 Good afternoon everyone. Welcome to this beautiful summer day. We're going to start with the Executive Director's Report, Susan Barrett. Thank you Mr. Chair. I have some scheduling updates. First, for next week we will not have a board meeting and also the week after that we will not have a board meeting. So it's May 16th and May 23rd our board meetings are canceled. On May 30th we are planning to have a legislative update. And I say planning because I am very hopeful that the legislature will have adjourned by then. But even if they're not we could still have a legislative update. And we'll also update you on our budget as well. And then I do want to announce that on June 6th we are putting together a panel discussion on Vermont's health care workforce. We've invited folks from the administration, from the hospitals, from the FQHCs, and I don't want to leave anyone out. But a wide variety of health care workforce providers. So that should be very interesting. And just a reminder for folks just to sign in. If on the way in, at the front. That's it. Thank you, Susan. The next item on the agenda are the minutes of May 2nd. Is there a motion? I'll move it. Second. It's been moved and seconded to approve the minutes of Wednesday, May 2nd without any additions, deletions, or corrections. Is there any discussion? If not, all those in favor signify by saying aye. Aye. All opposed. Okay. So at this point we'll invite Michael and Emily to come forward. He's walking Michael. Don't stop. Thank you. Thank you. I would turn to the Director of the Health Information Exchange Program at DEVA. And my group has to Deputy Commissioner DEVA. We're here to provide an update. H-901, which is a new proposed legislation, calls for an update and a work plan to be delivered to you all, as well as identified committee members. On May 1st. So we delivered that, which I believe you all have. So I think we worked out with your staff that we were going to change our bi-monthly cadence, which we had established, to provide you with updates to align with H-901. So that's what this is, a continuation of that conversation. Great. All right. So on the list of discussion topics today, we wanted to go over the details of H-901 and ensure that everybody understands each of the facets of that bill. Which, if I had to summarize, is basically continued monitoring and oversight of the health information exchange health IT work that began a decade ago. But really this continues the evaluation work that began in 2017. We're also going to review our progress. Since the evaluation report was released, we have been here once, but we wanted to ensure that you were aware of, are you my two partners? Yeah, why don't you move in a little closer? Thank you. So intimidating to have a new face. So for the second point here, we wanted to review our progress since the release of the evaluation report, which came out in November 2017. We wanted to just ensure that you all were aware of the work that happened between November and when we delivered the work plan to you in May. We're going to go over the details of the work plan, leaving some of those details for vital to present because they will discuss how they will actually be addressing recommendations related to the operations of the HIE or the behind. And then the contingency planning is part of H-901, so we wanted to provide an update on that as well. Just as background, so we're all just kind of thinking from the same frame of reference. In 2017, Act 73 called for an evaluation of health information exchange in Vermont with real specific look at the operator of the HIE vital. And the study report demonstrated a few things which Don Gallagher looked you all about in January. So they noted that HIE is expensive and difficult for all states. Also that Vermont stakeholders affirmed that HIE systems are essential. They're essential to providing quality care and to measuring our health care system to further health reform efforts. They noted that Vermont is not organized in a way to increase its chances of success. And there we had a long conversation about our governance structure and the many oversight bodies that at that time were not seemingly coordinated. They noted that Vermont's HIE has yet to set a solid foundation and sequel there's lack confidence. And that there's clear room for improvement and Vermont can reproduce other state successes. So as you may remember, they provided a list of recommendations of which have translated to the work plan that we're going to go over with you. They were not time bound in terms of the recommendations that they provided, but they were sort of dimensional. And so we'll go over how we've translated those into tactical activities assigned an accountable party and created a timeline for execution. So one of the gratifying parts of this project is that there are many legislative studies and sometimes those studies exist and people don't take action on them. I'm really pleased that the investment we've made in the HTS study has paid off. A lot of H901 is merely taking the recommendations in that study and trying to bring them to life. We think it was the right work at the right time and now we're engaged in our partnership with Vital to see whether both parties can make real progress to those goals. If the four major questions in HIE are what does the state want? Can Vital credibly deliver it? Are providers better off and are Vermonters better off? It's really a focus on the first two things. What do we want and can Vital deliver it? So what you see here are the elements of H901, which is just making those HTS recommendations real and then adding in a few substantive components that we think are prompted by HTS's report. So Emily, if you want to walk through the individual elements, that'd be helpful. So the first of course is this work plan, which we're delivering out on May 1st. And so that's to provide you all as well as the legislature with a clear path for evaluating our success or failure and implementing the recommendations from their report. It also calls for progress updates to be delivered by monthly. And that's, as I'm interpreting it, progress towards implementation of what has become the work plan. So the activities we will execute to address those recommendations. H901 also called for a contingency plan. And this contingency plan would be triggered if Viva and Vital cannot implement the recommendations from the evaluation report. And that's to be delivered on September 1st. They asked for health tech to come back and continue their evaluation as a third party entity to look at our progress. And they'll be providing you all with a report and recommendation on their observations on October, by October 15th. They called out the need to deliver a health information technology plan or what we're calling a health information exchange plan. And they're synonymous by November 1st. And our steering committee is working on that now. They also asked for two reports by January 15th. First a recommendation on Vermont's consent policy, which we've talked about in this venue. As well as a recommendation on how to improve interoperability in the utility of EHRs. And just based on legislative conversation, I think that's specifically around the use of a sort of centralized EHR. And how we can better utilize technology to support the point of care. Just to make one quick and obvious point. Each 901 is not passed as both houses have been sent to the governor. We are behaving as if the present version of each 901 will eventually become long. So we've complied with the main first deadlines, even though that hasn't taken effect yet. Of course in the legislative session, it's not over till it's over. And so whatever comes out of the legislature is signed by the governor will abide by. On the consent policy, we expect that to be an open and transparent discussion among stakeholders. I think once the legislative session is over, D will be in consultation with you and with other stakeholders about how to organize that. And that'll be something where myself and the general counsel will probably take the lead in trying to structure that conversation. Are there any questions about the components of each 901 before we move on? Okay, so as I mentioned, we wanted to make sure to update you on what this made from the time that the evaluation report was submitted to you to today or when the first work plan was submitted. So as you may remember from when Don Gallagher from HDS was here, one of the significant issues that they pointed out was a lack of clear governance and a lack of strategic plan driving this work. So in November, we convened the HIE Steering Committee. It's a small group of dedicated people who represent different facets of the healthcare system who are fully focused on developing consensus-driven strategic plan. And that's the plan that will be provided to you no later than November 1st for review and approval. So during this time, we've done a considerable amount of work with this group. They meet twice a month for four hours, four hours total. And during that time, they've set their guiding principles. They've framed out what the HIE plan will cover and they've developed use cases or some business needs for HIE. So now their work is to translate those needs into objectives and goals that are achievable for the period going forward and we'll update that plan annually. In about the November timeframe, we also established the HIT Advisory Committee. And that's Michael and I working with the Vital Board Chair, a couple of select members from Vital's Board, as well as their executive team. And we got quickly to work meeting once a week to develop a plan to support Vital specifically through this transitionary period. And you'll see in your work plan and the appendix, the short-term goals of that plan or the short-term plan is included as an appendix of the work plan. So we got together that work, that work plan guided our work. And we continue to meet every other week to ensure that, you know, communication is solid, that we're supporting them during this transition and that we're being good partners. We noted that last summer here, we also sort of changed the contracting vehicle with Vital. So in the past, they were primarily funded by a grant that supported their core services as well as a smaller contract that allowed them to do development work. We've since changed those contracts to be deliverable-based contracts, there's two of them. There are stated goals in each of the contracts and they're to report on progress in a formalized way on each of those goals at a regular cadence. So we had already made that adjustment. We've extended Vital's contracts from this fiscal year through the first six months of the next fiscal year and further refined how Vital is going to address the recommendations that they sort of create that solid foundation or approve upon the core functions of the HIE. And we've created incentives, financial incentives in that contract for HDS's recommendation. I think in all these steps, we're trying really hard to give Vital two things. We're trying to create clarity and accountability in HIE. And so we're trying to make it very clear what the state wants from Vital and create a framework where we can hold them accountable for delivery. I appreciate the effort Vital and its team has made over the past months to reorganize our contracts in that way and to extend our contract. So we're both very clear about what we want and we have a framework for holding folks accountable if they don't deliver it. So far, that has been, I think, a real improvement in the relationship between Diva and Vital. And we'd like to structure ongoing contracts, future contracts in the HIE work plan in the same way. We'll give people the creativity they need to succeed, but we also hold folks accountable for the results of their work. Just to underscore Michael's important point. So we transitioned from a period of time where Vital was expecting sort of a core, sorry for lack of a better phrase, bucket of money to support their work going forward to a really formalized structure where we're having a real conversation about the goals that we want to achieve, what deliverables will be to support the achievement of those goals and how we're all going to work together to move forward. And just one additional point. It's not about holding Vital accountable alone. It's also about holding Diva accountable. I've been very demanding of our own team to say if we want something from Vital, you need to have something like a driver diagram that says, this is what you're going for and this is why you're trying to reach that goal and this is why we think we'll work. And I think it's just been a good process of trying to demand more of ourselves if we're going to continue to spend and invest taxpayer money and buy it. So moving on to the work plan. So just a couple of notes to orientate the work plan and I believe, do you all have it? I don't know how to do it. I just want to make sure. Do you just have the slides? It starts with a memo and it looks somewhat... Yeah, you got it. And I want to apologize. When you have a lawyer draft an HAT work plan, you get a work plan that starts with a memorandum. I will take responsibility for that. Okay. So to orientate the structure of the work plan. So first it's really important to note, as Michael was saying, that we developed this work plan in partnership so that HAT advisory committee was our mechanism to work together and really set forth the goals and objectives that we wanted to achieve together to further the HIE landscape. The HIE Steering Committee and the Vet Award have reviewed the plan. We incorporated their comments before sending it on to you. And the work plan is structured. It's a pretty basic structure. So it starts out with our overarching goals and those are taken as sort of extracted from the HDS evaluation report. We've linked objectives with each of those goals so you know what we're working towards to achieve the goal. Each activity is intended to drive achievement and we've assigned accountability and timing to each activity so you know who the actual accountable party is, who the stakeholders involved are and when the time frame is that we're going to actually execute on the achievement effect. So to move on to the elements of the plan. So the first two and what you see listed here are the goals, the overarching goals of the plan. So the first two are to implement an effective HIE governance model and develop and manage to a strong HIE plan. So these are fundamentally addressed by the development of the HIE Steering Committee and their development of the HIE plan. So I won't spend too much time on this but please let me know if you have questions. I think just one quick note on this is that we expect that the HIE Steering Committee, which we're hard, will come up with a governance model and include that as a recommendation within the HIE plan. So there are a small dedicated group now. We expect that that group will grow. And we'll have subcommittees that will address certain dimensions. We'll have an executive body. We'll have a really formalized way to oversee execution of this work going forward. So now they're in the strategic planning phase and going forward they'll be in the oversight and strategy development phase. The second set of goals here are ensure that the HIE, operated by VITAL, is well governed and compliant with federal and state regulations. Ensure the VHIE operator is focused and delivers upon its core mission and making the VHIE operations accountable to all customers, including the state. And those are the real crux of the work plan of how we're getting to what does the state want and can our vendors deliver. So we'll go through that in more detail. And finally, this last goal here, demonstrate progress in implementing our foundations from the Act 73 Evaluate Sheen Report and plan for contingencies. Those are really the sort of the mandates from H901. So all of the things that we've listed there are listed as activities within the work plan. Okay, so I should have said, so I'm not going to go over into much detail those first two goals or the last one, but I'll focus on those middle three. Okay, so starting with the first one there in that section. Ensure the VHIE is well governed and compliant with federal and state regulations. Let me orient you to where we are. So this is starting on page five of the work plan if you have it. And if not, I'm going to go over to the next two. So you'll see on the left-hand side that there's our objectives. And then if you move, if you read from left to right, you've got the associated activities who's accountable, start and end dates and the status. And so we'll provide you with the continued status every time we're here, every other month. So in order to achieve this goal, we've set the following objectives established in HIT advisory group to support short term means. And again, the work plan that we established with that group is included as an appendix list document. Appropriately staff would be high operator, which I'll let Vital speak to at greater length. And we'll know that Mike Smith has come on board and they've made some other staffing decisions to ensure efficiencies of the operation. Ensure compliance with operation and financial regulations and standards. So there's a couple of things that we're doing here. Vital is preparing a third party to conduct a performance and operational audit, and that's at our urging. So this will be a precursor to the state fiscal year 19 contracts. And on that now, I'll provide more detail on that. Evaluate contracts for compliance with state and federal regulations. So that's hard to do. I'll say that HTS pointed out kind of a twofold need there. They wanted to make sure that we were adhering to Bolton 3.5 and any other regulations that we have around contracting. And also just making sure that we're adherent to sort of the federal guidelines. We have a pretty strenuous process with the feds now for our contracting. So it goes something like we request money and we provide scope timing and link to the meaningful use program, or what's now called the interoperability program. And so we have to demonstrate to them how our work is going to further health information exchange in the state. They approve that, then they have to approve all procurement documents. So before we release a request for proposal, they review and approve that. Then when we have a contract, they review and approve that before it's signed. And then we provide them monthly progress updates by a written progress report and we also call with them. So already the feds have considerable or what I would consider considerable oversight on our sort of planning and procurement processes. And the final objective here is to improve the be high public reporting to increase transparency. There's a number of activities listed here, which are all under vitals per visa. All right, now to the next one. This is the next goal here. Ensure that the be high operator is focused and delivers upon its core mission, which I think is probably the area that folks are, I guess, most concerned about. And so this is on that next page. Sorry, it does not have a number. And so again, you see the objectives here listed down the side on the left. Extend vitals contract with FIVA for six months to allow for the completion of the HIE plan. Further is our objective to use the state's contracts with vital to transparently type program goals to HIE financial investments. So again, we've worked with vital to really refine the achievement of goals related to them enhancing their core functions that were pointed out by HDS in the evaluation. And we'll continue to use those as mechanisms to have those strategic conversations and to have some accountability for how we're moving forward on sort of solidifying the HIE core functions. Also, an objective here is for vital to develop a be high strategic plan. And here you'll see all of the stakeholders that they will consult with and I'll let them provide more color on that one. And finally address issues with the HIE core functions identified in the evaluation report. And at the end of this document, you'll see a contract matrix which links the HTS recommendation to drivers of success, what activities we need to do to actually address that recommendation, what deliverables are related to those drivers, and what's the funding mechanism for achievement of those drivers. So I would say that the president CEO of vital asks a really good question, which is, so what is success here? How do we define success? Part of the reason that Diva chose to enter into a six month contract extension is that right now for us, success is executing upon the recommendations of HDS report and fulfilling our obligations under H901. I happen to think the most important thing the state can do to answer the question of what is success is to produce a thoughtful, incredible HIE plan for your consideration as a pool party. And so our thought was that if we extended the contract for a full year, we'd be putting in deliverables that are potentially not aligned with that report and that would not be a smart way to try to be successful to go. So our hope is that as the HIE plan to be submitted to you by November 1st starts to really become, really come into view and become specific that we can use the recommendations and the directions set forth in that report to develop a further contract extension with vital for January 1st, 2019 and going forward. Because we just don't want to be caught in the trap of doing something that might not be the right thing. It's just really important that we're all on the same page of what our goals are. So we can probably define them and determine how to get there together. I'm to the next one. Okay. And the final goal is that it's making HIE operations accountable to all customers in the state. And the goals that you'll see here are very specific to adjusting the vitals board and our participation on the board. I will say that this is an area that I think we'll look to expand upon. You know, vital sustainability will be dependent on their work, meeting their stakeholders, excuse me, their customer's needs. So I think we're all really interested in working together to support them in becoming sustainable. Okay. So to provide a status update, like other facets of H9-01 and I'm moving away from the work plan now, I'll just ask questions about that. Okay. So one of those aspects of H9-01 is that we developed a contingency plan. This is so we have it available, should vitality be by demonstrating that they cannot actually address the recommendations from the Health Tech Evaluation Report. So on the contingency plan front, we released an RFP and selected a vendor in April. We selected Capital Health Associates, who may be familiar with them. They have been in, I'd say, the HIE sphere in Vermont for a number of years, and that was particularly attractive as we're looking to do a very short-term project, and we needed someone pretty knowledgeable in the area. We expect that they'll begin work probably around mid-May, and then they'll deliver that contingency plan to the board and the General Assembly by September 1st. So on this next slide here, should I stop with your question? So just so we're all clear, the requirements of the contingency plan are written out in H9-01. It will include a description of the health information exchange services that need to be replaced, a process for determining the manner in which the services would be replaced, and the mechanism for acquiring their replacement services, such as a request for proposals process, an assessment of the state's ownership interest in hardware systems, software systems, applications, etc., that would need to be licensed to a future operator of Vermont's health information exchange, a plan for transitioning operations to a new operator and the impact of change on health care providers, health care consumers, state government, and Vermont's health care reform initiatives. So just concluded just thinking a little bit about the risks to this plan. First of all, as I said before, H9-01 has not passed the legislature. For some reason, that bill does not come along. The HIT fund, the ongoing support of the HIT fund would cease, and so we'd have to determine how the state of Vermont would proceed with its HIEHIT investments in the absence of a dedicated revenue source. Most of this work requires CMS approval. Most of it draws down a significant amount of federal funds. That process is well underway, so we think that's a modest risk to this work. A more significant risk is capacity, which is just a fancy way of saying there is a lot to do in a very short timeframe. And so there is not a lot of room for error on the side of DEVA or VITAL or the contractors who are involved in this. I think we are very focused at DEVA in making sure that the things that we can control are well aligned and moving quickly. But this is certainly a serious risk to trying to get this much stuff done in between time and time of the year. The HIE steering committee, they are new. They have never produced an HIEHIT plan. And so to me, to my mind, that's the most important thing that DEVA can deliver. But we haven't done it before, and so there's always a risk there. None of them are in the room right now, but I really want to give them a thank you. They have really taken up the mantle of responsibility here and tried to do the right thing. And they've put an enormous amount of work into helping us figure out where to start and thinking about what the state might need for HIE. And then a little bit, we just think about the fact that this last bullet point is just trying to say it might be hard for people to see the payoff right away. So as I said before, the four key questions are, what do we want? Can vital deliver it? Are providers better off? And are vermoners better off? Most of the work in H901 is focused on the first two questions. What do we want and can vital deliver it? You can make a lot of progress on that prior to medical providers and patients seeing a benefit from it. And so one of my concerns is that we can be successful in each aspect of this plan. And when we talk to policy makers next year, they may ask, well, how are patients better off? And we might just not be there yet. And so I think people are going to have to be patient. I know given the history of this work that it's hard to ask for additional patients, but I just want to be very frank with people that you might have sort of a mismatch between people's expectations and actual progress makes. I think a lot of the benefit might be internal to the vendor in the state and the program and less apparent to vermon's providers and patients at least in the next 8 to 10 months. I think that's all we have, Mr. Chairman. I'll start with the question. Michael, what's the dollar value of the capital health contract? And is that paid for through the state budget or through vital's budget? Sure. So it's value at $250,000. It is supported, well, it is supported with $90, $10. There's some semantics to CMS that we're still going back and forth on. And so that 10% does come from the HIT fund. They're already working, correct? They have not begun work yet. We're still waiting for CMS to approve their contract, which we expect to come in next week. Who is specifically from them going to be working on this? So it's the three partners, Hans, Cassie Smith, Craig Jones, and Katie McGee working in collaboration with a legal firm whose name, I'm sorry, I don't remember off the top of my head, but I can send that to you, as well as a consulting firm called Match Point Partners. And they're a firm dedicated entirely to organizational transitions. I think just to add a little more context, given the compressed timeframe, it's important that we spend time on the work. And we have to be careful about how much time we spend onboarding contractors. And so here you see HTS, the same party that wrote the original report, is back to do more work. And Capital Health Associates, which is probably more familiar with Vermont's HIE than any other vendor, was the successful bidder there. And I think that, well, there's always the risk of not having a sort of outside the box thinking that might be helpful. You do get the benefit of people that you don't need to onboard, like they can hit the ground running. I think that's important in this project. Any questions? So looking down the road a bit to 2021, the expectation from a fiscal point of view is that a vital budget would be downsized, as I understand it, by about a million bucks, and that they would be filling in the bidder term, I think 2020, with some tariff forward. And that either when they get to 2021, if the systems have not improved to the point where folks out in the world are using vital services and paying revenue for that, that it would be further downsized as a possibility. And I fully appreciate your caution about patience. But I'm wondering if we are fully patient, which I intend to be, because this is a heavy lift, as I see it. We have kind of divided the world up into two elements. One are the process elements, which are noted in your handout of all these reports and quarterly reports and contingency plans and et cetera, et cetera. Those in it of themselves won't improve the systems. They will guide the improvement of the systems, but won't improve the systems that are needed in 2021 to bring revenue into vital and get it on a self-sustaining basis. I'm wondering if there is being too much compressed into these next two years, we're looking at 2019 and 2020, to get us to the point where vital is something that people want to pay for and buy on a voluntary basis. What might we expect to be a kind of the most patient about in order to direct resources to get to that ultimate on-the-ground performance that we hope for that allows vital to be self-sustaining? So in our previous discussions, so let me, I think it's helpful to characterize some of our past discussions with Vital, which predates the current interim CEO. There was always a focus on sustainability, and that means more of Vital being able to pay through it for itself because people want to purchase it as a service and less state investment, which is the trajectory that most states want to be on with HIV. My candid comments to Vital's leadership at the time was, please focus less on revenue and more on value. Revenue should be a happy consequence of you providing a product that really gives value to Vital's providers and values to their owners as patients in the healthcare system. And I think we are still giving Vital leadership that same advice. I deeply appreciate having a roadmap to greater sustainability in less public sector investment. However, what I'm really concerned with is the creation of value, and I think our patients will be tied to our perception of high-value services being created at Vital. That prompts the excellent question of, well, how do you judge what's valuable? My hope is that we can use both the HIE plan and getting reactions from it out of the provider community, and hopefully in a future round of Vital contracts, asking them to go back out and do some of the surveying work that was done in the HTS report to try to make sure that we have a good connection to what others and patients will find useful and valuable. And to keep looking at that is an indicator of whether more state investment in patients is warranted. What I don't want to do is set an arbitrary benchmark of X percent of revenue needs to come from private fees by YD. Because I happen to think that we'll be setting ourselves up to fail. We should keep moving in the direction we're moving and constantly evaluate whether we think we can look in the mirror and say more value is being created by Vital today than was created yesterday. So when Divas' value, how do you define value is what you're expecting from Vital? When a health care provider can turn to me and say, part of how I care for Romaners relies upon services we get from Vital or the HIE, then I think value has been created. I know that that is a sort of abstract and clumsy measure and I think part of our job is to define that and turn it into something specific and measurable. But, you know, I want providers coming to us saying, you know, you give us tools in the blueprint for health, you give us tools through the ACO program, you give us tools with our, we have a relationship with federally qualified health centers, you give us tools with Vital and those tools are important to us and the people we care for. And I want an audience, a constituency rather, telling us that that's important. Because I only want to pay for things with taxpayer dollars that are really meaningful and useful to Romaners. The only thing I'd add is that, you know, it wasn't an accident that HealthTech called out specific services as core functions and that's what we're really concentrating on now because their theory, which is based on how many other successful HIEs operate, is that if they do, if Vital is able to provide space service, they need to have a series of core services sort of solidified to add those value-based services on top. So what we're really focusing on now is supporting them and making the foundation of their operations successful so they can... If you have a question on, you highlighted capacity as really kind of a major risk. And if you were to look inside Diva as well as Vital, I mean, where do you see that biggest potential issue on which side of the fence there? I mean, is it equally on both sides or do you see it more on Vital? I happen to think it's equally on both sides. I think Vital, like most partners, is only going to be successful if it has a very clear idea of what its client wants. So I think the state has a lot of work to do with internally and with its stakeholders and its other vendors like HTS and Capital Health Associates to very clearly ask Vital for what it needs. And so for me, one of the tricks is we have a lot of good team members that are willing to work hard on Vital. But the thought leadership part of this is really hard. And so we have to create space for people to do that kind of visioning while keeping the contracts in the process going. And it's really hard to kind of build the plane and fly it all at the same time. And so I think that's the big risk because the risk you run is that you either instruct your partner to do the wrong thing or something that's not the wrong thing but just not the thing that's most meaningful. And so I think we have to be really careful that we're focused on what we're telling them to do via the future HIE plan that's delivered to this board and our future contract. And that's a hard part for me. And then the other thing that I worry about is that HTS pointed us towards other states that have had some success. But I think it's fair to say that nobody has figured this out completely. And so our directions are going to be our best guess but there is no turnkey solution to this. We have to make a series of value judgments and I want to make sure that we're in the best position to succeed with those recommendations to fly them. So hitting back to the follow-up. What you can, what you perceive to be value and then on you said that the provider found the value and do you think that the providers are in alignment if one provider is a member of an ACO another provider is completely independent another provider is in a hospital setting that's not a member of an ACO do you think there's enough alignment on what they consider? I personally, I don't think there is consensus about what people need as tools but I think the job of the HIE plan and frankly the job of our overall health care reform which the goal of which is to create an integrated health system across the whole care continuum is to try to get at those questions. Now our HIE steering committee is the first group of people who we've pushed really hard to try to answer some of those questions. I think two things can be equally true we're very happy with their effort I think part of the reason we're having them proposing a new government model is because it could be broader particularly an adding provider and practitioner of voices but I think that though we don't have a consensus for you we're working hard to develop more of one and I think that's going to be one of the tasks to answer Mr. Callum's question that we've got to be really intentional about continuing to ask people what they want because otherwise you can fall into a trap of thinking you know what the community wants. I will say now just sort of tying into the work of the board to the extent we have an accountable care organization program that has 20% of the monitors in it in year one we have a partner that we can ask those questions to and though we may not get a perfect creative certainty we at least I think will get an informed opinion about what a large block of providers might be interested in and so they are really a key constituency as well in trying to ask what services would be meaningful in helping people care for the monitors and to create a more integrated healthcare system. Yes. Thank you for that. Also thinking about duplicative services right one care offering various information analytics and things like that. How do we think about those providers that don't even have EMRs that can speak in onwards? I think obviously there's going to be work to be done the various types of providers and what their input would be but my question actually was more about so much uncertainty in Washington these days uncertainty is probably a kind word and I'm wondering what you're thinking about in terms of future federal funding support for HIP in general and what you're hearing and how that plays into your future planning. So the sort of the funding stream of the act that we function under is called HITECH and our HITECH CMS representatives were here with us a couple of weeks ago and they told us a couple of things one that you know the 90-10 or the federal match we're talking about all falls under a connection to what was called the meaningful use program just totally focused on the adoption of electronic health records and so that will take us through about 2022 and they increasingly I mean I think it started every year now it's becoming every couple of months are expanding their view on what that means and I guess that means allowing for funding of broader initiatives to fall under that and they've also just proposed that meaningful use now transitions under interoperability programs at CMS so they're trying to further think about how CMS continues to have a role in achieving what they call interoperability or connecting systems on behalf of patients and providers there's another funding stream MMIS which is the Medicaid management system every Medicaid agency has one and they use them in different ways and CMS is increasingly trying to encourage us to think about how to leverage as a Medicaid agency that funding stream to further health information exchange work so I guess that's all to say they are thinking about the future of this work they are thinking about the future of this work and the general message that we're getting from them is they're working quickly to figure out what continued support looks like your point about federal uncertainty is really well taken I mean we've had to deal with that a lot with the Medicaid agency over the past 17 months and sort of the thing I tell my team is hey you know pray to remove your feet you can't let federal uncertainty paralyze the work you have to keep going that said the disappearance of a preferred matrate for this work will not make the need for this work disappear and so even though it's a few fiscal years off we have certainly as an administration we've started to have internal discussions about how you might pay for this if it's an ordinary Medicaid expense as opposed to something with a very preferred matrate so I think we've started that a couple years in advance we'll see how that conversation progresses there's a lot of pieces to that but it's well taken and it's on our radar I think the best thing that helps you get through difficult pieces of this is to have a good partner so far the discussions the last few months with Vital have been very good they've been productive and they've been modest and difficult sometimes but I think we're getting to a better place we're grateful to be up here today talking about their budget which we do hope that you approve because we think we're on the right track but you know this federal uncertainty is something we have to weather together I have one other comment related to what Jess was asking about in terms of federal funding and also going back to Tom's question around self-sustainability because this has always seemed like a tricky balancing act to me in terms of pushing for self-sustainability because I can see how that would improve relationships with end-user so providers providers are paying for it that makes the organization vital much more attuned to what they need and want on the other hand it does mean it's net more expensive for Vermonters because we'd be losing that federal match so that's just a comment for you to think about as you're working on the HIT plan because that'll be an area that I'll at least have some conversation about I think that's exactly right and that's a component of our discussion internally and with the legislature every year because to the extent you still need these services if you pay for them with private dollars you're way making healthcare more expensive and so that is now that we have created a lot of federal investment we have to be very careful about that federal investment so the point is well taken Any other questions or comments from the board? So looking down the road and say things work out real well in terms of finding the areas of value for providers and responding to them but across the entire landscape in Vermont there are some providers that get it and participate and there are others that should get it but don't participate from Diva's point of view would you consider coming to us in situations like that where we have certain regulatory authority over budgets etc. and say oh by the way here's an area where this hospital for example might be more efficient if they avail themselves of these proven valuable services that Vital gives I think we would be to the extent we identified tools that we thought were essential for the creation of an integrated health system alignment with all payer model we would certainly want to be candid with the board about whether they ought to be used and why they're not being used I think that the HIE plan will start to get to your question because it will prompt us to say to ourselves hey what problem are we trying to solve here and right now we're trying to solve problems of institutional competency and credibility and to make sure that we are planning well for the future I think I can imagine a situation in the future where you're trying to solve certain last mile problems for example if you had 80% of people doing something that had a really catalytic effect on health care reform and 20% of people who just don't want to do that I think we could find ourselves in the future in a place where we want to solve that problem but right now we're really laser focused on each 901 elements that go into that if you don't mind me adding there are already things in place that we can use as ways to think about how we want to engage the health care system so for example the connectivity criteria the vitals going to present to you at the end of the year is a great way to establish standards for the type of data that we'd be receiving in exchanging okay this point we'll open it up to the public for any questions or comments yes Ken first of all I have a question really to the Green Mountain care board because it's always been a little unclear as to what the role of the Green Mountain care board is from my point of view in regards to Diva and Vital does the board have the power for example to pull the plug on this project on these projects this is maybe the fifth presentation 10th presentation that I've heard over four or five years and there's always kind of an acknowledgement that a whole lot better could be done and there's been a whole lot of shortcomings and it's not for lack of trying this is complicated part of health care reform but it's never been clear to me that there's a whole new board sitting up there from five years ago for example there's a lot of distress at least on the part of some board members about for lack of progress lack of clarity and frankly a lot of pushback from the public and part of the professional community so my question is is this from now into the future is the board just sort of monitoring the kind of anticipated progress and improvement that will be made or not I guess is the question so I can see my own personal perceptions are I think H901 is an acknowledgement that Diva has a much more of a rule and so you'll see that if that passes we would not be having a review or oversight of the core activities but strictly budget so as I see it and I could be completely wrong the board still has some powers because if the budget's not approved I'm not quite sure where they would go from there I would just add from a straight legal perspective that the legislature established vital as the vendor for the HIE so in terms of pulling the plug and in terms of who operates that that's to me requires some legislative discussion but I agree with Kevin I just might add that you know the points three and four that Mike talked about that they aren't you know our providers better off and our patients better off when that question and I think that question should be asked by health tech solutions or their equivalent in 2021 or so when this effort has had time to breathe and if the answer comes back similarly then as it did last December then I think a whole bunch of people will be saying why do we continue investing in this thing it just isn't working and again I think that the whole purpose of 901 if it passes is to set in motion a set of sequences that creates a contingency plan so that a plug might actually be pulled if deliverables aren't met yeah yeah this one's confusing can 901 really put forward not to pass I'm hoping the legislature asks itself that because if it doesn't pass and you don't invest in HIT where do you go I mean the whole market the whole economy of healthcare is got this as a fundamental building block now moving forward so what do I invest in is a question that's very relevant but do I invest I'm not sure is the legislature on the right track if it even tries to ask that question or is that a question that really doesn't make sense so the legislature is also on the right track if I might Mr. Chairman Dale I would just say three quick things one the legislature you know they've got a lot of scrutiny to 901 but I would just say they've been very fair and providing us with some room to do work to try to improve this recognizing that this is not the first time that Diva and Vital have said this is a tough challenge and we need time and energy and space to try to take on this challenge as far as what would happen if for some reason the bill did not pass as I said before the need for this work does not go away the funding source goes away and so the administration would have to talk about at what level could it support HIT with the present Medicaid expenditures and have a dialogue with the legislature about the next year's budget adjustment act and then also it's easy in shorthand to talk about pulling a plug nothing in life is that simple if we were to ever wind down our relationship with Vital we would have to be really careful about how to do that I think the existence of the agency plan work acknowledges just how complex that could be and so I think regardless of what happens we are in a longer relationship with Vital to make sure we are being responsible about whatever is next I like H901 because it gives the state an opportunity and Vital an opportunity to be really intentional about the future and try to think about how things look if we are not able to succeed and what happens if we just continue struggling with a problem that many states have found particularly difficult Sure this is of the board therefore based on what he said in the general that's all true can the board recommend or is this too political to the legislature and the governor how important it is that something has to pass in H901 so I guess I would ask Michael this question because I'm sure he's following that portion of the budget more closely than I have but I'm not so sure that the dollars are necessarily linked in the budget to the passage are they yeah it's really the claims tax the portion of the claims tax that supports the HIT fund is due to sunset on June 30 and so the most important part of the legislation is the continuation of that funding source for the HIT fund and so it's the existence of the fund and the revenue source that are most key to that piece of it are spending a poor day in the budget as to what's in H901 when it comes to that there's language in the budget about our spending by the administration's spending authority on HIT and so we I believe we would still have we would potentially have that unless someone took both of those things however we would have to have without the anticipated funding source we would have to have a difficult conversation about how much of that appropriation would be proven to spend I would just say to Dale until everything's done at the legislature but so far we've had a very collaborative process on H901 and we're optimistic that we'll be given the next fiscal year to try to execute on the plan that was described today other questions or comments Paul if not we thank you Michael Neville and this time if we could have Michael Robert answer anything else Chair we have everybody introduce themselves I'm Mike Smith I'm the Interim President CEO of VITAL I'll start with Frank Good afternoon everyone and Frank Harris I'm the Interim Chief Technology Officer for VITAL Hi I'm Bob Turneau I'm the CFO for VITAL I'm Christina Schoket I'm the Chief Operating Officer at VITAL thank you very much for taking your time this afternoon for this review of our FY19 budget I'll also entertain any sort of questions on the work plan but as you we seek your approval for this budget you can see that we're probably a much smaller institution than your much larger institutions that you normally look at review and approve and we really appreciate the time and effort that the staff put into the questions I think it's important and I'll get into that in a minute why I think it's important why we use this budget document as a planning document for not only FY19 but FY2021 and how we incorporated some of the things that Michael talked about in terms of core responsibilities as well as trying to open up questions about VITAL I think more conversation is better I wanted to get to a couple of things I have been following H901 it has passed the senate passed the house passed the senate with amendments we were very active in the senate in terms of trying to make sure that the bill had a few amendments on it the first amendment dealt with how we establish if we're making progress and one of the things that the house version had was a declarative statement that said in June of 2019 VITAL was exclusively to run the Dehigh would end and what we said in the senate and I think the senate I believe the house understands this as well is the problem with that is no matter what we do even if we're successful the legislation says that the Dehigh exclusivity with VITAL will end the second has put in an amendment to that language that says it's tied to the work plan let's tie to success to the work plan and that amendment was put in the second amendment actually came from a discussion that we had here when I first was here from a board member when she says wait a second it's kind of you know you're trying to change the composition of your board as is suggested in the HTS report but guess what it's in the legislative statute some former secretary of administration put it in legislation what the board make up would be one of this, one of that and that former secretary of administration should be admonished for that but nonetheless the bill now the amendment gives us broad categories within various health care institutions where we can look for in terms of reconstituting the board the last amendment that we suggested was that this board again was the consent issue this is a huge issue it's a huge issue that we have not looked at in the past because it is a controversial issue but I think it's a needed conversation that we must have not in sort of a legislative combat mode but in sort of taking and getting everybody around the table and discussing this and I was pleased that the administration, the legislature that have decided to let's start that conversation about opt in and opt out and I think that's an important conversation to have we had it has passed the senate there has been a last minute amendment on it we were hoping that the house would concur we don't know with this amendment this amendment is sort of non-dremain, well I can't say that it's germane because it's on the piece of legislation but it doesn't have anything to do with the legislation basically what it does is establish a joint legislative IT committee sort of like joint fiscal committee on IT projects that has been attached I don't know what the house will do at that point as Michael had talked about as a deputy commissioner and talked about this is in that legislation is the claims authorization as you know that authorization has to be resubmitted every year and reauthorized every year used to be every three years now it's every year and the legislature is moving forward on that I just wanted to give you an update on that I do want to thank Diva in particular Michael and Emily for all the sort of assistance and dedication that they've had in coming up not only with our budget but the work plan I think it's important I was the one as Michael had talked about I was the one they asked the question what is success don't we really need to fundamentally understand what success is and if you look at the work plan if you look at the contract there's a tying in of those HTS recommendations in all of that whether it's the contract extension or not like I said I really thank the board for the opportunity to put this budget together you will see that this submission is much broader much more in detail than you have seen previously that's because this we use this document as a planning process for us to look not only in fiscal year 19 but into the future we also thought and we understand when we provide a lot more information you'll get a lot more questions and certainly we saw that we did get a lot more questions but that's good because what we believe is that not only here at the Green Mountain Care Board but elsewhere we need to have this conversation we need to be talking about direction and we need to be talking about what the feedback is to the direction that we're going I'll give a short overview of the budget then Bob will provide some of the budget detail as well as the follow up and I want to follow up on some of the themes of the budget because there are themes in this budget Frank Harris our Interim Chief Technology Officer and as we transition that position will transition to it has already to a director level ultimately Frank will be our part time technology strategist instead of the Chief Technology Office he'll talk about technology and Christina will talk about some of the things we're doing in operations and Q3 so without any further ado if we could sort of get well we've got it already up there Bob let's just go to the slide deck we thought it was important to sort of lay out the priorities and if you look at this budget what you will find is that we are transitioning to a leaner and more focused organization and that includes one million dollars in reduction from state revenues over FY19 and FY20 and we're talking about something that Michael talked about and Emily talked about how do we enhance our services how do we sort of look at priorities that really make a difference in this FY19 budget there are six priorities as we see it increase the number of providers who consent to have their data vehicle in the V-high and there are two ways of doing that electronic consent which we've had success in doing in the last six months and legislatively which we hope to have success talking about that aspect as well but if you look nationally those that have opt out are roughly 92% participation rate roughly and if you look at those that have opt in we're at right now 32% Rhode Island's at 50% just over 50% so this is a very important question as we go forward better matching of our patients with their records we'll discuss that as we along with either Frank and Christina implement easier ways to access the data we've heard a lot about well you've got this way of accessing vital access but what about incorporating into our EHR and that's something that I think is fair it's something that we have to explore and how to do improve our quality through terminology services and up front connection criteria we'll talk about that manage the security of the V-High Frank will talk about that and promote transparency we're going to probably be a little bit more active on the airways and the press and other places we'll talk about what we do and how we do it I think it's important and this budget document is one way to do this our FY19 objectives are we gain confidence we gain credibility of our vital clients including the state of Vermont by addressing the recommendations from the Act 73 report and that's a theme in this budget presentation now vital short-term and long-term focus to get to a question I heard later what is value well value is high quality data value is strategies to ensure accurate and complete health records value is efficient effective useful delivery to providers and value is collaboration with our partners it's also imperative because we talk about a lot about state government but we have other clients that are out there one care for Vermont for example is one of the other clients that we have out there we can't forget about those value added products that we provide out there I think it's important to remember those products as we move forward the FY19 budget is balanced but we said let's look forward let's not only look at FY19 actually looking at FY19 is easier looking three years ahead is much more difficult as you look ahead because you've got to think and anticipate what's going on looking ahead we see that FY20 budget is balanced through the use of carry forward monies FY21 is budgeted through providing value added products to state government and Vermont providers we will need approximately $500,000 in FY21 to talk about sustainability so the risks we're a lean organization we have talent that's there good talent that's there and that's good being a lean organization because it means it increases efficiency but the loss of crucial talent could have an impact on effectiveness now we've tried to mitigate that by cross training and by organizationally bringing the organization not through a silo system but to bring it together in a more constructive way an unfavorable HTS follow up evaluation could have an impact on state contracts we have legacy reconciliation issues that need to be settled within the parameters of the reserve our reserve over that reserve could impact the budget vital must meet its NIST requirements and I'll have Frank talk about that and then the budget items must trend as planned the next two slides are something that staff gave me when I first walked in the door so I could understand what was going on and what we were doing in terms of what the V-High is and it is a it is a database that are used by hospitals primary specialists like the FQHCs home health hospices commercial laboratories medication services mental health and nursing homes but there is also another side where that information is used and if you go to the next thing this is a infrastructure that provides data to the Vermont accountable care organization the Vermont department of health immunization registry the Vermont blueprint for health clinical data registry patient ping and the VCCI which is the Vermont chronic care initiative as well there is another side you'll hear us talking about medicity you'll hear us talking about HDM HDM is this component is the first component that I spoke to there's a point in this slide that when when it was included in this slide I didn't think two things about it but as information starts coming in I want to make sure that I'm really clear on this slide it's as potential support to other regions and states we're not interested right now in going into other states or doing other things what we're interested in at Dartmouth at Plattsburg how do we do that and how do we make sure that that record is following the patient that's what we need by that with that I'll turn it over unless there's any immediate questions I'll turn it over to Bob who is much more proficient in knowing the details than I am thank you Mike good afternoon that are relevant to our FY19 budget this afternoon before I start I'd like to thank Agatha Kessler and Sarah Kensler for their guidance and patience with us helping us to get to this point with the presentation where we are providing the board with the data that informs their decision so and thank you our FY19 budget was shaped by many factors the budget was developed from a review and assessment of vitals cost at its lowest level by the person and by the vendor we compared what we have spent with what we anticipate those expenses to be in FY19 the above assumptions are what vitals sees as the most important in terms of our budget for FY19 first and foremost is that we need to complete the contract extension requirements second is that the award of the fall on contracts must occur on January 2019 and as Mike has noted we also need to maintain our critical skills and talent to make this all happen next we need to achieve cost reductions and maintain those for the future and then finally we need to complete the transition from our hosting service rack space to tech vault and I'll talk a little bit more about that in future slides if we look at revenue this budget incorporates a $500,000 reduction in state funding to the FY19 budget and in addition it decreases the FY 20 state funding by another half a million dollars the FY20 forecast is just here to illustrate what we would anticipate the funding to look like in that fiscal year our major funding from the state comes through two contractual vehicles there is a core contract which you see above which covers the V-hide operations and maintenance and the APD or otherwise known as the advanced planning document which establishes and remediates interfaces these are the connections between healthcare organizations and the V-hide in addition this contract ensures high quality data being transmitted to the V-hide and supports the HCOs with exchange and access of health data information can we just go back and rub this slide again can we just talk about the decrease in the other state contracts and lying all the time sure in specifically the last line in other state contracts that should have read the bulk of that is the SIM contract which has since those funds their availability has been eliminated by the federal government so over time this has gone away as a funding vehicle for us in FY18 there actually is a small amount of carry forward of another contract from FY17 about $147,000 that was attached to specific projects that were delayed until September of 2017 in addition in the FY18 forecast we have a project for VCCI which is a small project around $72,000 it's split between 18 and 19 with a balance in 19 did that answer your question so what's the $42,000 for our 19 it's the VCCI contract it's the balance of that work what is the work that is to build a what's called a VPN a virtual private network and stand up a very small data mark with the VCCI so that they can access their data that's coming from the VHI this next chart is intended to show the extensions of the current state contracts and the following contracts that will be awarded at the beginning of 2019 we expect that the fall on contracts will be full year in length spanning the second half of FY19 and the first half of FY20 we anticipate that the discussions with the state will begin at late summer and conclude in the fall as right now we have no indications that this situation will not come to pass this next chart is a summary of vital expenses by year our budget here matches cost with the reduced revenue and incorporates investments in investment technology to enhance security improve patient matching and data quality as recommended in the HDS report and in addition it reduces future costs by helping us migrate from rack space to tech fault and that positions us to future savings with the move to more cloud based technologies personnel is the largest component of vital expenses sure one of my questions was about the education and outreach planning over time fairly significantly at the same time with the goal of increasing consent and I understand there could be a legislative change that could help with opt out but if that doesn't happen it seems like education and outreach is the methodology through which you can increase consent can you just talk a little about that one unfortunately we have been faced with reductions in funding and one of the areas of education and outreach was our summit and we have eliminated that from the 18 budget and also the 19 budget and in doing so to match our staff with our funding we eliminated two individuals who were associated with marketing otherwise known as educational outreach to match with the revenue let me try to answer that question because it is an important question as you have alluded to the e-health specialists at the time were out there trying to talk to various people about using Vile Access and helping them along the way we do have people that are still doing that but you raise a really good question on education and outreach if we have opt out we're going to have to switch those people's existing staff's responsibility to that outreach effort to make sure that people understand we're also going to have to outreach ourselves in terms of using earned media and other avenues to make sure that's going to happen there is the outreach that you're seeing the reduction is different than the outreach there was a lot with the conference, there was a lot with providing outreach through these e-health specialists we have redesigned that and how we're doing it but you're absolutely right we're going to have to focus those people that are doing that sort of work now on the aspect of opt out in 2020 to talk about that at that point but if we don't have opt out we don't get an opt out from the legislative process then we're in opt in and how are we going to achieve the level of consent that we want without outreach and education so I mean I feel like in some ways right now we're doing here's what we're doing and I'll have Justine talk about this in a little while but here's what we're doing we are actually using electronic to increase our our our consent levels to that we also are sending out these staff members to go out and work with the various providers in order to use the vital access and other other capabilities that we do have if they're in the budget it's just not designated as education and outreach but they are in this budget and they have cross purposes now in terms of what they do I think it's important I think you raise another really good point there's going to come a point when we plateau but we've shown significant increase in consent in terms of what we've been doing with the electronic version of consent but there's going to come a point where we plateau and it's probably going to be around the 50% level at some point and no matter what we do whether we educate or continue to try we'll continue to try to strive for that there's going to come a point where a significant difference is going to be between opt in and opt out thank you Mike personal costs are the largest component of vitals expenses they make up about 50% of vitals total expenses they have been decreasing over time since FY16 when they represented 57% of vitals total expenses this budget keeps our labor costs flat and also reduces some of our employee benefits to again fit within the funding envelope that exists as Mike mentioned vital is a lean organization we have been staffed with a level of funding while we are one deep in some skills we are still capable of meeting our contractual requirements however there is no margin for error as Mike mentioned we are employing techniques to establish redundancies within the skill set of employees through cross training, engaging technology consultants to assist in the event of a loss of a critical skills and we have reorganized to promote coordination between our teams vitals head count has declined by 7 or 22% since FY17 these reductions have been across the board but the largest has been in administration our FY17 budget has no new positions in it moving on to modicity they are our largest vendor they have been the vendor for the V high since 2011 when a competition was held to replace GE healthcare our contract with modicity inspires in June but we expect to renew it at the same terms most of modicity's cost are monthly charges with the exception of the interface connectivity so their cost had been relatively stable over the past few years we expect them to remain stable in FY17 our next component of files expenses at 17% of total expenditures is information technology expenditures these cover expenses for data security network services and maintenance and software licenses and services for things such as the hdm terminology services and of course our indirect IT related expenses this also includes this estimate also includes an expansion of our terminology services efforts into what is called CCD parsing which is taking electronic document and breaking it down into usable pieces of information for healthcare organizations this effort has been discussed in our six month work plan and it is one method of improving the quality of data being transmitted to the V high which is a core function of vital there are also new projects that are linked to the HTS recommendations such as improving project improving matching by patients which are also in our budget in FY19 70% of our total cost has gone to programs while 29 or 30% is indirect this 70% was a benchmark used in the HTS report it is illustrated of a number that shows how much effort is going to productive efforts under contract in our environment we are working on contracts where this number is less of a relevant number than it would be with a grant it is sensitive to changes in the base that is labor and material and as you can see it has been the indirect expense has been relatively stable over the past several years moving on to the balance sheet let me just if I could when you come into an organization you look at a few things one is the overall personnel cost and in the vital case it is 50% if you match that with other organizations you will find that this is below what the average is to most other organizations when you look at it you see how efficient you are going to be in terms of your use of personnel and if you look at it vital has eliminated it is overall sort of administrative headcount which is good and then you look at where you are investing at least I do where you are investing and technology given that we are a technology healthcare technology company investing in technology seems to be the right trend to go and then lastly this is the last chart I looked at was the indirect rates you always look at the indirect rates how much are you spending on programs spending on sort of the administrative aspect of it all of which these slides were included I think that showed that a vital is being efficient in terms of what it is trying to do and the efficiency and investing in the right things in order to meet the core requirements that have been established for us and that we have agreed to I will spend a few moments on our balance sheet it is a relatively simple one most of the vital assets are current in nature such as cash and accounts receivable our cash on hand is projected to be $1.2 million at the end of FY19 this represents about 78 days of cash on hand typically organizations are looking to have around 90 days of cash on hand for us this represents really a good place to be given our previous visits to the Green Mountain Care Board and our discussions regarding the availability of cash one final note on the balance sheet is the minor amount that really the property plan and equipment makes of vital and that PP&A if you will is made up of three elements it's the lease hold expenses of our office around $25,000 it is also laptops that our staff use which are around $17,000 of net book value and finally it is the network infrastructure that we are using to run the HDM and that's about $96,000 there's a question on cash you're seeing quite a favorable shift on analogy with receivables going down and pails going up which is obviously a way to help manage that but after they're going in the opposite direction how are you managing that and what you see on cash because I think you're seeing about AR decrease of about $440,000 year over year an increase in prepays and accrued of like $210,000 so I would just say that that could present a risk to your cash position if in fact you don't shift that so quite a bit of that is energy management yes what I would say is that in terms of the reduction in AR there is a significant rollover of cash from FY18 into FY19 due to a number of factors one is just the cash conversion process is around 50 days so there is a sizable component from FY18 that is rolling over into FY19 along with the billing shutdown that happens at the end of June and those two things combined with affect the first part of FY19 being that there is more revenue coming in in FY18 than FY19 so understand so if we move on to liabilities FIDL has very minimal liabilities the majority as has been noted is our payables the majority is our payables the majority is our payables the majority is our payables the majority is our payables which constitute about 40 days payables we have no debt even though we have a line of credit which we have not used we believe that our payables balance is easily covered by a projected cash position and then finally our budget includes the capital outlays for FY19 which cover funds to reduce FIDL's office footprint and this will aid in saving us money in the future and also to expand the network infrastructure especially memory we're currently using about a terabyte worth of or increasing a terabyte worth of memory every month to conclude my presentation I'd like to thank the Green Mountain Care Board for their thoughtful consideration of FIDL's budget and activities and look forward to a favorable response to our budget approval request just to explain to us a little bit about what TECHNOLT is so to host the systems that FIDL uses to process the patient data requires that they be hosted in a data center those are special facilities that are purpose built to house servers and a company like FIDL does not want to be in the business of building data centers they're very expensive facilities so we get that service from a service provider in some fashion historically FIDL has gotten in from a service provider called Rackspace and FIDL is transitioning away from that provider and is transitioning into a different provider called TECHNOLT and that's a company that's in South Burlington, Vermont and they basically house servers for companies in the state of Vermont as one of their customers as a matter of fact so that's what it is Do you do any geographic diversification to protect against a natural disaster so that there's something free to protect the information I will speak a lot about that in the presentation but the status that VITAL is in right now as Mike talked about there's two large pieces to VITAL's architecture the MEDICITY system is what I think of as the point of care system that's the system that clinicians use to look at their patients data while they're caring for patients that is hosted with MEDICITY and they have that capability they host it in two different data centers and they have a disaster recovery capability to transition from one to the other if there's a physical problem with one of the data centers on the HEM side of it that capability is not where it needs to be today and so part of the technology initiatives that we have identified in the near term is to improve that capability so today it's hosted at TECHVALT and we have plans to create a diverse hosted instance of that in the cloud and I'll talk about that when I go through the strategic initiatives why don't you waltz right into it yeah sure glad to so thanks for the opportunity to talk with all of you today it's my pleasure to tell you about the technology function within VITAL and sort of what we see as important plans going forward can everybody hear me alright ok so next slide please I think if you had a chance to read the technology strategic plan you'll see that I think it's extremely important that technology doesn't exist for its own purposes we're not in the business of building elegant infrastructures and that's not our objective it's to support companies objectives in the company's direction and so the technology objectives the areas that the technology function can impact on really align it's right directly with the priorities that Mike talked about a few minutes ago for VITAL and they also align directly with what was identified in the Act 73 report the HTS report around the core services that VITAL needs to focus on and do well on the next slide and those are data quality data availability and ease of use patient matching patient consent and data security and privacy and so I'll talk about each one of those and some of those initiatives that we have planned in those areas we go to the next slide so the strategic initiatives that we're talking about here the first one is really in response to where it identified that there a potential concern of VITAL's architecture being complex and talked about looking at the opportunity to consolidate the infrastructure under a single vendor and so Mike talked about the role that electricity has played and I talked about that's the point of care system the other half of the infrastructure is the HDM infrastructure the health data management infrastructure and two or three years ago VITAL made a decision to self develop that side of the infrastructure at the time the vendor did not have a product offering in this area and they do today and so we're taking a critical look at that direction to see if that's the direction that we ought to continue with my philosophy when we underlined as one of the strategic principles in the strategic plan for technology is that a company like VITAL shouldn't self develop capabilities like this unless they provide unique value or their self development provides a more cost effective path otherwise generally speaking our direction should be to buy capabilities like this and so we're looking at that now there's a pretty significant curve ball that we had in the past week or so which I think is potentially a positive thing but it's going to make it hard for us to really get to closure on this as quickly as we've hoped and that is that we've learned that our vendor modicity is potentially being acquired has agreed to be acquired by another company called Health Catalyst and Health Catalyst has very significant capabilities around what the HDM does on the data analysis side of things and so we're going to be following those developments very closely and we want to see how those go sometimes those acquisitions can be really positive events for a company like ours and sometimes they aren't a lot depends on what the acquiring company, what they're intending to do with the product it's pretty early days to give a read on that but I'm cautiously optimistic that what you're looking for is that your current software capability is a nice fit for the acquiring vendor and they might wind up with an outcome where the capabilities get rounded out a lot better so we're going to be following that development and I think really any technology function within a company ought to always be looking with a critical eye at their strategy and so I see beyond just that the Act 73 report called for us to do this I think we ought to be always doing this as a company so the oh I'm sorry disaster recovery so that's what you exactly what you were asking about before so the ability to recover into another geographic location and in the next area I'm continuing to advance the infrastructure approach and minimizing overhead costs and I look at this as you know the idea is to meet the mission with the infrastructure at the minimum cost because really at the end of the day building hardware infrastructure for a company like Vital is an overhead cost and so as we talked about improving our disaster recovery capabilities streamlining the current architecture because it's in transition so to shed the rack space infrastructure that I talked about and consolidate it as planned two or three years ago into the tech vault infrastructure and then a likely move into a cloud based infrastructure some of you may be familiar with those strategies but there are providers like Microsoft and Amazon that are providing infrastructure as a service to a company like ours today and they really provide some very significant opportunities to a company like Vital you can scale your capacity up and down as needed very rapidly without capital acquisitions of hardware you can get your capacity just in time like when you're buying your own hardware you're always buying it in a sort of a step function and chunks and you have to plan for future capacity and so some of it sits idle until you grow into it and in a cloud based approach you can get it just in time you can avoid periodic large investments when you need to grow your infrastructure instead you have a more predictable and consistent expense over time and like I said there's an opportunity to reduce overhead because large scale providers like Microsoft and Amazon can achieve the economies of scale with a small company like Vital can so big opportunities there isn't it one of the barriers that you're putting forward the cost to shift them to the cloud I think that the first thing I would say is we're going to take a really hard look at this from a business perspective and make sure that the economics are there before we make a move and we'll be collaborating with our partners at Diva in all the decision making that we do here but we won't make the transition unless the economics are there my belief is that and I think what we will find is that the costs of a transition are going to be more than covered by the savings and the improvements that I talked about and that's why you're seeing really I think in the IT industry a sea change of companies going to cloud based infrastructures generally speaking the trend in the industry is to shed owned infrastructure and to buy it as a service I agree that the higher cost before you get the savings and the timing of that based on your financial situation it's not good things it's a bit of a challenge but the cloud is where ultimately the costs actually I think we'll find are surprisingly modest and the reason is that Vital's technology is already what's called virtualized so today servers don't buy hardware every time you want to have another server it's really implemented in software and that software lends itself to being shifted to different hardware platforms incredibly and relatively low cost so we called out our forecast was $100,000 to make that transition and I think we could see that return very rapidly and besides the other benefits but I want to say take that with a grain of salt because like I said we'll be taking a really hard and detailed look at this before we make the shift so next slide please in the area of data quality data quality is really a multi-dimensional issue of course and there are a lot of parties that have a part to play in data quality for example the source organization needs to collect the data properly just as one example but certainly I think the first four bullets on this slide call out what I would see is the real clear mandates where Vital needs to play a strong role in data quality and the first one is as a catalyst for data standards it's one thing to say that someone has concerns about data quality but that's not in and of itself actionable it has to be specific it has to be something that you can really measure and act on and really at the end of the day data quality you could say is adherence to standards and so the reason I said a catalyst for data standards is because that's not Vital shouldn't be setting the standards by itself but involving its many partners in deciding what those things are but that's key to measurability the next one is you're certainly familiar to you from the work plan that was discussed earlier and that's to support the formal data governance function with very open participation by the impacted parties and I anticipate that the technology function will need that activity and it's extremely important to make decisions about the data advancing the capability to measure data quality with actionable information like I talked about it has to be measurable and Vital is in really a unique position as the holder of the data to be able to analyze the data and measure where we stand in terms of the quality and what the gaps are and what the issues are so that they can be acted on and then advancing the maturity terminology services to standardize data and Mike talked about this but really when you're thinking about improving data quality there's improvements that need to be made at the source for example so let's say a healthcare organization doesn't collect a piece of data well that can't be remedied centrally if it's not collected in the first place and so the source organizations need to be part of the solution but a lot can be and should be done centrally by Vital to improve data quality an example would be if organizations collect the data in different ways sometimes that can be very tightly tied to their business processes there are a lot of end points involved and it can be difficult to change those things at all the end points and centrally the data can be translated and standardized so that it can be used in a common way and that's what terminology services do so and then finally working with others to develop an overall systematic approach to data quality management like I said there's a lot of players in this so the next slide patient matching I sort of emphasize in italics here that this is a really core capability because to me a lot of the value proposition that Vital should provide is that it can collect data from diverse sources and unify it in a patient record and that's really fundamentally a lot of what the promise of health information exchange is and so we have to be excellent at this and as we look at this there's patient matching capabilities that we have with our vendor today and Christina is going to talk about some of the work that we're doing to leverage those to improve the current state of the database which is very important but we think that ultimately we need to add technology add a master patient index capability to the technology mix to really improve the situation here and it's got to be you know our principle that we'll drive this by is that it's got to be unified across the entire architecture and so we're looking at solutions there it's a interesting and the next bullet is that there's a cost challenge there these aren't inexpensive tools but they are also tools that have a high degree of interest in a lot of the participants in the system so for instance the accountable care organization that's a really essential capability for them to be able to look at their patients care across the entire healthcare system the blueprint for health wants to leverage that because they're trying to look at the entire care for patients the Vermont Department of Health already has a master patient index that they have self developed and they have people who work full time maintaining that we've had some very early discussions with them but we know that they would love to be part of a unified solution as opposed to their own solution and so there's an opportunity to partner with a number of parties here to meet the cost challenge but also I think the mandate has to be it's got to serve the purposes of all those parties we don't want five or six master patient indexes operating in the state we really want to try to have one so when we intend to do that as we look at this question and then data availability at ease of use I was a clinical information systems manager in Vermont's academic medical center for a number of years Christina was a clinical information systems manager at Dartmouth and we both know from experience that healthcare providers they're extremely dedicated to providing quality care for their patients but they also have enormous time pressures on them and they have to do that extremely efficiently and you may have great data on patients but if it's hard to use and it's humbling they're not going to use it and so and they really hate having to use multiple systems because it's time consuming for them and so we're really focused on trying to integrate to electronic health records to make it as easy as possible for them to view data from vital right within their workflows that they're already involved in and this is particularly important when you have a situation where not every patient's going to have data in the beehive and so sometimes they look for data on a patient and there isn't any there and so that makes it doubly important that it's really easy to do and then I think a little bit more of a supplemental capability a single sign on capability so at least they only have to log in once if they have to look in another system next slide patient consent there's a technology role here Mike talked about it and that is to make it possible for organizations to collect patient consent within their own registration systems and have it automatically flowed to vital as opposed to having to again sign on to a separate system and enter the patient's consent status and Christina will talk about we've seen very significant improvements very rapidly as a result of having implemented an interface of this sort with the UVM Medical Center and I think there's a lot more opportunity to do that and so that's I think where the technology role comes in to the patient consent question and of course there's a lot more to do and then finally security and you know we look at that as you know that's paramount if the confidence and the security and privacy of the data isn't there then you know nothing else is going to work and you know I want to emphasize that I think Vital has built a really solid foundation and has had a really solid track record of improvement in the area of security but for any company in today's environment there's a never ending battle and requires constant diligence and so we intend to continue the robust program of regular audit by industry consultants and we've been using center GISTEC who I think do an outstanding job we are working on really having open governance partnering with Diva and the agency and digital services and it's starting to set up regular monthly meetings focusing just on security and privacy and the issues there maintaining a very accountable and specific and actionable plan according to the national institute of standards security standards and then finally transitioning to what's called the cyber security framework which is really the coming trend in how to manage a security framework really covers the same kind of information that the current business standards do but approaches it in a different and potentially more useful way and so we're intending to implement a framework there Can I just interrupt for a quick second before we jump to the next slide Can you go back to just, you've gone through many of these technology or strategic initiatives can you go back to just slide 25 This way I can get a sense of the priority or the weight that you're putting on each of these Yes In some sense could you give us a quick substantial or human resources you're voting to each of these or in other words what's the priority of these Is it the priority of the order 5 or is there some other priority there I'm trying to figure out where you're part of your resources to achieve which of these initiatives fairs to the foremost Honestly it's hard to pick among them Like I said I think data security and privacy that's table stakes I mean it's like you have to have that buyer's constant diligence so to me that's just the absolute essential one and probably where I'd start to think but beyond that I really think it's 2, 3 and 4 where I would say are the most important parts and that is if you're not matching the data to the patients correctly and optimally like I said that's a fundamental value proposition that the high health information exchange has to provide and so you need to do that extremely well as Mike talked about patient consent is very limiting if we don't see improvement there we have a lot more data than we can let clinicians look at due to the patient consent issue so advancing there and then like I talked about data availability and ease of use I really think that's another one of those hurdles that you can have great data on the patients and they may have consented to people looking at it and it's matched up to it really well but if it's too hard for people to use they won't use it does your staffing have reflected those priorities? I would say yes but you know I think the thing that I would emphasize is that it's a small staff and so it's not like you know we've got tens of people that are moving around it's a small team but I guess I would say more like it's where we prioritize our efforts among the staff so they're not typically there are some exceptions we have a person who's dedicated purely to security for example but they typically are project driven across these priorities so what should we believe in the fact that we just focus on that quality is the least of those? Yeah I would say you know it's it's like any one of those that I said was lowest on the priority list you're probably going why did you think that was the lowest priority but I would say the reason that I would say that you know I probably picked out one last was because where I think the data quality issue becomes most important is when you're trying to use the data to improve health care quality and improve the health care system and I think that that's one thing that you know I'd like to make sure that you know the board doesn't lose sight of is that the point of care is a really critical value that Vital provides for clinicians to be able to see data of their patients while they're caring for the patient but a huge part of the opportunity here is to improve the efficiency and quality of the health care system and that's looking at the data in aggregate and so that's sort of where the health data management infrastructure is oriented toward and that's where the data quality issue becomes particularly acute because in order to do that kind of aggregate analysis the data has to be structured well and has to be standardized so for example if I'm looking at diabetes patients and I want to see how many of them had their hemoglobin A1C checked in the last six months if there's different terminology being used for that test and I don't happen to look for all the terms I'm going to get inaccurate information and so it's I think it's that's why probably I would say I picked that one last even though like I said it's hard to pick them on all of these and you know we put these out there as the high priority focus areas all of them including data quality so Before I give it over to Christina any other questions but the question was like a Sophie's choice on this one Yeah And then we have to see how we send our private money so I was trying to I was wondering if that really was your one to five or if you had any and it was a great question and one of the things that I that we tried to do in the work plan and in the budget with the contract with the state is really put some meat on these things in terms of the deliverable what's the cost of the deliverable what's sort of the incentive in the deliverable as well and those are in those you know this and others are in that package I'm going to screw that up That's okay Can you all hear me? So I just I want to be respectful of your time I know we're probably a bit over how we doing We don't want to rush some people Okay great thank you very much so the benefit of going last is that my partners in crime have said most of what I would have said so I'd like to just go through the Q3 activities maybe just highlight some of the areas that are in alignment with what has been said so far so in order to address the areas in the HTS report that were called out we through this fiscal year 18 contract really hunkered down and started addressing some of the concerns prior to working with the state on the next contract and this goes to Jessica I think you asked the question about the outreach and education and so we have been focusing on client and education it's really a reeducation in streamlining our staff we've talked about moving away from a siloed organization where we have teams that work on specific things really doing cross training and really again streamlining the work that we do so that we can use those resources in the most appropriate manner again being good stewards of the of the state's money and the other clients that fund us so we have used our staff to go out and educate on when someone asks about an interface we also talk to them about vital access we also talk to them about consent we've gone out to those users who we know have been permission to use vital access the provider portal but they don't seem to be using it very often and it could be they just haven't had a need to look on a specific patient yet or perhaps it's that they've forgotten or they don't know how to use it or they may not have seen the benefit and some improvements have occurred over time so we have been doing that work and we've been focusing on consent re-educating to collect consent why they need to collect consent in order to help improve the number of patients who have agreed to opt in to have their patient data shared we've also I think Mike mentioned the electronic consent implementation we've worked with UVMMC or University of Vermont Medical Center Northeastern Vermont Medical Center in order to at the time that they collect consent they mark that within their own EHR or patient registration system the the registration secretary or the clinician does not now need to sign in to the VHI to mark that same consent once they mark it in their own system we've worked with those organizations vendor to trigger an automatic message to go right to the VHI and flip the consent within the VHI so it's transparent to the provider and it's real time so you'll see the improvement in our consent based on that work in order to improve the utilization like I said before again going back out to re-educate users in fact one of the recent encounters that we had with the counseling service of Madison County with a provider that had actually been permissioned in 2015 when re-educated showed the improvements and the provider said why am I not using this system so it was really great to hear that just doing these efforts we've been seeing where people have seen the improvement and maybe now more than when it was new understand the benefit in this sort of exchanging clinical electronic data we are still implementing vital access again the provider portal contractually we are supposed to on board 14 locations we're already up to 11 we will probably go over the 14 locations but that's okay we want more users of the system and we want to aggregate more data that's the interface portion making sure that we can collect that data from organizations to contribute and share that information on their patients for fiscal year 18 we're contractually obligated to implement 85 we already have 63 locations live we will most likely most definitely go over the 85 but again we want to collect as much patient data as we can and then again improve and patient matching that is critical critical to the success of any HIE and so we have been working with our HIE vendor Frank talked about the technology portion about how we can look at other ways to improve matching we are working with Medicity in order to come up with better ways to do matching in the system that we already have it has been engaged they created a tool we are working on that tool and that will also lead into our contract for fiscal year 19 in order to continue to improve our patient matching we want to hold our HIE platform vendor accountable to helping us improve in this area so through the electronic consent that I walked you through at University of Vermont Medical Center in the northeastern Vermont Regional Hospital as well as that outreach and education we have improved from where HTS reported around July 2017 we are in the 19 to 20 percent consent rate through those efforts we are now at 32.5 percent of the patients who have opted in to having their patient data shared electronically so once the patient has opted in and the data is able to be shared we of course want to increase the utilization of those providers to actually access that data and there is two ways that we have highlighted here so the gray bar at the top is that vital access provider portal where the provider actually logs on and he or she can search for their patient and review a comprehensive patient record and through our re-education efforts and sometimes it depends upon whether it is flu season or not whether or not there seems to be something going on in the community it can fluctuate but we have been seeing a trend upward and I believe since July 2017 that is about a 42 percent increase from when where we started so we know we are headed in the right direction and I will talk about other areas to continue to improve in a future slide and then rate quarterly provider queries this is a patient level right yeah you know we used to report on provider theories and we moved away in order to do patient queries but I can make a note of that and if that is something that you would like to see how many providers across the system are using the system right that is the main utilization I do have a small number of providers with many patients and that would reflect yeah I think we might even report on that now so I can definitely get that for you in order to show you that okay sure alright so then the blue line shows the veterans affairs query and exchange capability and I will just talk about this for a little bit because this again will lead in nicely to a future slide so the veterans affairs using what we would call a network to network query they have an EHR but it is a lifetime record it is located throughout the nation so it is almost like its own EHR is a network hub so we have set up a network to network query where if a veteran a Vermont veteran is seen anywhere that provider at that location can query the V-high and if the patient has provided consent we can share that patient record back to what Michael Costa and Emily have always talked about which is having this ubiquitous access to have data follow the patient where that patient is seen we want Vermont veterans to be able to have their providers collect data so in this this is if a patient is seen outside of Vermont at one of those veteran areas this is the number of queries that have been done over time what is not on this slide which we will be including in future is the number of providers who are now query the veterans administration's electronic health record and its over 300 in March 2018 so more coming on so this is just to give you an idea of the locations that are contributing data to the V-high again locations can also receive data from the V-high in the form of laboratory results radiology results transcriptions which are in your reference slides which I won't go over but they are in case you need that information this is just about contributing data so that you're able to see the work that needs to still continue in order to collect more data the important thing to know from this is the total potential locations is just any practice that exists in Vermont and the surrounding areas as well as locations with a known EHR we may not even be knowledgeable in working with the state who even has an EHR or not so this kind of tells you what your universe is and these are the live locations that are contributing data it's 269 which may look like only a few but that is hospitals obviously many many patients and it's also it's representative of the organizations that are a priority through the blueprint through one pair of Vermont and through the Vermont Department of Health as well as other clients who have said we want to contribute data so it's all based on a priority so we've talked about where we're heading and for the fiscal year 19 contract extension I just wanted to give a bit more detail on certain areas so we still want to increase the consent we've made that pretty clear throughout this presentation what you might not know is in that contract and I think this is in that contract matrix that Emily Richards was talking about that we are being incentivized in order to try and hit a 35% rate of consent we're working with two hospitals right now in order to implement the electronic consent in their EHR again we trigger and send the patient consent decision to the V-high electronically I'm sorry they are Northwestern Medical Center and Southwestern Vermont Medical Center I believe it's both of those I would also like to move into the Brattle Barrow Memorial Hospital area we just haven't talked to them because they've been dealing with they recently switched EHR so we want to give them a breather for a little bit while they've been doing that but that I think will accelerate some of that improvement in consent rate again being cautious that we would probably plateau at some point because the same patients might be consented in and it will flatten out but we still want to do our part and we want to again implement easier ways to access that data again you can have great data you can have a patient consent in but if a provider doesn't find it useful to go and view that data what have you built and we want happy providers so this gets back to what Frank was talking about which is there is the capability of being able to do a single sign on which is literally a blue button within the provider's EHR we work with the vendor when the provider wants to see more data they hit that button transparent behind the scenes it brings them right to to the the high provider access with vendors who have a bit more advanced capability again think of the veterans affair they do that query type of process other EHRs we're working with the University of Vermont Medical Center in order to have them query and actually retrieve and then it pops right into their own EHR again transparent to the provider and they can see the data right within their EHR in a format that they're already comfortable with so we're working with them on that and I believe in the fiscal year 19 contract we are looking to do one of each a single sign on and a query so in order to improve the quality of the data this gets to that quality question which is to use what we've invested in the terminology services solution that we have and come up with a plan to actually embed that into our production system we want to work with an organization that is submitting data especially onto a downstream reporting system or registry and outline areas that we believe analyze their data and outline areas that we believe that we would be able to work with them to improve data there would probably be the opportunity for them to improve data right at the source and we want to really kill two birds with one stone have them fix their own data where necessary helps their own providers and then be able to actually enrich some of their data so that it's useful downstream as well and we want to do a baseline and then we want to report on the improvements and show that to the organization and the downstream system we also want to do patient matching in this area and that is what I was talking about before working with our vendor as well as what Frank mentioned which is working with our partners to identify a patient matching solution an enterprise solution for the state and have everybody way into that and what we're looking to do in the patient matching ground is on a baseline that was released when HTS did their report actually do a 40% increase by the end of the fiscal year contract extension period which on December 31st 2018 and then we want to partner with agency of digital services I think Frank talked about that in working through the security plan and we also need to make sure that we complete the high architectural assessment that we started working on with the state it was put on hold and we've been asked to get that back up with them starting in the next contract and that's it and we provided reference slides that are just updates from the last time that we worked here in February in case you had any questions on this great questions or comments from the board I should start with a quick one this is about the city contract you said that this is up in the end of June I think you said and that you're fairly confident that you'll be able to retain the same contract you've had in the past but then we learned that modicity is now potentially being acquired so that suggests to me that there could be some potential risk in the negotiation of that contract and I'm just wondering how do you all feel about the risk of that contract given the recent acquisition plans and potential there leverage so I can say that modicity has not increased their contract in fact they have reduced their contract specifically in the medication theory services by 60% over time so we have a really good relationship with them and we look at the amount of work that we do within their system and try and write scale it for what we pay we do have a meeting with them next week to learn more about this merger I'm not really sure if they're going to have any answers but it is a question that we're going to be talking about and trying to reduce the cost of anything which I'm sure is what Mike's saying I'm just wondering if they're going to be bigger they may have more leverage right I'm just wondering you hit on something that's going to be really interesting there's some risk involved here in what this is going to look like in the future it's going to be these things usually come together in a course of a month or two or three or four we have an immediate contract coming up with them that we're going to we're going to sign and then we're going to try to figure this out we had them coming in next week to talk about the single architect structure well that's still going to be a discussion but you absolutely right there is some risk here as with any sort of merger what will that entity look like what will they perform when you merge what sort of products go and come in that merger it's going to be interesting I have to live through a merger and know how these things kind of work and it's going to be interesting but I don't want to minimize that that's where that's where I'm focused on thank you I just have a question with the morale of your staff it's because one of the things you brought up was the risk of your organization as well as what you brought up in capacity and I totally always think for cost savings it's one of the things I push but you guys did cut benefit costs and you cut retirement costs and there's kind of uncertainty about the future so I just wonder if you're sitting in that seat working in IT and there are maybe other jobs out there and how are we going to keep the retainings and are there any kind of retention plans you've had out there to try to keep hope sure that's a great question and one of the things that we decided and I think it's important when we were addressing this we were upfront with staff everything that you see here we've put on the share drive for staff everything that we've discussed we have we've discussed with staff ahead of time one of the things with the benefit cuts that you look at is that the area that we we didn't touch the match rate for the retirement but there was an incentive in there a 6% incentive of annual salary that we did reduce I have never seen that before maybe you haven't had the healthcare industry but I had never seen it before it was a it was a unique benefit that I had just never seen I explained to staff I'll leave it to Christina she interacts with them every day I think they appreciated us being upfront with the challenges we also explained the three-year challenge to them as well I will say I think the reaction has been positive more than negative on that now am I hoping that's the case yes but at the same time I really believe as I go around and I go around a lot and talk to staff that they appreciate the fact that we're being open and transparent with them and we're not surprising them with anything else and we've been that with every staff meeting that we've had it's been open and transparent and I'll ask Christina she works with them every day I echo that we were a little fearful in the beginning you know when everything was occurring in January you know how would staff react and oh my gosh would we have a mass exodus and it's really been surprising we've been seeing the teams like we talked about really starting to break break down those silos even by themselves really jump into the cross training they feel that they're providing more value among their colleagues we do have some clinicians on staff which I feel are really now coming into their glory because they're able to really help work on the data quality they're excited to understand that we are getting back down to basics and we are working on these core areas I think that they understand that and they know what they're marching toward we're about the HIE steering committee they're excited to know that everybody's working on really communicating and really trying to define that answer to Mike's question which is what is success and do we all know what we're marching toward another thing that I'd like to add is that we're looking at incentivizing the staff in ways that don't really require any investment you know we had a piece of parter and party and a potluck and people brought in food and we celebrate we celebrate the wins and sometimes that those are some of the simple things that they just need to see to feel valued and feel that they're actually adding to something that they're extremely passionate about which is making sure that patients get the care that they need and that the outcomes are favorable for providers other questions or comments on the board now we'll open it up to the public any questions or comments yes I have a comment to make one for your question one comment is I heard Mike Smith make a disparaging comment about himself and I just wanted to reaffirm that he made many more mistakes in his leadership role not just that minor one that he alluded to having said that I want to go on the record of saying he was also outstanding in performing in his roles in state leadership having said that you know when you do a good job a lot more is expected and a lot more is expected now and there's just one issue that I just wanted to raise and maybe it's a question about 35 years ago I first walked into a health and welfare committee meeting and one of the topic was lamenting about the lack of standardization in reporting of healthcare and this over you know three decades or four decades has been the bane for a practitioner community but for the whole healthcare community and I would say it's one of those issues that tests vital ability to do something because after 40 years it's sort of still on the agenda with this token we're going to try to standardize more forms of whatever and what we still have is a mess so the question is is there any particular strategy you know other than calling on Superman because it's been 40 years of trying to simplify to standardize and to streamline reporting so that we could all benefit from it so when I think of standards so yeah you're talking about standards in reporting and some of that comes down to just standards in connecting and trying to get the data and so we have Emily Richards mention that we're working on connectivity criteria I think it was you Emily, sorry I hope it was Michael I apologize so vital has been working with Diva to come up with connectivity criteria that's enhanced that the Green Mountain Care Board will eventually review that new connectivity criteria that will be part of the HIE plan and part of that is to really establish standards for the state of Vermont based on standards that exist out there and there are many many standards and it is the bane of my existence and the best way that I believe that Vermont is positioned is to stay abreast of all of the standards that are out there and be positioned to be able to accept data in whatever standard that is. I'll give you one example of where this could have been an issue so the University of Vermont Medical Center wants to do that query directed exchange with the b-high and we were going to do a direct connection directly to their EHR epic. They have since decided to do that network to network query using the ONC standard which is called the e-health exchange. It is the same network query that's done by the Veterans Administration that I talked about through their EHR since we're already on that platform we've already meet those standards we could say to the University of Vermont that's just fine if you want to connect that way we're already set up to do that and we can continue on. So hopefully we can do that connection regardless of what standard somebody wants to connect by. Does that help answer your question? Can I move forward? Yes. Second Director of the Vermont Program for Public Health Care on slide 8 and I think this kind of dovetails with Ken's comments. I definitely see an opportunity from my organization's perspective where you have identified the importance of some expected outcomes and include improved patient safety and avoids medication errors but that is a particular interest because our organization currently is the subcontractor of the statewide patient safety surveillance and reporting system and if there's any way that data can flow in an unkindered free way that can help unburn in hospital personnel and make all of the systems safer for patients we are having helpers in that project and we look forward to an opportunity to thank you for this conversation. Thank you. Thank you. Any other questions? Seeing none, thank you very much. At this time we'll invite Sarah and Agatha to come down. Our presentation to get, there it is. Alright, thank you. So this first slide is really actually this is Sarah because my quality advisor to the board record. This first slide information that the board already knows to reiterate from prior presentations the requirement the responsibility to review vital budgeting for activities came to the board in 2015. So this will be our third review of vital budget. As Kevin mentioned earlier H-901 which is kind of in process in the legislature removes the responsibility to review for activities so Agatha and I as you saw we reviewed vital budget but not for activities today. That's something that we've elected to put on hold until H-901 has resolved. So today we're just going to walk you through the criteria that the board has in the past used to review vital budget and make a staff recommendation. So the criteria was adopted, has been adopted and it's a little different this year because there's kind of three moving parts. There's the HTS report, the transition to vital and then the pending legislation. So we recommend using that same criteria but looking at that criteria through the lens of those three moving parts. And specifically when you're looking at the criteria and this is what Sarah and I did as we reviewed the budget is to focus on transparency the alignment with the HTS HIE goals as described in the HTS report and stakeholder recommendations. So this slide lists one through four and we're going to go through each one of these slide by slide. So the first and I wanted to mention that there was a question during public comment about the board's role in the vital budget process and I think that the four criteria that we're about to go through kind of shed some light on what the role of the board is. So like the first criteria is transparency. And Sarah and I as we've been working on this we really keep coming back to the one of the goals of the board's role is a transparency layer that it brings all of this into the public eye. So in reviewing the first budget criteria the review process will be transparent and will incorporate public input. And in order to do that the transparency will be measured by compliance with the budget guidance that we sent to vital overall transparency of the budget process also it will include a 10 day public comment period. And so in our assessment vital has complied with the budget guidance they've been very timely and organized very accessible collaborative and so we feel that they've complied with the budget guidance additionally the public comment. So on a 10 day question to date there since today is the 9th 10 business days approximately so two Wednesdays from now. Correct. And it's a recommendation we can adjust that we can adjust that date. I think we had originally presented to the board a schedule that included a little bit less time for public comment but since the meeting on the 23rd was canceled we took the opportunity to extend that public comment period a little bit if the board is a mental person. Historically how many comments did we receive on what was due? I do not know. I off the top of my head don't recall having a lot of comments but at least I can flip back I don't recall it being heavily public. Obviously staff will review all of those comments and compile them and present them to the board again prior to any vote. So based on our review of FIDEL's budget and completion of the public comment period we would consider this criteria has been met. This first criteria. Any questions about that first criteria? So the second criteria is really about the alignment with our state goals for the EGE program and our health care system in general as well as the staff recommendations or stakeholder recommendations that Agatha mentioned earlier. So here we have some language that we shared with the board a few weeks ago in terms of our recommendation for how to consider that met and what we're saying is that in the absence of a current HIT or HIE plan we see the HTS document and those recommendations as the critical pieces that we wanted to ensure alignment with and Diva and Vitalans providing back the contract to us also included an actual matrix lining up how the deliverables of that contract meet the recommendations in the HTS report so that's something that the board's been provided with. And in addition we know that Diva and the HIE steering committee are working to develop an HIE plan which is due to the board in October I believe to support future budget reviews so that's something that we can kind of come forward. So based on these things I think Agatha and I would recommend to the board to kind of deem that met. Any questions about that criteria? Third and this is really more of a process point. The board's review must be structured in time so as not to impede Diva and Vitalans contract negotiations and one of the things that we did working with Diva and Vitalans this year was we moved our review process a little bit later so shortly the board's reviewed Vital's budgets in March before the end of the contracting period so Diva and Vital are still negotiating. We review the budget and then it changes and we need to do a review this year by delaying it until May. We've allowed them to have a completed contract that's already with their federal partners for reviews and we know we're kind of looking at a final budget so based on this we would recommend that that criteria is also met. And then the last criteria is that the process must result in board decisions that are sufficiently clear to enable Vital to do its work and Diva to support that work without requiring repeated clarification or intervention by the board. So in order for the board to make clear decisions sufficiently clear decisions they need sufficiently clear data and material and we've structured the budget process to get that information to you ahead of time in a fashion that meets those needs that you can make clear decisions. And so the board will ensure that written decisions stemming from this budget review are sufficiently clear based on that. In our review and the budget presentation today we consider this criteria is also met. So in conclusion Agatha and I would recommend that the board, pending public comment of course, approve Vital's FY 2019 budget as presented. Because the second half of the budget is kind of waiting on a contract that's not yet finalized we would recommend approving the budget with the caveat that Diva and Vital return in probably November or December about six months from now and that the calendar year 2019 contract is finalized so that we can receive an update on the budget. See whether or any major discrepancies from the budget that was presented today and kind of whether that makes any changes in the board's opinion. Any questions? Any questions from the board? If not, questions or comments from the public? Seeing none thank you very much. Thank you. And just it appears that we will likely be voting on this on May 30th. The potential data is scheduled for May 30th. Yes. So with that is there any old 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? So moved. Seconded to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you everyone. Enjoy the rest of this beautiful day.