full review of that will happen next year. You read that right? That is correct. Okay, and can you just talk a little bit about what you pulled out and why you pulled out particular items from that larger list? So as the year progressed, the HIE steering committee got strategic updates from the group that were providing the consultation on the roadmap. As they got those strategic updates, they began to incorporate that into the HIE plan. And so you will see those things that we already had some insight to that already incorporated in there. In addition to that, in our first pass of the roadmap, we went through and identified things that already began to match up to those five core efforts that we were making this year. And those elements were brought forward into the land. Thank you, that's helpful. And then I've had a couple other questions that are related more to the technical roadmap. So maybe I will just let you know what those are so that you can feed that into your process as you review it. And I don't, you know, doesn't make sense necessarily to speak to those now given that the steering committee hasn't looked at it. But I was particularly interested in the automating of the quality reporting in terms of that effort. I also noticed in that the non-technical plan in the technical roadmap, there is a lot of discussion around quality and the line quality measures. I wanted to just make sure that you knew there was a report, the Green Mountain Care Board did not that long ago that made some recommendations around further aligning quality measures. And one of the areas, this comes up a lot, alignment of quality measures for us from the provider community, as I'm sure it does for all of you. And one of the areas that's not well understood, I don't think is what the state has control over versus what's driven at the federal level. So I think any sort of education or information or clarity that you can bring around that question would be helpful because I think understanding what we can leverage and what we can't control is important in terms of that alignment. And then there's also, of course, the whole aspect of potentially self-insured employers being able to do their own thing. And then on the provider directory piece, I was curious to know whether you'd be looking at any connection with the licensing data, for example, since that I would assume that there's already a wealth of information with the licensing agencies around providers and whether it makes sense that that's totally separate or whatever. So I'll just pose that for you to think about. And that was it on what I had on this strategic plan. Thank you, Kevin. I just have a question on the Diva contract with Vital for 20. What Vital is representing in their budget is an increase from like $2.2 million to $4.1 million. And I just wanted to know, is that some services as you talked about that made your moving from Diva to Vital at this point? That's exactly right. Since the original submission of their budget, the collaborative services project, particularly has been clarified, both in phase one and in phase two. And elements such as the repository have been moved over to the Vital contract versus an outside contract with another vendor. Great, thanks. First I want to say congratulations. This is my first introduction to this with the health tech solutions. I think that was the name of the consulting firm. And it seems that both the HIE, the HIE plan and the Vital were struggling to find a focus. And as you go through this presentation today, it's clear to me that you all make great progress and that there is a momentum that is built in an end game that people can work toward constructively. I am curious as to how you're approaching the transition of the Vital leadership. You have a new person coming on board. Clearly your government structure is working and has some momentum behind it. And I'm just curious as to how, what you advise the new Vital leader to be thinking about and how you might best integrate that person into this momentum. That's a great question. The Vital leader has just been identified and announced. So we will begin working with that individual as the mission comes on on December 2nd to orient her to the strategic plan, the governance process, and the upcoming contract year. Hoping to create some alignment on what our vision and mission has been and continues to be with a real focus on the technical implementation. You don't mind me saying too. So when I started a couple of years ago and met the Vital leadership team, they kind of moved in mass. Like they worked all together, all of them, all of the time, right? So since that Vital leadership has changed significantly across the organization and now it's much more sensible. There are individual leaders for individual work streams and we've been able to, I give a pair of teams of people with their correct teams of people and work on different subjects and progress them individually. Just an enormous improvement and allows us to be a lot more efficient in the way we work in the past. I also think that I'm optimistic that under Mike Smith's leadership that they have set up a strong infrastructure within the context of the teams that Emily just mentioned and that for the foreseeable future, those teams are well-established and set up to carry forward the work that's already outlined here. And I'm sure that as the new CEO comes in, that she will become oriented to her team. And I asked our Sarah today two questions. So, number one, does the steering committee have minutes and I'm told to do? And the second question was, has there ever been a conflict within the steering committee where there was votes taken and there were two sides of an issue and one prevailed and one didn't, or is it pretty much a collaborative exercise where things are intensely discussed, but there's not a lot of profound battles going on. Interesting question. So, the steering committee has evolved a lot as they take in, right? So when they first formed, their real goal was to demystify this situation. Each of their perspectives had to really illuminate what the issues and challenges were so we can move forward. And so from that standpoint, the group was really cohesive and able to talk about their shared challenges. Now we are entering a realm where individual organizations have individual positions and we're going to be asking them to weigh in more on how we invest in connections between an electronic health record and the HIE, how we achieve this unified shared platform under the collaborative services project. So we likely will see more of that in the future. We haven't had it, honestly, to use voting very much, but in the future it seems like that could come up. So I've seen some maturity even in the last couple of months of the group as the HIE technical roadmap elements were presented to the group. We have seen some differences of opinion. That's one of the reasons why we want to come through the roadmap very carefully. For example, the vendor who produced the technical roadmap put in end users, several elements of end user services, including analytics, including things like the care management tool. And as Member Lunge mentioned, also things like coming up with a quality index. And there has been disagreement among the members where they have had significant conversation but come to consensus. As we begin doing things next year, like identifying which organizations we want or types of organizations, all the organizations that we want to connect with, I do think that there will be differences of opinion where we may need to move from consensus to voting. Just a quick follow-up question actually about the steering committee. I know the shape of agency, and you're looking for a technologist which makes all the sense in the world. But as I was looking through the folks that are on the steering committee, it struck me that you don't think that, at least maybe I'm not sure, but maybe you've been telling us, it doesn't seem like you have a super user. Somebody who is that end user who's using it all the time. And I'm just curious about whether or not that wasn't intentional or you're thinking about maybe adding somebody that would be a super user or just what the thought process there was. There's been a significant conversation in the group about whether we can find a clinical leader to join the group. And I do think that that may emerge in 2020. The groups that represent some of those end users like by State Primary Care and the Vermont Hospital Association feel like where we have had times where we've needed and put big on out to their members together. But I do think that potentially you may see a merge next year, I think. Thanks. So, you know, one just shift kind of from the 2017 group and how they prefer to still plan to how this year's group was thinking about it. The 2017 group thought they wanna keep this small and we only wanna engage groups that already exist because we know that the provider community is already using their, volunteering their time on different groups and so we'll go to the Primary Care Advisor Group, for example, to get feedback. But I think this year's group, as it really delved into more details, realized that we need more subcommittees, we need people who can be more so dedicated bodies on certain topics. Thank you. So from here we're merging kind of the strategic plan and the strategic agent and the consent report to report out the progress that we've made on the HIE. And there's been a significant team that I wanna give credit that's worked on this including folks at Diva, folks at Vigil, and many of the stakeholder organizations have put a lot of time and effort. I'm gonna turn it over to Maureen and Andrea who've really been leading on the stakeholder engagement and the technical performance. So I think I just wanna start by reminding us all about the project that we've undertaken here. Act 53 moves the Vermont Health Information Exchange from an opt-in consent policy where patients had to actively express the consent that they would like to have their health histories viewed by their providers through the Vermont Health Information Exchange to an opt-out policy where it will be the norm that folks providers will be able to see their health records in the Vermont Health Information Exchange unless they take a step of opting out. And the intention of this was to align the policies better with the preference of most Vermonters. You know that when asked, 95% of people say that, yes, they would like to opt-in and have their health information viewable. We also know that that's true, not just here in Vermont, but it's typical across the country for that preference to be sort of out of that ratio. We also know that in order for the Vermont Health Information Exchange to really be useful at the point of care, particularly when it's used through vital access, that providers need to be able to expect to go in and find a record. If you're going in and routinely not finding your patients in there, you're just gonna get out of that habit pretty quickly. So when we have most people in the school will become much more useful to providers and therefore useful to the patients that they serve. As we make this shift, we've all agreed that meaningful consent is the goal and that we really want people to have an opportunity to understand how their health information is being shared and being viewed and used and have an opportunity to opt out should they wish we really want to make that possible for people. In order to get there, we've established three main work streams here. So one is stakeholder engagement. The second is mechanisms to support opt-out and that's where vital has been really instrumental and then in the evaluation methodology. I say that for vital has been really instrumental but actually we've been teaming across all of these just that sort of area of expertise. Want to remind you folks about our timeline here, opt-out consent goes into effect March 1st of 2020. You're gonna be hearing about this from us one more time before March 1st. So January 15th of 2020 will be updates to the Green Mountain Care Board and legislative committees. The annual, this will also be incorporated into the annual reporting for the health information exchange for the health information exchange for the nation site. So the implementation of this project. When you take a look at your slides, you'll see that there's some things here that are great, these are things that we've told you about before. So I'll move quickly through those and some things that are in black and those are things that we're sharing with you here for the first time. So we have been doing through stakeholder engagement this ongoing work of connecting with advocates for all remoders and advocates for special populations and people with lived experience. What's new here in the stakeholder engagement work is a partnership with a marketing agency to develop digital and grant communications. And then we're also gonna continue that work of stakeholder engagement all the way through to March. For the mechanisms, vital has been developing mechanisms for managing consent really made some breakthroughs there. We're on track to have those mechanisms in place on February 1st. They already have a consent hotline that we call when asked questions. And that's been live since Andrew told me this is where we're walking in and I can't remember, 20, 15, 15. So the organization already has plenty of experience answering consumer questions. That hotline right now cannot actually accept and set decisions. That's something that's coming down the road. Right now it certainly is available to answer questions. Yeah, very much, March 1st, absolutely. And vital has to find new mechanisms for opting out and those include a will and good phone, an online form and by mail. We've expanded the network of providers who can register a consent decision, for instance, including the remodernish bid. Trying to remember what VCCI has been for. But they are already working with the new Medicaid population to counsel them about their right to opt out and to register those decisions. And if I- Do you want to take questions as you go or wait till the end? Yeah, let's do it as we go. So a couple of artists popped up. Please. When you say phone, is it going to be as simple as a text? There's not fans for texts right now. That's a great question. But it is a great question. So the challenge with that is verifying identity. And- How do you verify identity on a call? Another great question. I was going to say that for later in the presentation, but I'll take it now. The, there are two components. So we certainly have access to VHAC data. And on about over 90% of room watchers have some sort of type of data in the VHAC. What we have established is that we, that it is appropriate for vital to use VHAC data with an established set of criteria to verify a person's identity over the phone. Does that make sense? Yeah, it still might be a little difficult. The other piece of this is that there's very, and we actually very much appreciate the stakeholder feedback about this, is we're making this available, but only for patients that choose to opt out. Because it is the consensus of the stakeholders and everybody in our group that there is less harm than in coming to a patient if someone pretends to be someone they're not by opting a patient out of the VHAC. So we have made that available via phone and it's not available for someone who has previously chosen to opt out but would like to opt back in. That'll be a different mechanism. You know, this all goes back to previous conversations we had here the last time that we've been in and that is I really think the legislature gave me the possible tax that you can send each person water. I heard you mention that a marketing firm has been hired for materials, but I don't think you have a budget to get those materials out for people. So it just brings up those questions about how you're gonna meet that impossible task because it seems like they asked you to do the limbo and they've set the bar about an inch off the ground. I don't know how you do it. So one of the things that is new since the last time that we were here is the legislature did not appropriate funding but we were able to carve out a portion of the funding that was approved in the October high tech of advanced planning document from CMS and so we will be using a portion of those funds to fund some of this work which means that there are additional mechanisms that are available for getting information out to the public. Now it's not a lot of dollars but it's enough to make some specific and targeted efforts at a broader public messaging campaign in addition to leveraging the advocates. So if you get into the day that you've been put in the mirror and say that you reached out to each of the moderates. At the end of the day, I believe that we'll be able to look in the mirror and say that we've made specific efforts to target Vermonters through a wide variety of, not a wide, but a variety of public messaging avenues that we will have been able to reach out to populations who specifically have additional concerns about having their information shared and can do that through some of the advocacy organizations. So believing that we can get to a significant portion of Vermonters, beyond that we will focus our efforts on those individuals who have data in the health information exchange. Are the marketing materials that are being developed by the same agency that you've hired, are they being sent out to every advocacy firm that you are and live on this effort? Yes, absolutely. So I would have actually said about 10 years ago that we could not have achieved this reach with the sort of budget that we have today. And that was prior to the advent of social media or folks being really on it sort of all the time. The fact that we have partnerships with a number of advocacy organizations who have strong social presences and are also partnering with hospitals and hoping to partner with insurers. We're still working on building some of those partnerships out, but we do know that through social we can get some relief or less money than we might have been able to in the past when we were needed a large TV radio budget to sort of a work report. But to answer your question specifically about getting these out to advocacy organizations, yes, absolutely, we're developing a toolkit where we'll have a set of things like social posts, law or newsletter content, brochures, just a variety of materials that they can use with their members to spread this message. The Ramon are without a computer. So the Ramon are without a computer, I think we are hoping for a couple of things there. One is we're hoping for a relationship with an advocacy organization who might be able to counsel them about this one on one. In the absence of that, we are hoping that the news media will help us with this. We are looking at ways to get this message out through sort of some of our broad statewide news media by partnering with our colleagues at the Vermont Department of Health. They have a strong PR person there who can help us with that. And also through the little town papers, which we know that people actually pick up and open and read when they come once a week, we're hoping to use those as well. What percentage of Ramon are self-help? Because I'm thinking people are gonna have computers, but in terms of cell phone and social media, do they have a sense of... I don't know that, but I definitely know that it does help with penetration of access to the internet. So, let's see. The last thing we had thrown the mechanisms was that VAL is actively testing the technical environment for opt-out. We'll get into that a little bit more in a bit. And the third work stream here being our evaluation work and that we have a plan for evaluation that's happening right now with a committee that's been assembled and it's gonna convene for orientation in December. Just a little bit of a preview of the rest of this presentation. So our stakeholder advocates or work with the stakeholders and advocacy organizations, this began back in July. We previewed some of this with you last time we were here. We were really engaging with a whole range of types of organizations to understand the concerns and communications needs of the people they serve. Really have them think together with us about communication strategies. Ask for help connecting directly with the people they serve so that we can do like focus groups with people with lived experience and so forth. And then ask these advocates to be messengers to participate in that role out of the communications materials using the toolkit like we talked about a minute ago. So the advocacy organizations being engaged with here included advocates for all remandors. So the healthcare advocate and the ACLU. And Andrea mentioned this earlier. They were really a tremendous help in advancing our thinking about the threshold of identity verification necessary for opting out of the health information exchange and really thinking about this new lower threshold that's different than the threshold for opting back in, for instance. So I think that was really great progress that we made with our partners there. Then we also worked with advocates for special populations. So that included populations with additional privacy concerns due to stigmatized conditions. For instance, HIV AIDS, mental health disorders, substance use disorders. Populations with additional privacy concerns due to safety. For instance, people with experience with domestic violence. And then populations who may require different communications approaches. So people from English is not a first language. And also the community of people with developmental disabilities. So we went and we did focus groups with a number of people with lived experience. We were invited by the advocacy organizations. This came out a little differently on the screen than I expected. Mostly it's the same, but we've got some funny characters over there on the left. What you're seeing right here is sort of a spill of animation we use to describe the Vermont Health Information Exchange in these focus groups. And essentially telling people about how the information they share with the provider flows into the Vermont Health Information Exchange and then can flow back to other providers whether they present an emergency department to much pain to be able to remember their medication history or go to a new doctor in another town for the first time. We were also able to, I think those characters what they're meant to say is what happens if you opt out? And what we were showing there is that when you opt out the information is still in the Vermont Health Information Exchange is just not viewable to your providers. So there's some nuances we were playing with how to communicate. And what we really learned in this process is something that is encouraging which is that this is explainable. I think when I took this project on initially I thought, oh my goodness, how are we ever going to explain this really complicated technical thing to patients? And I'm confident now that we can. I think our challenge looking ahead is to do it not in sort of the five, 10 minutes that I had at the beginning of each focus group with undivided attention, but in 30 seconds as people are scrolling through their social feed. So it's not that we don't have a challenge ahead of us, but I am optimistic that it's something that we can meet. So we had seven focus groups included some of the special populations that referenced earlier and people who were patients of medical centers or sort of just general population. And in that we really learned quite a bit and more than we were able to share with you last time we were here where we were sort of part way through this work. In the last time I was here I talked to you about how clear it was becoming that people just didn't know what the Vermont Health Information Exchange was. And I want to build on that now and say I think that there's little current knowledge about health information sharing rules and practices generally. People are operating a fairly low information environment and operating with a lot of trust of their providers that their providers are keeping their information private. I do think that this is important for our work important piece of information for our work because we found that when we explain what happens if you opt out of the health information exchange and explain how your doctors will share information sort of in the usual way folks become the few folks who are trepidatious about the health information exchange become much more comfortable with it. It just becomes, oh that's the modern way of transmitting this information once they understand that their providers are allowed to share information about their physical health already with other treated providers without any additional signatures. The whole thing becomes a little bit more comfortable for them. So our challenge is going to be not just communicating what everyone health information exchange is but sort of how it fits into how information is allowed to be shared anyways. The next thing I'll say that we learned here is gonna sound really basic and obvious but I think it's worth repeating and that's that health information is personal and that privacy matters. There's different levels at which it matters to people and it's pretty clear that some of that depends on who you are. So there was one room that I was in and this was the only one where this came up where somebody said, you know, I'm an open book. I don't mind if people can see my information. That would be just fine. That was very rare. That was one person of all the folks doing that with and that I ultimately came to understand is really a privilege if you can sit in a place where that is true for you. And for a number of folks, particularly people who have conditions that have been sanitized for communities that have been historically marginalized, there's a lot more concern about what might happen to them, should their information get out more broadly and even concern about what their new provider might think of them or might assume based on sort of past records. So just something that we need to be aware of moving forward is how this impacts different people and different populations differently. Something that everybody was really able to agree on and kind of in sort of the same way there wasn't a lot of variation across folks here is that more information is equals better care. There was a little bit of an asterisk on that which is folks were saying it's better care if my doctor sees it and uses it. And folks are aware, I think, that their doctors have tremendous amounts of information coming at them and that care works best and that physician-patient partnership works best when the provider is actually able to access and spend some time with their information. There's a sense of hopefulness around health information exchange that we picked up in these meetings especially with folks with really complicated health histories or who had family members with really complicated health histories. And that hopefulness is around reducing the administrative burden of healthcare for them and really allowing them to get to the heart of the matter with their doctor and not be spending their time remembering the date of the second of seven surgeries that their child has had but really being able to move past those details and really dig in on what matters with their providers. And folks are feeling hopeful that health information exchange can help achieve that. And the last thing here is just what I mentioned earlier that this is something that is explainable when we have some time and attention. Any questions about what we were learning from our monitors in these groups before we move on? So our communication strategy here, three prompt, we're going to be working through providers. This is who patients say they want to hear this information from. It's also just the logical place where the data is created and used. Through advocates, this is reaching special populations through existing strong and trusting relationships. And then directly from the state of Vermont and vital. And this is reaching Vermont or just not reaching other channels and reinforcing the message because we do know from communications theory that it's going to take multiple touches in order for people to digest this message. Direct from the state of Vermont and vital, I'll say that thinking includes news media there. Our communications partnership includes an advertising agency who is going to be developing digital and print communications including a small website, a video brochures that will be available in most medical centers and provider's offices and social media content. We've partnered with other departments beyond Diva at the state to leverage both their digital properties and some of their production resources. For instance, their public relations staff. And then another communications partnership is for the legislation. The legislation was encouraging us to work with the healthcare advocate to make sure that people could get questions answered through the healthcare advocate and we're partnering with them to train up their staff to make sure that they're ready to support decision-making. So our timeline for this, we are working fast and furiously right now. Creating opportunities for feedback on the messaging with our advertising agency in the first week of December from advocates and hoping they engage in the most lived experience there as well. We're launching a simple website December 16th with more content added through January. We'll be training advocacy organizations on sort of all the nitty-gritty details with Vermont Health Information Exchange so that they can help support sort of one-on-one conversations with their members and answer questions there. We'll be distributing messaging tools to advocacy groups beginning in December with updates distributed through February and toolkit training in January. And our very first messages from the state of Vermont and vital will go out in December, but we do know that we want to intensify those in January and February both as we're getting closer to go live but also recognizing that traditionally you just treat December as a lost month for communications efforts unless it's a post-Christmas sales. When you were identifying the advocacy groups to reach out to, how did you measure your success and what was the response, right? Sure, so the response rate was good. Almost everybody we reached out to wanted to participate in conversations about this. We've had one-on-one conversations with folks across, oh, I want to say every special population you can think of, but of course I'll get in trouble by saying that it's certainly we've missed somebody but we've made a real effort and we've put a bit of a snowball single so anytime we're with an advocacy organization we're saying is there anybody else you think that we should be talking to about this subject? Typically folks have offered up some ideas and we've tracked those down and the folks there have said yes. It's also the fair to say that one of the other demonstrations of success is that those advocacy organizations have helped to coordinate and invite folks in to talk with individuals of lived experience that they're serving. And so that I think is kind of also another demonstration of success. I was curious if you got any pushback from providers about their role. Yeah, absolutely. So we had two really interesting conversations with organizations representing providers and one of the things that I think everybody was hoping would come out of this process was a reduction in provider burden and previously providers were the only ones who were managing consent decisions and by all has now taken on that role so that's a huge step forward. Looking out to March 1st, organizations that have historically collected consent electronically and really built that into their workflows and have that operating smoothly are likely to just sort of flip the script and move to opt out consent and just continue doing things that way. For organizations that have been doing this on paper or have been doing it sort of less routinely, they may make the choice to just go ahead and have a brief conversation with the folks that they see at registration, hand them a brochure and say, please direct your questions to Vital and Vital, this hotline is where you can go to register your consent decision. We think that's gonna be a lot easier for providers and we've been supported by, by state, the Vermont Medical Society, the Vermont Association of Hospitals and Health Systems, they've been partnering with us both to really think through this and what it's gonna mean for providers and then also to help develop communications that go direct to providers about this topic. So Maureen, one of the things that I wanna mention in that it was a game changer is when the providers, as Maureen said, didn't feel like they had to collect and transmit the data information. What there was kind of a panic moment when they said, well, we still have a role in it. And he said, yes, we will always have a role. But the biggest barrier they were experiencing was the actual transmission of the data. So when we said that we could collect that information by phone and that they could support someone in making that call, it did change the conversation. Thank you. And then the other question I had was in terms of the other departments that you worked with on leveraging their social media, et cetera, obviously the Department of Policy of our invention, I was curious which other departments you've worked with. So I probably should have been more nuanced in saying that. I should have also said other divisions of Diva. So we have our Hague Health Access Eligibility and Enrollment Unit. And they have a social presence and experience reaching out to our monitors for enrollment. And so they are the main other one I'm thinking of in addition to BEH. Although we have been encouraged to think about other social channels like ag and so forth. But a plan of whether it's appropriate to go too far beyond sort of helping human services with this sort of thing. Thank you. So the last thing here is really how to opt out. What are the options here? And we've gone through much of this already but really just to remind folks that our focus here is on easy opt out options for monitors and reducing burden for providers. And that the options will be at providers offices meaning at most providers offices. You look at some providers offices who will get to register this decision at other providers offices. You will get presented with the option through a brief conversation and a brochure. And then you can make a phone call or you can go online or you can do this by mail really trying to reach people of a wide range whether they don't have a computer or whether they would just prefer to do things by phone. Constator Andrew do you have anything to add to that? Yeah sure. I think the overall message is we're trying to make it easier protect patient privacy and produce the burden on providers. So it's, we think we're on the right track and based on our conversations with other stakeholders and advocacy groups. They are also in alignment with that. I will also add that in addition to calling the vital consent outline which will be the same number that it is now. They could also contact the officer of the healthcare advocate. And I think that is part of Act 53 as well. I just wanted to mention that. One detail that I haven't pointed out yet that I think I probably should is that all consent decisions that were made before March 1st will be carried forward. And that vital has been working and doing work to test to ensure that those previous consent decisions are carried. So I think that that's a nuance and I want to make sure folks caught. Vital has brought a lot of the technology behind the scenes and is beginning to test that technology already. And so that's the other aspect of this, not just not just doing the outreach but also making sure that the consent. So the last thing here is testing how we did. Did we reach everybody? And Mary Kate Bowman, back at Diva is helping develop an evaluation team. And that evaluation team is going to be addressing four key questions. That's how we've reached people. Is the message clear? Not just to us, but is it clear enough that it is understood by the people who receive it? And are the opt-out options easy? We'll also be keeping an eye on which providers are often opt-out as we shift to this environment where vital is really the primary organization managing consent that will become less and less critical to the project. The evaluation committee has been assembled. We'll be meeting in December for orientation and there will be an evaluation plan draft completed and included in our next submission, report submission to the Green Mountain Care Court and the legislature. I can anticipate one of the questions will be when will some of the initial evaluation data be available? Because I know on the slide it says that we've added information to the patient experience survey. We anticipate that that is currently in the field and that those results will be available in 2020. In addition, vital is continuing to collect some of the metrics that they have been in terms of the number of positions that have been registered and some of the other available data and as necessary to present that. Thank you. Member Holmes, did you have a question? You were looking at it. Actually, the question about the metrics and the else that's coming up first, so I won't be there. I have just a follow-up on the technical components. In the November 1st report, if there was a little outline of the different activities that you're engaging in, and I was just curious to ask if everything was on track and what you're either most worried about and most optimistic about on the technical side. Those are great questions. First of all, to answer the first question, yes, we are on track here on track. We are currently testing a configuration update and that's going well. We are on track to be capable on February 1st, which is what we're supposed to do. I think what we're most worried about is protecting patient privacy. That really is something that we take very seriously and we feel like we have vetted all of these options that sometimes may be a little too long in complex conversations, but they're all really important. So we're worried about that and we're also worried about being able to audit and so far we have the capability to track everything that we do and we feel really confident about that. I think what we're most optimistic about or at least me, I can't speak for the entire team, but I'm optimistic about who we've been able to work with with Maureen and Jenny and Emily when she was not only then many others in the group have made significant contributions as well as they've made them stakeholders. Good, Jess. So I did endspan, you did endspan the question about when that would be available. Other question would be, you have the concept of hotline on now. So I'm wondering about the traffic on that hotline that takes the questions, concerns you're hearing. It's interesting, we actually don't get a lot of traffic and you know, as you measure that, we probably get a couple of consent calls a month and they're mostly about can vital send my record to ex-organization, those kinds of questions. So there is certainly some education that needs to happen in terms of what a vital role in an ecosystem is and we unfortunately are on the right track with that. There's a lot of work to do. And then finalist comment is I just want to thank you for the thoughtfulness and fairness to which you're trying to implement the layout plan for the state. And I think even what you've laid out is impressive. Any other questions from the board? If not, we'll open it up to all the comments or questions. Eric. I just want to thank the team for the thoughtfulness and engagement of the stakeholders. I think taking meaningful consent as a kind of guiding star and not focusing just on providing a burden but making sure our monitors have a meaningful opportunity to understand what they're consenting to. I think that's really valuable. You know, also the lived experience of our monitors I think is a critical way to think about informing decisions and it's a data source that we don't often use enough. And you know, the evaluation process has also been interesting and I think Mary Kate is an exceedingly competent and thoughtful person. And I look forward to working with her on the evaluation as part of that team. And it is your correct number on to the exceedingly thoughtful and deep process. Thanks, sir. Other members of the public? Yes. First of all, thank you. You're welcome. I'm the general disabilities council. I too would just want to express my thanks that the concerns of our community have been heard and we continue to partner well with the team and appreciate the process that's been put in place. Other public comment questions? Seeing none, I wish to move on. Thank you for a very presentation. Thank you. I'd like to stay warm. Thank you. I love you too. So at this point I'll invite the folks in vital to come on down. We were actually hoping that you'd like to somehow figure out a way to bring a new leader in so that you can meet her. We tried. She's the only one I'd like to invite. So you're stuck with me for today, but my name is Andrea, I'll bring on the director of client services for vital. I have Christopher Shink to the far right, director of technology, Carol Stone, operations director and Bob Ternot, chief financial officer. We also have Frank Harris, our strategic technology advisor in the audience today, or our lifeline in case we need it. And thank you for having us here today. We really appreciate the opportunity to provide some updates for you. You may have noticed that Mike Smith is not here. And he's otherwise occupied as you've probably heard, but we should really- It's probably a little less time to write his play now. The question name is definition of retirement. That's another conversation. So we really, we would be remiss if we didn't mention his contributions to this organization. So we're very grateful for that. And we wish him well, obviously, in his new role. That said, we feel like we are very well positioned to carry them ahead and forward and to come upon our recent accomplishments, our recent accomplishments. And before I turn it over to Bob Ternot, we have some second updates to share with you today. I'd also like to share that that Anderson has been appointed to next vital presidency vote. Her start date is December 2nd, which I think most of the people may already aware of. But that said, are there any questions before I turn it over to Bob Ternot for a financial update? Nope. I'd like to thank the Green Mountain Care Board for the opportunity to speak with them about vital land and its financial status. The first thing I'd like to do is bring the board up to date on the status of our financial audit for FY19. That was our latest complete year. Then I'd like to discuss our upcoming CY20 contract and then review our financials. Okay, in terms of the audit, this was the second year with Gallagher Flynn as our audit firm. The audit was completed at the end of October. It was reviewed and approved by those board of directors. This was a clean audit for us. Again, this was the second year in a row, no significant findings. Before I leave this slide, I would like to mention that in context of next year's financial statements they will be affected by a new standard on revenue recognition. I would imagine that folks on the Green Mountain Care Board are awfully excited about FASB announcements, but we will be working with the Green Mountain Care Board to determine what the effect will be on our financial statements. What I've presented today is my best estimate on what that impact would be. It could change during the course of the year as our understanding involves of the standard. Since our budget was approved back in June, there has been some significant events which have impacted the budget. The most significant is as previous presenters had mentioned is the addition of the second phase to the collaborative services project. This new phase is the acquisition and implementation of new data repository and the incorporation of VITAL's HDM and the Vermont Clinical Registry into that data repository. In addition, the new contract has a significant increase of work scope and represents an increase in the capabilities of the V-con. We at VITAL really appreciate the opportunity to work on these projects and recognize the importance of this work to the state of Vermont. So we see this as a vote of confidence by the state following the hard work that we've done over the past two years. It should be noted that negotiations for this contract were completed in early October. It went into a review cycle. We expect to sign it at the end of the year. So with that, Bob, in your budget order, there was a requirement to come back in December for these type of adjustments. It sounds like you're not gonna have this in executed until the end of December. And it's my understanding that you talked with Sarah that it may be more appropriate to have that in January. Is that your thinking? Yeah, I think that would make the most sense. Chairman Malt, VITAL is prepared to support that. Does anyone on the board have any objections to that? Okay. I just have one question on the million and a half that was being added this revenue. And will you be able to identify what expenses you're putting in as well for that? So obviously your expenses went up by about a million and a half as well. Yeah, I will talk about that in a previous slide. But if you'd like, we can skip forward. No, that's fine. Okay, great. So moving on, this is a matrix comparing CY-20, our new contract with CY-19, our existing contract. And the first two columns that you'll know compare the two existing contracts. And you'll note that this new contract represents almost a doubling of the contractual value on a calendar year basis for VITAL. While some things have remained the same such as our operations line item and our data access, data quality, connectivity, workscope. The new contract adds new workscope for consent management to prepare us for the change in consent policy in March. Along with workscope for connecting EMS and emergency services to the VEHA. Along with the phase one projects of the universal MPI or master patient index along with terminology services and a new RAPC to be hosting. As I mentioned previously, the new contract also adds a second phase, the acquisition and implementation of the new data repository. The two right most columns here in this chart split the CY-20 contract into VITAL's fiscal year 20 and 21. Just to clarify, the term for the new contract is January 1, 2020 through December 31st, 2020. VITAL's fiscal year, on the other hand, runs July 1st through June 30th. So VITAL's FY-20 fiscal year will have two new six months, pardon me, of this new contract. And as you can see, most of the phase one work is estimated to occur in FY-20 and most of the phase two work is expected to occur in FY-21. Moving on to revenue, this chart includes our final audited numbers from FY-19, which are presented along with VITAL's FY-20 budget, the one that was approved back in June by the Department of Care for it. Also, with it is a forecast for FY-20, which reflects the addition of the new work scope on the CY-20 contract. Now, our original budget for FY-20 assumed that the CY-20 budget would be less than the CY-19. We had always expected that there would be a continued decrease to our state funding. Secondly, that collaborative services partners would each pick up the implementation cost of the project that they were leading. This construct has changed since our review in May. And finally, the original budget included about $400,000 of revenue associated with costs shared amongst the participants. The new FY-20 forecast includes the revenue for a new work scope, including consent management connectivity to EMS and emergency services, along with the phase one work, and phase two acquisition costs and the start of the implementation. Phase two really represents more of an unknown for us at this time because we won't have finished our vendor selection. Until that happens, we won't have a complete picture of the magnitude and the timing of the cost associated with phase two. Right now it is really a rough order of magnitude estimate. And so we hope by the first quarter that we'll have a clearer picture on what that cost is and when the timing of that is. Finally, the last column on the right is our current financials through September, year to date. It shows in total that we have recognized $1.3 million or 22% of our current approved FY-20 budget. This puts us on target with where we expected to be in September, which was a year to day budget of 1,271,000. So just a little bit over what we expected. We expect that our expenses are to be 1.5 million greater than our budget. This is driven by a number of items. First, there will be an increase in our IT expenditures, especially in the network cost area to facilitate the changes that we're implementing along with consulting support to augment vital staff in implementing these new projects. And to point out that we also have in this budget or in this forecast, we do have additional costs for education and outreach associated with the consent management. So we have money for brochures, posters and also a modification to our website to facilitate educational outreach for consent. It is our strategy as we move along to keep our workforce lean and adding only a new position to address the ongoing maintenance of the new functionality. We've done that with the mindset that we don't want to bring on a whole slew of new employees going to have to lay them off at the conclusion of the project. Finally, in terms of our expense forecast, I've added a contingency of around 2%, and this addresses the unknowns associated with the phase two project. Overall, we expect to be at your end to be at the same net income as what we had budgeted in FY20. And finally, on this page, as shown in the far right column are our current expenses. While they are $330,000 low cost plan, this is driven by two things. One, lower labor costs than projected and lower IT costs. Part of this is due to the inventory of labor and services connected with the collaborative services project until we actually recognize the revenue due to the completion of the projects. Since we don't have a contract, that won't happen until the first half of FY20, or the first half of C-1. Before you go to the next one, can you just explain on the personnel-related expense line, why your forecast is going to be five times what the first quarter is? What's the new positions that are being added? What is the new? We are in the process of adding two new individuals, one an Edward security analyst, and the second. MBI and terminology services maintenance. In addition, we expect that we have our strategic technical advisor is also in that mix as well. So moving on to balance sheet, vital balance sheet is strong. You will notice that there is growth in work and process. Again, these represent inventory costs that vital is keeping on the books until we complete certain aspects of the project and can recognize the revenue on the completion of the project. So right now in FY20, in the third month of the year, we have about 300,000. We expect that to actually rise to about 800,000 by the end of the year. And there really will be two, if you will, tranches. This tranche that we have right now in inventory represents phase one work that we have in inventory. We expect that that to be relieved from inventory. Again, first quarter, first and second quarter of FY20. The largest portion in the forecast for the end of the year really represents phase two implementation costs, which we won't be able to recognize for everyone until we've completed those projects. We expect, if you look at this in totality, that our cash flow is sufficient to cover our work scope as we go forward. So even though the estimate for our liabilities will increase in this period, we believe that we have the financial resources to cover this. What happens in the first few months of your year that you bet your 19 out of it receivables at 1.2 after three months or down to 6.51? What is the timing there that makes for such a large discrepancy? Mike used to chide beyond that the state doesn't have a blackout at the end of the year, where toward the end of the year, there is a slowdown in some of the payment of invoices. When I forecast, I have always taken a very conservative approach and kept between 45 and 60 days of invoices on the books. And in this year, the state has been very, if you will, they have been very good in making sure that they have been after our invoices that we've submitted. And they've been very timely. So I probably am somewhat conservative on my forecast. But it also is an aspect that at the end of FY20, I also expect that we'll have some fairly large invoices out. It was interesting to see if the new Secretary of the United States just would be as timely as the payments. I hope so. And this chart just summarizes our cash flow position. As of September, we have a very strong cash flow position at 147 days. By the end of the year, we expect to be at over 80 days. But still, we feel that this is enough on hand to cover our cash requirements. So before I turn over the microphone to Christopher, are there any other questions on my presentation that I can answer for the board? Lori? First, just going back to the million and a half that we had in revenue, you obviously had million-tap expenses. But you didn't really align how much of the expenses were specifically related to that revenue. I mean, you're putting in a contingency or putting in consultants point versus hiring people. So just trying to understand what that million-tap was generating for an expense side. You talked about education, increase in IT consultant support, some of those things. We're not all directly related to the additional revenue and a half, but it is to be the pickup between our FY20 budget and our FY20 forecast primarily represents the increase that we feel was necessary to bring us to be able to complete the work that is in front of us with the CY20 contract. So for instance, we're adding another 800,000 for consultants to support us during that time period. That represents solely, that represents distinctly work that is to be done on the collaborative services project. And then looking at your cash flow, do you see a change from budget, the negative 2018 going to 702, so a $500,000 change? It's not as impactful because you eat your cash position at the end of 2019. You came in at 2.5 versus when you started your budget at 2.2. I just wanted to talk about how come for you with where your cash position will be ending and you would talk to the past about needing to be able to have this cash to bank in effect if your revenue is going down. Maybe that's not going to happen now in 2021 because of the new phase 2. I think the biggest wild card for us in terms of cash flow for the end of the year is really what are the timing of the payments and the magnitude of the payments for the vendor that we select for phase 2. And we don't really have a definitive, we don't have a contract with any vendor, or we don't even really have, I'll put this back, we have RFP submittals, but they're not one of the proposals from a vendor. So we're a little bit out near the edge of our headlights on this. So for me as a financial person, that's one of the biggest things that worries me is just the timing of those costs and the magnitude. And so right now what's in there is I have about $750,000, which is an estimate, in terms of what would hit our extents, well, what would hit our cash flow in the FY20 at the end of that. And then just one last question on your working process increase, just recently, the $800,000. And you talked about the fastly change to our revenue recognition. Do those go hand in hand? And I mean, have you assumed any of the revenue, revenue forecasts that would be generated from this lift there? I think there are going to be two different things going on. There is an effect due to the fastly ruling in terms of performance obligations. And some of those performance obligations may actually stretch out beyond the fiscal year and may need to be recognized in the following in the subsequent fiscal year. That's part of the FASB standard as I understand it now. And then the other part of it is that we may not have completed work, and that work may roll over into the next fiscal year uncompleted, and therefore we can't recognize the expense without recognizing the revenue. So there are just kind of like two different things going on. Thanks. In our last update in August, I shared a few details of our focus on security. Here are some updates since that last week. As security is our top priority vital, we continue making smart and secure technology choices. Just after our last update in August, we completed our offsite backup. We also operated our office security program with improved access controls, security cameras, and more. In September, we further secured our employee VPN, completed our scheduled third quarter security scan, and working with the agency of digital services, we finalized our business domain assessment, which included improving many of our policies and procedures, such as our chain advisory board and our design review board processes. Finally, last month, we began vendor contracting for a 24-7-day security monitoring service, revised our vital access auditing documentation, and began implementing a password manager for our employees. Beyond security, we are still committed to making smart technology choices. Vital is choosing modularity, allowing us to plug and play technologies and facilitate the collaborative services projects. We are choosing agility to give us scalability and disaster recoverability, which is being driven by our recently completed business impact announces. These choices not only provide an enhanced technological capabilities, but also financial benefits. They stabilize our infrastructure expenses and avoid capital expenditures while reducing financial obligations and commitments. Most importantly, as BioNACES technology choices, we are aligning ourselves with our collaborative services partner organizations. Before I hand it off to Carolyn, we're going to talk more about the collaborative services projects. Do you have any questions about our security or technology? I do. So what is your geographic backup for a problem that would occur? Say there's a flight. Where do you have data stored? So our primary data center is in South Burlington, and we have local backups there. But we also have an off-site backup, which is in the Azure East region. The leak is in the DC area. So if we had a complete catastrophic failure of our data center and even our local backups were completely destroyed, we have a backup in Microsoft's Azure data center. And I'm sure you did the analysis. We believe that what impacted Winooski would not impact that center as well. The South Burlington data center? Yeah, the South Burlington in Washington. I'm just curious. It's a fascinating topic. Years ago, I remember being part of a legislative delegation that looked down and tried to convince Wall Street when the rules were changed that required backup. I can't remember what in the miles if it was 200 miles or what. That Vermont was sufficiently just outside of the radius that they got to locate some backup here. We weren't very successful in that effort, but I'm just curious how you ended up picking that site. So when you look at our strategy for where we're going to store our data, there's more things than just as far away from our current location as possible. That has latency and data transfer and things like that. So typically, to winter 250 miles is a pretty good strategy. Now, of course, there are possible events that could affect both Washington DC and Burlington, Vermont, but we do have plans going forward to even further protect our data and have an additional archive data location that's on the other side of the country. That's actually going to tie into the Collaborative Services Project. Super. Thank you. Any other questions? Very good. Thank you, Mr. As you know, and you heard from Devoto, you've been working in partnership with Diva, the Group for Health, and one here, Vermont, on this Collaborative Services Project. It's super exciting, and we're trying to streamline the way things are working. So we focused on the first phase is on the foundational infrastructure that was identified a few years ago as a key component that we needed to improve. The Universal MPI, our Mass Education Index, is the first piece of that, a selected vibrato for the solution in June. And in September, we completed our implementation of the group development, and then we're testing right now. And we'll let you know that the early results we're seeing from testing look really promising. And this will get us towards one of the HIE plans goals of trying to get as close to one record for every patient in or person in Vermont that's in the system as we can. The next two pieces, the terminology services and the interfacing, we've selected Term Atlas and Rhapsody, hosted by the Maine Health Information Exchange for Health InfoNet, and their subsidiary Curious Innovations. They're currently setting up the environments right now, and we are targeting the end of the year for this to complete. This will include three environments, one for development, one for testing, and one for production, as well as disaster recovery to your point, Kevin, as a backup plan and those will be available to us all by the end of the year. After that configuration implementation and testing will start in early 2020. We've made great progress this year on phase one, and this is also setting up for the second phase. This is the second phase kicked off in October, and this involves selecting a shared health care data platform. This will replace, as Jenny mentioned, both the V-Hi data management solution and the Vermont Clinical Registry, enabling efficiency in this moving forward for both of us, and allowing us to shed some of the older legacy platforms that we both have. The primary goal right now is to support these two programs initially. However, as we're moving forward, we're keeping an eye on other capabilities for other types of data or services in the future, like social determinants of health, or claims data that are stakeholder and really asking us to ingest in the future. Since this is going to be a shared platform, we've assembled a poor team of stakeholders to help select the platform for multiple agencies and programs across the state. These include representatives from Vital, Department of Vermont Health Access, the Agency of Digital Services, and the Center for Health, One Care Vermont. Vermont Care Partners, Vice State Primary Care Association, and the Vermont Care Board staff. So, the collaborative group has been super engaged, and we've been meeting weekly, sometimes more than weekly, and they're providing valuable insights that help keep the project moving along in a time of manner. One of the first tasks that the project team undertook was reading on the scope of the project and the process we wanted to use. The team chose to use an accelerator but thorough process due to the desire to have the platform ready for January 2021 for the state reporting needs. This is an aggressive timeline, so we wanted to accelerate the project right from the start. What we did to start that was we used the request for information that Vital did in late 2018 to help us evaluate potential vendors for the project, and also use the 14 to identify any other known vendors that we might have missed in 2018. Vital had done an RFI looking at feasibility of switching platforms at that time. The goal, the immediate goal is selecting the top three to five vendors for a full evaluation by this 14. These selected vendors will be brought on site for two days of intensive presentations and demos in December that'll cover eight specific areas that the team wants to see and evaluate. The demos will involve not only the 14, but other subject matter experts identified by the 14. We're trying to be as inclusive in this process as we can and get everyone's view back. Using this format will streamline the traditional processes of gathering detailed information, the written responses, and then scheduling the demos by combining it all into this concentrated timeline so that we can accelerate this. We'll also be undertaking a separate but parallel effort to do due diligence on the companies on these vendors during this timeframe. This will include financial positions of the company, vendor reference checks, and then external client checks as well as their preferred vendors or their preferred clients. The team has established draft scoring criteria based on the areas that we're looking to evaluate and we'll go over the finalize this over the next few weeks. After the presentations, the next steps will be to score the vendors and produce our cluster proposal to include the final pricing of the solutions and any additional questions that the teams have after the full process. And then to make a selection in February is the target. We've made great progress so far and the protein's been an invaluable asset in the process going forward. Any questions? Do you want to turn over to Andrea for a report? I guess you have a question. The part we report are their usual metrics. That should be familiar and they are ending in the month of September. The need for use is security risk assessment consultations. You'll see a drop in the numbers. We can often see these kinds of fluctuations toward the end of the year as health care organizations prepare to attest for needful use. I think we'll see, I believe we'll see that go back in October, but it's a valuable service that is health care provided relying on to improve quality and efficiency of their health care workers. The percentage of Vermont patients providing consent. We can see this end of September is starting to plateau, which interestingly enough, we had sort of a pool of people, a vital predicting there would be a plateau at about 50%. So we'll see how far we get here. But after March 1st, 2020, we expect this to be 95%. Can we take any criteria? The new replacement interface this is in September. We had a target of 89 completed work plans this year. We've obviously extended back to the 121 completed work plans tremendous effort of the operations team. And 22 more are in progress. There are also 11 locations meeting tier two criteria. So this is speaking to the new criteria that's coming up in 2020. We should see more of these next year. From a point of care perspective, we continue to maintain and hopefully in the pre-zodalization of the three ways to access patient information. The top green chart, bar chart remain steady. Those are the number of vital access patient record providers access in patient records through the web portal. The bottom red column is the cross community access piece. Those are the queries out into the integrated solution queries across networks from organizations healthcare healthcare records. And the purple column are a single sign on chart access is via the web portal. Which one makes it steady as well. Another aspect of point of care utilization of the provider results delivery. These are ordering providers having laboratory results where they all do reports and transfer reports deliver seamlessly into their electronic health records. A lot of times the providers do not know that those are facilitated by the vital. And we have seen a little bit of an uptick. We predicted it would go down and we actually made it. We're not sure if we'll see impacts from the UMMC consolidation or not, but we may. And I think the message here is that over a million results have been delivered across starting in January 2019. So significant service that we provide and 443 providers receive those results in the center month. And so it actually concludes our update. Are there any other questions we can, I can answer, we can answer. Questions from the board? I just have a quick one. Can you go back to 21? Sure. Can you give me a sense of the denominator kind of connected to the effect here? What is the denominator of 11 locations as how many are you thinking is potential? Yeah, so I want to say within the state of Vermont, we have I think it's 1,200 locations that we've identified out of those we know that about 500 have electronic medical records. And out of that subset, I think we're, I'll get this wrong. So I'm just going to say above 215 locations that are connected. So what we've done this year is with the advent of the new product territory, we've gone out and those 121 completed work plans were an evaluation of these locations to say, where are you along that continuum? You clearly are connected. So your employer in the process of connecting right now. So you're meeting tier one. Where, you know, can you meet tier two and we've laid out where they've met tier two and where they've fallen short of tier two and helped develop a plan with the health care organization to get themselves to tier two. And we've had 11 locations actually that represents two different vendors get to that place. And I have more coming that just met in late October. So, you know, we're working with the organizations and their vendors and the criteria is really providing a useful tool to be able to save to a vendor. This is what you need to do for all the health performance programs in the state. And here's the bar you need to clear. And they have concrete marching orders. So that's helped both the clients be able to put some pressure on the vendors and also us. And we've had some good success. I won't say it's the golden ticket because we're still doing the HR vendors who can prove to be a little difficult sometimes. But it's definitely helping the conversation. Other questions that come to the board? If not, we'll open it up to public comment questions. So, you know, I wish to thank you for your presentation. Thank you very much. Those who are staring at the clock, the clock is long. It's four after five. Thank you very much. Thank you. Thank you. Thank you very much. Thank you. Thank you. Is there any whole business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you, everyone. Have a great rest of the day. Thank you.