 The first item on the agenda is the Executive Director's Report and move the fact that Susan is off this week. Our Associate General Counsel, Lynn Coombs, will be delivering that report. Thank you, Mr. Chair. Good afternoon, everyone. I'm gonna pinch hit for Susan this week. I just have three announcements to make. The first announcement is that our meeting next Wednesday, August 14th will be canceled. So we will not be meeting here. The following week, we will be starting our hospital budget hearings. The first one will begin on August 19th in Castleton. We will also have hearings on the 21st, 23rd, 26th, and 28th. The locations of those hearings do vary, so please check our website for more information. And finally, the last announcement that I'd like to make is that the board will be releasing its QHP rape review decisions for Blue Cross and MVP sometime later this week, and they will be available on the board's website when they are released. Thank you, Mr. Chair. Thank you, Lynn. The next item is the minutes of Wednesday, July 31st. Is there a motion? So moved. I got that. It's been moved and seconded to approve the minutes of Wednesday, July 31st without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor, signify by saying aye. Aye. Any opposed? Thank you. And the next item is a discussion with Vital. We'd welcome the team down, Mike and company. And whenever you're ready, Mike, you can just take it away. Okay. Well, thank you, Mr. Chair, and good afternoon. Thank you for the time to present this update report. Let me first introduce the panel. To my right is Andrea and Bob. To my left, you've gotten to know them from recent presentations. But a new face up here is Christopher Schenck. He's our relatively new director of technology and now relegated to the audience is Frank Harris, our strategic technological advisor, who has promised me that he would stay at least until I leave. So he will be here. Also, she hasn't arrived yet. She had an HIE steering committee meeting, but Carolyn Stone is our director of operations. She will be joining us in the audience. She's an integral part of the vital operations and anything you need to know about operations, Carolyn is the person to talk to. I just want to take a moment. Most importantly, did you put Chris through a proper initiation? Well, that's still ongoing. I've mellowed in my older years here. I just wanted to take a moment of your time to sort of reflect upon where this organization has been, where we are now and where we are going. Over the course of the last few years, this organization has done a number of things. First, it's reduced its state funding significantly. Well, at the same time meeting all of our deliverables that we were assigned in our various contracts. We cut costs by reducing staff and benefits, mostly at the executive and administrative level. And we spent time through technology planning and through initiative spearheaded by D.B.A. of tapping the bricks a little bit on our technology spend in order to seek ways to spend more effectively and efficiently, such as the collective services project that Christopher will discuss in a few minutes. Of course, during this time, we have, and I want to take a moment here, we have really pushed existing staff hard to make sure these necessary changes were implemented. And they could have said, we're out of here. The demands are too great, the sacrifices are too many, but they did. Instead, they dedicated themselves to making this organization better. And if you ask me what I'm most proud about during my short stint here at Vital, it is the dedication of the staff. Without them, none of what the progress that we've made over the last year and a half could have been done. A few years ago, you'll remember, or some of you will remember, we had only six days of cash on hand. Today, cash on hand is approximately 180 days. Bob will go over the finances in a minute. We build cash for two specific reasons, but there's another reason as well that I'll discuss in a minute, but for two specific reasons that we are now utilizing. First is to cover any operational shortfalls, our three-year budget plan called for us using approximately $180,000 of cash there, plus in this first year. So we'll be utilizing some of those cash reserves for that second. For cash flow purposes, we need to cover gaps between the need to cover expenses and when revenues come in for those expenses. For example, Vital is now covering the expenses of the implementation of the collaborative services project before the expected revenues are received. We expect to spend approximately 1.2 to 1.5 million of cash over the next four months before we can deliver the operationalized products. And our funding for those deliverables will be through a new state contract. In terms of other funding, we've started with discussions of the new 2020 state contract with the state of Vermont through DEVA. And we will begin 2020 contract discussions with other entities as well, probably in this month and next month. We are in discussions with other entities about expanding revenue opportunities. We think there are some significant opportunities out there for additional revenues. This, by the way, we will have to use some of our cash in order to ramp up the delivery of these services in the future until that revenue flows in. I don't have any specifics on it because that still is sort of in the planning stages on what we're doing. But in November, we should have more clarity in terms of those revenue opportunities that we are pursuing. Also, the legislature extended the funding, as you know, the legislature extended the funding mechanism for Vital for two years instead of the normal one year that a misguided Secretary of Administration put in a long time ago. The next few years are filled with exciting possibilities for the VEI and Vital, especially with phase one of the collaborative services project underway and phase two in the planning stages as we move forward. We're gonna be talking about a new consent policy, which you'll hear an update on later on and the possibility of expansion of services to assist in healthcare reform in this state. Of course, I will see the start of some of these projects but not their conclusion. A new leadership will take Vital to the next level of success. So let me update you on where we are in the search process for a new president and CEO. We have just closed the time period for the submission of resumes. We had a robust response is how I would characterize it. The board's executive search committee will begin reviewing those resumes shortly. I expect interviews to begin in September or October with the final selection targeted for the end of November or start of December. Start date is expected to be on or before January 1st. So I know, I have one more meeting, so I'm not gonna say goodbye. I have one more meeting, check-in meeting to say before you in November. At least they can know of. Yeah, at least that I know of. So I know I've covered quite a bit in just the introduction. Are there any questions before I turn it over to Bob? You're safe. Thank you, Mike. Good afternoon. I'm Bob Trinot, CFO of Vital. I'll be discussing Vital's year-end FY19 financials. We should note that these are unaudited numbers for FY19. They can and will change during the course of the preparation of our audit, of which the field work is slated to begin late October with a conclusion in time for our November review for the Green Mountain Care Board. So moving on to revenue. Our revenue is essentially on budget within a tenth of a percent of what we budgeted for the year. We completed 49 interfaces for our CY19 contract, which began in January. We still have another 40 left to go, but we have done a Yeoman's job of completing these projects, which are essential for ensuring connection between healthcare organizations and the VEI. In addition, we delivered data access for laboratory radiology and transcribe reports to 17 HCOs, that's out of a total of 24 in our CY19 contract, along with increasing connectivity by helping 10 HCOs meet tier two standards, which are a more robust connectivity standard. We just to roll back, we successfully completed our requirements for the FY19 extension, and that was from July through December of 2018. That was part of the FY19 extension. Should be noted that the completion of our contractual requirements required substantial effort, as Mike said, from the staff, and focused support from several contractors. Moving on to expenses, vital was below planned by around $800,000 for 14%. This was due primarily to vacancies in the administration and technology teams. We are filling those positions as we speak. Moving on, we also had reduced consulting costs, and this was due to a change in the recruitment process or the methodology for the CEO, that saved vital some cost by changing the approach. We also had reduced costs from health catalyst, and if the Green Mountain Care Board remembers, health catalyst was formally known as MEDICITY. It was acquired by health catalyst back in July of 2018. There, the expenses for interface work were reduced. We were able to consolidate several interface projects and save some money in that cost element. We also had no need for a contingency, if you'll recall. Our budget had $100,000 for a contingency to cover any unknowns that we hadn't included in the budget. And fortunately, we did not need to utilize that. And finally, as Mike had mentioned, we had a pause or a tapping of the brakes, as Mike likes to say, on technology spend in order for us to evaluate our technology projects and whether they could be incorporated in the overarching collaborative services project. For instance, we had about 140,000 for MPI improvement in our FY19 budget. That's just shifted into FY20 and is part of the overall collaborative services projects. Our balance sheet remains strong. Cash on hand, as Mike said, is 180 days. Our liabilities are very manageable with our current financial resources. The quick ratio for year-end FY19 is 7.8. So essentially we can cover our current, our liabilities with our quick assets which are cash and receivables by eight times. This positions us well to support the financial requirements of the new collaborative services project along with meeting the reduced funding in FY20 and also the development of new revenue sources that will need to continue us on our path of sustainability. So that is the sum of my presentation this afternoon. If there are any questions from the pre-medical board. Any questions? Maureen? Yeah, just a couple of questions. On the information technology, the 432 favorability, you've talked about some of that moving into the next year. Will those be overages to the 1920 or are you covering them in your current forecast? I think some will be overages and because they had originally been scheduled in terms of the implementation in FY19. So the implementation cost is in some instances a large chunk but in other cases, the majority of it we've absorbed in our FY20 budget. We had planned to do that work and it just carried on. If it didn't happen in FY19, that word just shifted into FY20 under our FY20 budget. As Mike likes to remind me, we have kind of the mandate to look at FY20 to bring that deficit of 182,000 down to zero by the end of the year. So we will be looking at opportunities within technology and also other cost elements to find any other savings that we can achieve. And then you've done a good job managing the balance sheet. The AR still seems high relative. I mean, are your terms more like 75 to 90 days or? That's a great question because the AR is made up of two large invoices one had been billed for May, which was around $660,000. And the other was an unbilled amount for June because the way that our cash conversion process happens is that we end the month we have until the 15th of the next month to provide the state with deliverables. The state will review that over a 10 business day period and get back to us with their acceptance. It's a very formal process, but it works very well in terms of our integration with the state on ensuring that they get exactly what they want and when they want it and in the form that they want it. But that cash conversion period is anywhere from 55 to 60 days. So what you're seeing is the result of two months where we have not been paid for those two months. Now, we haven't paid the May billing, so it's just a matter of timing. Is there seasonality at the end of your year to between billing and? No, I think I've always tried in my budget to put two months of receivables as into our budget. So that's kind of been noted, but to your point, yeah, is there seasonality? Yeah, there is because it's the end of the year and typically you get two months worth of receivables from the state that are unpaid and they paid May and we expect that they will pay June when our invoice is submitted. No, it looks good. I just wanted a couple of questions on that. Thanks. Thank you. Other questions for Robert? Okay, proceed. This is the new guy for the next week. That would be easy. Thank you, Bob. I'm happy to be here today and I'm excited to be working with you. As you know, planning for the collaborative services project has been ongoing for a few months. There has been significant progress since our last update in May. As part of this project, the shared master patient index is the first step. Vital is leaving and will be sharing with capital health in one care. In May, we indicated that we selected the Colorado's universal MPI solution pending successful contracting. That contract was signed in June and implementation began last month. For terminology services and interfacing, the collaborative services participants chose to partner with Maine's HIE Health InfoNet. The terminology services solution called term ATLAS was created by Health InfoNet and this part of the project will be led by Capital Health. The selected interfacing solution is wrapped to be hosted by Health InfoNet. We are currently completing a single contract with Health InfoNet for both services. A new data platform has been added to the collaborative services project as a second phase. Vital's efforts with the previously presented future platform has positioned us well for this project. Currently, Vital is leading the collaboration and is working with Capital Health to begin the RFP process. The data platform will be a shared healthcare repository for the Vermont Health Information Exchange, the Vermont Clinical Registry, and the one care data mark. Importantly, this platform will be available for additional partners in the future. We look forward to continue sharing our progress of the collaborative services project. Now I'd like to move on to data security. At Vital, security is our top priority. We'd like to share just a few of our enhancements over the last six months. During the months of February and March, we completed one of our regularly scheduled comprehensive vulnerability scans, raised the bar of our security framework, and collaborated with the Agency of Digital Services through an extensive technology review. In April and May, we began encrypting our email, enhanced the protections of Vital's internal data files, and implemented improvements suggested by the ADS Technology Review. Finally, over the last two months, we established a process of managing vendor risk through security assessments, our completing the implementation of off-site backups for our data center, began developing a business continuity plan, and submitted an RFP to several vendors for managed security information and event monitoring systems. As the security at Vital enhances, our progress will continue to be shared. Does anybody have any questions? Questions? Well, we're letting the new guy out pretty easy. Yeah. Thank you. Interesting. Thanks, Christopher. We have some metrics to share with you for the month ending June. Vital's dedicated, the Vital team, has dedicated almost 600 hours to meaningful use and security risk assessment consultations. This work is primarily focused on improving the data quality of information entered into electronic health records, as well as assisting healthcare organizations and providers in their efforts to qualify for the electronic health record incentive payments. Our quota for each month is 80 hours, just as a reference point. The percent of Vermont patients providing consent continues to increase. We did hit our target rate of 42% at the end of May, and we'll continue to provide you updates. As time goes on. Regarding connectivity criteria, and more mostly focused around work plans, we have a target of 89 work plans to be completed by the end of this calendar year. Currently there have been 59 completed, and there are 63 in progress. So we are anticipating that we'll be well above the 89 by the end of this year. Something we're really excited about are the number of locations meeting tier two connectivity criteria. We have 10 locations that currently met that threshold, which is really exciting, and that really means that the organizations are capturing common data elements, and those elements are being transmitted to the BI. Moving on to point of care utilization. In our efforts to expand access to data, as well as improved utilization, there were 3072 queries or 27 queries at the end of June for the web-based vital access provider portal. This is actually almost double of what it was at this time last year. Moving down to the red and purple, cross-community access as well as single sign-on are the newer ways to access information, and those are incrementally improving as well. Provider results delivery at the end of June over 100,000 live results, radiology reports, and transcribe reports were delivered to 448 providers, and there is a little over 740,000 total messages for the beginning of the year, January of this year. That's all I have for updates. Are there any questions? I'll start it off. What are the reasons that you see for a reason why a work plan that's in progress doesn't reach completion? I think it's more of, not that it won't reach completion, but of timing, and that it takes a while to assess the progress, and the engagement of the organization is also important to identify the criteria that's needed. So far we've been really, really lucky and happy with the level of engagement with organizations and their willingness to work with us on identifying the data elements that are needed, and then making the changes, because it does take time. Okay, so it's just a matter of when the calendar year falls? Okay. Yes. Questions? Tom. Yes, I'm going back to your percent of Vermont patients providing consent, and I'm looking at the 42% bar that you have here, that threshold which you've crossed. I'm just wondering when we might see a new bar, and I know there's some variability there in terms of the consent process, and which way that ends up going down the road, but I'm wondering when might we, now that we've crossed the 42% barrier, when might we see what the next target is? Sure, that's a good question. This is actually our 20, in the 2020 contract is when you'll see the new bar, because this was actually a calendar year 19 target. So we were actually ahead of schedule. We hit that in May, but we actually have until December to achieve it. Does that answer your question? Yes. Well, I think the bigger question though is, if there is a change which there is in the policy, what is the ultimate goal? What do you think is achievable? Well, I think that it's going to be a completely different goal because we are now, so if we take the percentage of our monitors who have been asked, 42.86 and 95% of them choose to opt in, and 95% of them choose to opt in, we expect the rate to be around, the national average is around 95%. So it's hard to say right now, but we expect a high percentage of patients will remain opted in and a low percentage will choose to opt out, but it's hard to know. We're still really in development of, we're working with Diva and collaboration with Diva to identify different deliverables and that will be in the next presentation. Some of that might be in the next presentation. So I think in the last discussion on consent, I had let it be known that I had never been asked to ever even consider consenting in that my primary care doctor was retiring. Since that time, I do have a new primary care provider and I didn't want to lead them, so I never asked, but once again, I was never shown a document to opt in. Mr. Chair, I think it's reasonable to expect that you'll see this in the 90s when we switch over in March. How long will it take to reach that 90s? Well, because the policy is changing to an opt out, everyone will be in until, or if they've already chosen to opt out. Does that make sense? I think you're gonna see it fairly soon. It's a low percentage right now. Right after the March implementation. Okay, great. It's confusing. I just had a question on, do you have any technical concerns of that cut off date and all of a sudden it's switching from the opt in to the opt out and how are you guys prepared for that? That's a great question. And actually, I think I'll be here for the next presentation and we have a whole slide on that if it's okay to defer to that. We don't have any concerns at this time if that answers your question now, but we'll get into more detail. Okay, thanks. Jess. You mentioned working with locations that on data integrity and the quality of data. So I'm just wondering, are there common mistakes that you're seeing across multiple location trends and can you identify those and share with the other locations that you have not reached out to, so speeding up the data integrity process that happened? Absolutely, there are some common things. Actually, coincidentally I had a client reach out today and say, by the way, we have a patient with the wrong middle initial entered into our system and how do we get that fixed at vital? And the answer is the source system, your electronic health record will need to be updated and once those are updated, the messages get transmitted to the V-High and it's corrected. So those kinds of things happen all the time. In terms of common patterns, it's a little bit all over the place, but this part of the work that we do and it seems to be very valuable for providers and organizations because one wrong initial, one wrong letter can make two patients when they really should be one. I'm just wondering, is there a mechanism by which you're noticing some of these trends and disseminating, hey, these are five things you should be looking out for in your data. We think with the new external MPI, we're gonna have a lot of capabilities to do exactly that, to reach out to organizations, say, hey, we're seeing these trends, you may wanna take a look at what is going on here, but with the external MPI, it gives us a whole new range of capabilities to do things like that. And the timing of that? We hope to have that operational by the end of the year. Thank you. Other questions? I just have one, also on the connectivity requirement and criteria, are the 10 locations that you listed in slide 13 all hospitals or what type of provider organizations are less if you happen to know? Those are minute locations. Okay. So primarily practices, but right. Yeah. I didn't have one of them in question, let me just remember what it was. Oh, on the point of care legalization slide, can you remind us what the cross community access entails for the provider? I know with the vital access, it's a web-based system. People go to the web and sign in with the single sign on it's implemented with the DHR, but what's the third one I'm not remembering? Cross community access is a deeper level of integration. So if you think about it in the context of reaching out across the community from within your EHR screen and pulling back information about a patient, that's what cross community access is. Great. Thank you, Amber. And then lastly on the provider results delivery, it looks a little bit like this is a downward trend. Is that normal over the course of the year or is that connected in any way to the increase in the EHR adoption or what's going on? It's a great question. What we're seeing, I expect we'll see slightly downward trend over the year here, but this is primarily due to practices integrating into a hospital electronic health record system. So they're merging essentially and they don't have the need to get external results delivered because now they're all in one system. So we'll probably continue to see these trends as organizations consolidate and try to be more efficient. Thank you. Sure. Any other questions? You say, well, you have questions for me, thank you. No. Do you have any closing remarks to say before we open it up to the public? We're fine. Okay. Public comment or questions? Yes, Dale? 11, being produced in security risk assessment of consultation. March shows 103.5 hours for seven sites. If you look at the overall trend, it looks like there was probably average how about 10 hours per site. If I'm talking about all the six months together, I was just curious why is there something else in here as to why seven sites took 103 hours? Whoever wants to go ahead and answer that. I just want to make sure I understand your question. You're wondering why there are only seven locations in 103 hours? Yeah, because if you look at the other, you've got 97 hours for 10 sites. You've got 90.75 hours for eight sites. You've got 88.75 or eight sites. So you're sure. It's a high concentration. Yeah. I'm wondering why it's not a liar. Sorry. It may not be, that's why I was asking. Right. Now, it really just depends on what's needed and the work in the projects that we're doing with those clients at the time. So some take longer than others based on their needs. It's hard to predict, but we make sure that, so you will probably likely see a continued high concentration of a lower number of sites in a high number of hours. This is a tremendous amount of time each month to try to ensure that the quality of the data is captured in the right area of their mental record. And then the other piece of that is it being transmitted to the high? And are there other measures that that provider needs to meet in order to qualify for some of their other incentives? Does that make sense? Yes. So are there specific sites that are proven to be really challenging? Not necessarily. I think it's more just in the interest of continued improvement and learning the system. Thank you. Other public comments or questions? Susan. Susan Aronoff from the Vermont Developmental Disabilities Council. And I have a question about something that wasn't covered in the slides, but I thought that I had heard about it in the past as part of the vital rebots, vital tumor. Which is the concept of a patient portal. So I was just at a gathering with some healthcare consumers that you're gonna be hearing about in the next section like at Eva sort of reaching out to stakeholders. And that question came up a number of times. People said, well, I really like to be able to see what's in there and make sure it's accurate. Because so often my record isn't accurate. And so that question, it's come up before. If you have a plan for a time then for mothers who will be able to see what's in their own personal information to be in there. It's interesting because I've been asking the same question on the patient portal. What I think we can, what we wanna do is get through phase one and phase two first. Phase one being the implementation of an MPI, the terminology services, getting into the interfaces and the entrance of the interfaces phase two being sort of the database that we share in this. But it is not off our radar screen in terms of what we would like to do in the future. Of course we wanna make sure that we do not sort of confuse the argument with what patient portals are out there for the individual healthcare centers. So we're gonna have to be delicate in how we do this. But at the same time, it's something that we've heard now from you and others that would be something that would be a benefit to Vermonters and we're gonna be looking at it probably in a third phase here. I think it would help with the confidence building that people might need to opt in but even in the new scenario come March when people are just gonna be in automatically if they're deciding whether or not to opt out they might wanna look in and say, hey, it looks pretty good to me or uh-oh, that's not my name, that's not my initial I better use the other one. Yeah, that's a good point and just to elaborate on that a little bit more I don't wanna steal this under the next presentation but at the same time we are looking at ways in for them for a better mechanism in order to look at that information and look at ways to either opt in or opt out. Well, opt out. Is the biggest hurdle really trying to protect the security of somebody accessing someone else's information? That's one aspect of it and making sure that we do have the security mechanisms in place and the other is just pure timing and getting up to where we need to be technologically in order to do this. We've come a long way in a year and a half I would imagine in a year and a half you're gonna see a huge leap in our abilities to do various things. Other questions or comments from the public? Now I can promise all that because I'm not gonna be here. So. We won't make the other three people sitting at the table make the same promise. So I guess that's it. Thank you very much. Thank you. Another great quarterly update and things are moving in the right direction. Thank you. So at this point we're gonna welcome Jenny and the team from Diva to come down and whenever you're ready Jenny take it away. Carmella and other members of the board thank you for having us. We're very excited to share with you the progress that we've made in terms of both developing a plan for implementation of the transition from opt out consent or opt in consent to opt out consent. I'd like to, before we get started at least introduce the team members that I've brought with me today. As you know from the past typically it's Emily Richard who runs the HIE program within Diva who would do these presentations. In her absence while she is on family leave we've got Terry Beckett who has worked with the state before and previously has had Emily's position many years ago but since then has been a consultant to the office of the national coordinator who's been working at the national level on health IT programs. He is helping to lead up the team in constructing the HIE plan this year and also in kind of overseeing the consent process. In addition to that I've brought with me Maureen Gilbert who is a consultant to the department of Vermont Health Access and has been for many years on stakeholder engagement and really has been leading up the stakeholder engagement process for us and you know Andrea. So from here I'm gonna let Terry go ahead and get us started in terms of what our progress update is but before we do do you have any questions for us before we get started? Not before you start. Okay. Okay, so can you hear me okay? We can. Great, thank you. So today we're providing an update on the Diva-led activities as called for Act 53. Diva has specific responsibilities in Act 53 for section four which is to help the information technology plan. And section five which is the the HIE, the opt-out consent policy and the implementation of that. So we're doing a general overview of the requirements and our approach and then we'll go into more detail on the different work streams that we've identified. We've identified three work streams. Stakeholder engagement, mechanisms and evaluation. I'll sketch those out very briefly on the next slide which we can go to now. And then we'll individually talk about those in a little more detail. And of course, feel free to raise questions as we're going or however you prefer. So for a consent we've identified three work streams. The stakeholder engagement work stream is perhaps the most important at least for now and certainly the priority. We're trying to meet the requirements of the Act which is the substantial opportunities for public input. We're creating patient education mechanisms. And then the big part is enabling patients to fully understand their rights regarding sharing of their health information and then moving into mechanisms. We have to identify mechanisms for which reminders can easily opt out. And that of course is why Andrea has stayed on for our portion of the presentation. And then evaluation, we want to evaluate the overall effectiveness of our work. So just one more brief comment on stakeholder engagement. We're doing that to develop the best possible strategy for getting a message out and thinking into account of people's ability to hear the message and who should help deliver the message and Maureen will talk in more detail about that. And of course just a reminder that we have reporting and accountability built into the Act. So we're here with an August one. We have delivered the first legislative update to you. We'll be back in November one with another update. And in January 15th, a final report about the implementation and of course the actual rollout occurs on March the 1st. In between there, we also do annual reporting again on the November one for the health information exchange strategic plan update, which per the Act has to include some elements of what we're doing with the consent policy. So with that, I think we're ready to start talking about stakeholder engagement and Maureen will go with us. Hi, so I'm just going to start by orienting all right, so I'm going to talk a little bit about the requirements that we have for this process and then we'll get into the timeline and how it's been going so far. So Act 53 requires that we communicate with each remandor and you'll see that language each. We're going to come back to that. I think that's important. A number of different things. We need to communicate to them the purpose of the Vermont health information exchange, the way in which health information is currently collected. How and with whom health information can be shared using the Vermont health information exchange. The purpose for which it can be shared, how to opt out and how patients can change their consent status in the future. So that's quite a list of communications objectives for us and we're doing a deep stakeholder engagement series in order to understand how we can achieve those objectives. We're also starting in that process to think about, of course building awareness early, starting now we're working on building awareness through this stakeholder engagement series and we're also getting commitment from some of these organizations who are advocates for special populations that we're trying to reach. Their commitment to act as messengers here. We know we can't get this message out to each remandor without commitment from all of the advocacy organizations that are interested and many of our partners in the state. So our timeline here, it's an aggressive timeline. We are already in the stakeholder engagement process that's gonna continue through November. There's a couple of different phases within that. From November to December, we're also gonna be finalizing messages and materials design and beginning production there. We'll be rolling out to messengers a toolkit and training in December and January and then pretty quickly start in public communications through those messengers and also directly from the state. In February, right before consent, the new Consent Policy takes effect. We're gonna be intensifying that message just in those weeks ahead of time so that people really have a good opportunity to make a choice ahead of the Consent Policy being implemented. All right, so a little bit more depth here about the stakeholder engagement process, that period beginning in June, July. So the first step here and one that we've already taken is to interview advocates for the rights of all of our monitors and that's included the ACLU and the Office of the Healthcare Advocate. We've also spent some time identifying the special populations and special populations here are groups that we think have members with concerns about sharing their health data and who have told us that they have members with concerns about sharing their health data for reasons of stigma, for instance, that could be people living with HIV AIDS, reasons of personal safety, for instance, people who have experience of domestic violence and then special populations who may just require a different approach in terms of our communications to make sure that we really reach them and help them to understand the messages here and that includes people who have developmental disabilities and people who have other languages, who their primary language is not English. So we've been working to engage those special populations starting with their advocates. So first going out to advocates, Susan for instance has been part of that process and talking to people about how they might participate in being messengers, how they might consider participating in actually administering the opt out for their members on behalf of their members so that it's not something that just has to happen at providers offices but advocacy organizations might be able to participate in that and then asking them to really gather some of their members to engage in interviews and focus groups. So we can really learn directly from the people who are gonna be impacted by this change. Then in this July to September period we have our first round of interviews and focus groups with both special populations and members of the general public and through these interviews and focus groups we're really looking to understand people's communications needs. What questions they need answered in order to make an informed choice about staying opted in beginning in March or choosing to opt out and then how best to reach them. So we're really asking people, where do you wanna hear this message? Where is it gonna feel most relevant and how can we best reach you? We're then looking and really excited to go back to many of these same groups in October, November and do a second round of interviews and focus groups to test the messages to make sure that we're achieving the objectives of this clear messages hitting all those communications objectives that we mentioned earlier. And then starting to both test the opt out mechanisms that we're putting in place in March and use these groups to design future opt out mechanisms. We know that we have sort of an idea of the mechanisms that are gonna be in place in March. We have a good idea and Andrea will talk you through that later. But we also know that we wanna continue working after March to make sure that this is as easy as possible for every Vermonner who wants to opt out. So we're gonna use these interviews and focus groups to do a bit of design work with them. And then we know that our work is not gonna be over in March that we're gonna need to do ongoing learning about how best to communicate with people about their health information and continue to optimize our messages and our channels so that we have really clear messages and that we're reaching everybody and that that mechanism is easy. Any questions before we tell you just quickly about who we've engaged so far? All right. Sure. So I watched the legislation unfold and when I read the phrase each Vermonter I was kind of trying to in my head envision how you would ever reach that goal but knowing that this board would want to set a bar as high as possible to make sure that people are educated about the consent policy. I'm curious how you've interpreted what the phrase each Vermonter means. So why don't I tell you a little bit about how we think we might reach each Vermonter or as many Vermonters as we possibly can. And then I think we should continue to talk about sort of the definition of each here. But if you just reach as many Vermonters as you possibly can, will you meet the legislative intent of each Vermonter? Oh. No. I think that that's been one of the largest questions that we've had when we've met with the ACLU and the Office of the Vermont Health Care Advocate. I think it's not clear if you take it for face value each Vermonter, that means getting a message out to every single Vermonter in Vermont. And there's a Vermonter, just a Vermonter in Vermont. What if they're in the Peace Corps in Somalia or something like that? Exactly. And so as we go through this process, we're trying to define strategies that we feel will most closely get to that. And we believe that through our evaluation mechanisms, we will go ahead and test whether Vermonters have really received the information, have they understood the information that they've needed, and do they have the mechanisms in place. And that will allow us to help set the benchmark for whether we feel like we've achieved each Vermonter, you know, whether we can achieve the goal of making sure that every single Vermonter has received the information in a way that they can understand it is yet to be determined. I have a follow-up question on this topic, so I'll ask it now. I didn't notice an appropriation in the act. Was there anything in the budget to support this effort? We have applied for some funds through the IAPD to support some of the outreach efforts. Through the what? The IAPD still requires a 10% state match, but was there new funding in state match? There was not new funding appropriated, no. Thank you. You gotta help us with this. Were the anachronistically challenged individuals the board? Kevin, I'm gonna have to call a friend on that one. The reason I use the acronym is I can't remember what it is. I don't remember what it is either, but it's acknowledging that it's a 90% match from the feds. Thank you. Now I know what you're talking about at least. I don't think the acronym actually would illuminate anything more than that. No, I don't think that it would. Thank you. Other questions from the board? That's what I had on. Okay. And so the way that we're thinking that we're gonna go about reaching as many Vermonters as we possibly can is sort of a three-fold communication strategy. And the first pillar of that strategy is to really use the advocacy organizations and other organizations that we partner with regularly to work directly with their members. So people who already have trusting relationships, who already have communications channels, be it newsletters, social media feeds, and really leverage those channels as much as possible to reach all the special populations and then actually Vermonters in general populations as well. So we've got our messengers who we're working with. Then we've got the providers and the provider organizations. And we know, and we'll talk a little bit in a second about how important consumers, Vermonters, think it is to hear about this from their providers. So we really wanna make sure that message is getting delivered in the provider office. And then the third pillar is sort of broader public outreach. And knowing that we don't have a ton of funding on this, we're not talking about television or much-paid media, but we are talking about things like pitching to the news, making sure that this information is widely available through news and through just some tactics like front porch forum. We'll certainly come back with a more detailed list of tactics as those develop as we learn from Vermonters where they'd like to hear this. Could you consider what Maine did with a direct mail? You know, we have thought about mail and we're hearing different things from different advocates that we talk to about whether mail is an effective strategy and we haven't decided whether or how much to use mail. For instance, I was speaking with some advocates on behalf of older Vermonters earlier in the week and they were saying, you know, we have some folks who just aren't online and we need to find other ways of reaching them. And one of the ways that they've done that historically is through mail. But we've heard the other side too. Yes, for example, the ACLU specifically did not feel like that would be an effective mechanism to reach each Vermonter. Well, probably not in and of itself, but as part of a larger strategy. Go ahead, Robin. I was just gonna say, I mean, you wouldn't have the addresses of every Vermonter within your agency. Yeah. No, but as somebody who has run a campaign before, I know that you can go to the post office and buy each address without having to know and it's actually cheaper. So, yeah. So, Kevin, I think one of the things that, or Chairman, one of the things that you are highlighting for us is that we are not, we are planning on taking a multi-pronged approach. And that's one of the things that we think is very important in this process in order to try to reach our goal of each Vermonter and also to meet the needs of special populations. Thank you. All right, so just quickly letting you know where we're at in this process so far. These are the stakeholders we've engaged. You'll see that we have a column here for the advocates we've engaged and another one for the ones we've actually conducted member focus groups with so far. We are really open to hearing if there's another special population that you think it's important that we connect with. We're always open to expanding this list. I'm curious about what contact it means, like how did you contact teenagers? Oh, so this means contacting the advocates who are working on behalf of teenagers. For instance, Spectrum is an organization that we know works. So that brings up my second question. How geographically diverse is your reach out because Spectrum obviously doesn't cover the entire state, so. Sure. So something we wanna be mindful of, we've certainly worked with some organizations who are not Chittenden County based so far, but we can think about that as we develop the remainder of the focus groups. And many of the organizations that we have reached out to at this point in time represent the state and are helping us to identify where communities might be best to outreach to. And we will take that back as a special focus on ensuring that that's geographically diverse. But most of these other than Spectrum represent a statewide presence. We've also got the box check that says general public. How did you check that box? Sure, sure. So we're doing some focus, well the advocates for the general public we're thinking of as the Office of the Healthcare Advocate and the ACLU. In terms of members of the general public, our first strategy here is to work through the blueprint community health teams and have them recruit people on our behalf for focus groups. And so far we have done one in St. Johnsbury and have one planned in Burlington and are working to add more here. Maureen, I think it's also worth noting that in our second phase, we plan on doing much more public forums that could potentially be scheduled around the state to not just go through the focus group process but to engage a broader public. One of the things I just, I'll add when I read the legislative report, I was a little concerned because it didn't specifically reference mental health services and folks with substance use disorder. And I'm really happy to hear that I was seeing here, I was gonna bring that up today. So I don't know if there's a mechanism by which you might amend the legislative report to include both of those stakeholder groups because I think they're really important and I think they're obviously included so. Yeah, I think that brings up a bigger question for me and see if this would assist. Is there, as this moves forward, one of the things that we're doing is as we talk to different advocacy organizations and different groups of people, they are highlighting, and we're hoping you will today as well, highlighting additional populations that we should be reaching out to or different advocacy groups that we are reaching out to. So this is an initial list, but it will be dynamically kind of snowballing forward as we go and as is reasonable. And what you saw from one of Maureen's slides a few back, we do believe that this is gonna be an ongoing process. As we complete the evaluation results, we will identify additional potential mechanisms that we need, we will identify additional populations that may not necessarily have been served or are very well-served, and so we believe it'll be an ongoing and iterative process. So let us think through some mechanisms to keep you and others informed of who we're reaching out to. Yeah, and I think that's fantastic. I'm wondering is there a mechanism through your website where you can be not only updating, continually updating this list, but soliciting feedback and input from various folks. That's a great idea. Yeah, take it right back. One of the groups that sticks out initially is the faith-based community. And I take a look at Vermont having one of the higher populations as a percentage of people who are investing in health sharing ministries rather than insurance. And when you talk to those members, one of their biggest reasons is they don't want their information out to anyone. And I think that that conversation is going to have to occur. I know it's a small subset of Vermonters, but certainly winning them over to having their information in the database in case they are in a situation where it could be really helpful to them would be a valuable conversation. It's very helpful, thank you. Just one question on if you have any learnings from other states, because obviously a lot of the other states are already running this and we've heard they're about 95%. So the 5% that aren't in the program that are opting out, are we cross-referencing that to make sure we're capturing those people that may not want to be in? Part of our process and one of our steps in the process is outreaching to other states as we identify needs to find out what they've done that's been successful as has been identified. We don't have a large budget. We don't want to recreate the wheel if another state has already done this and done it well. We want to learn from that. And so in that case, Vital has done some outreach as has Diva to begin to make inquiries to other states. We also are tapping into resources we have here within the state. The Department of Health has a significant level of experience at doing statewide campaigns to get information out as has Vermont Health Connect. And so we are leveraging and using their experience to begin to consider the mechanisms that they use to get the word out and that they've learned have been successful and not successful because we don't want to repeat mistakes that the states have already done. There's a lot out there. So it's just not out there. So that's a great idea and we'll definitely make it more robust, but we have started that process to reach out to other states. Another great stakeholder group that you could engage is the business community. When you think about all the different associations that have newsletters and things like that, it would probably be an easy way to try to get the word out to a large group of people. Yeah, insurers is another one that's not on here. As Diva, both acting as the oversight as the HIE, but also as an insurer, we've begun to engage our peer partners as a way and also to engage their businesses. I didn't have a couple other suggestions for groups based on the legislative report, so you may already have reached out to these folks, but I was noticing that you had cultural brokers program, but not Vermont Refugee Resettlement. So I was gonna suggest that for folks with safety issues, the network against domestic violence could be a good partner. Maybe you've already reached out to them as well. And then the other place I was thinking is maybe the community action agencies that they have statewide presence as well. That's a good idea. And before we wrap on stakeholder engagement, we just wanted to let you know a little bit of what we're hearing out of the first set of focus groups that we've done. It's only been three, so I wanna be very clear that we could come back here having done six more and have a completely different story, but I think it's always interesting to hear where we're at so far. So far we've spoken with people with developmental disabilities, we've spoken with people living with AIDS, and we've spoken with some members of the general public who are patients of a community health team. In doing so, we've heard from everybody really across the board that they are not aware of the Vermont Health Information Exchange. And to a large extent are not even aware of the rules around how their information is shared in their health information is shared in traditional ways. So, is my doctor allowed to share information with another doctor via phone and fax without my signature? That is not something that everybody is really clear on yet. So we've got our work cut out for us in order just to get to the conversation about consent, opt in, opt out. There's a lot of questions as we're bringing up this message, is this about my insurance? Folks here at Vermont Health, they hear Exchange, they automatically go to their insurance. So we're gonna have to make sure that we're really crystal clear that this is about health information sharing, not about your coverage. We also wanna make sure that we don't worry anybody in bringing this up, that there's nothing that's going to change for you, that you have an option to opt out, but if you do nothing, everything continues as it currently is in terms of your coverage and your care. That's important to folks. We're hearing a real desire and expectation that providers know you as a patient and your care of history, we're hearing that loud and clear and folks really would appreciate not having to tell their story again and again, particularly the nitty gritty details, their medications, their allergies, really wanting to get quickly to sort of the heart of the conversation with their providers. And so welcoming the Vermont Health Information Exchange's ability to do that for them. Number of questions about who can view my data. So we're gonna have to be very clear that this means your treating provider can view your health information and it's not any provider in the state. It's not anybody within a healthcare organization. People want to know who it is and what the rules are around that and what the protections are. And lastly, where does this information come from? Folks have lots of ideas for us about tactics for reaching out, but their first choice messenger is almost universally their provider. We know that that's gonna be a challenge and that it's in fact may not be possible within the span of an appointment that a patient has with their providers. But if that is their preferred method, we need to think about proxies for that and how we get as close as we possibly can to that goal that they're stating of a healthcare provider sharing this information and their rights and options with them. Any questions before we finish? Let me just jump before you jump off so it's stakeholder for a second. I'm just thinking about the process of you've engaged stakeholders and the stakeholders will be a mechanism by which you disseminate the messaging. And you're providing some of these toolkits and webinars and training, but I'm imagining as the stakeholder list grows the number and diversity of agencies, organizations, advocacy groups that are disseminating the message. How do you think about ensuring that all of the information is accurate, is you're gonna provide these toolkits, but to some degree, you're relying on the training working and the toolkits working to get the message out correctly by lots of different groups, is that what you're talking about? So I'll start and I'll let Maureen add on to that. Based on what we've heard so far in the initial three focus groups, it is still the provider community that they prefer to hear information about how their health information is exchanged. We will, I believe in our initial, if that continues to be the case, I believe in our initial approach, we'll focus on the provider community but expanding that a little bit. So looking at our mental health providers, the folks who are providing services for individuals with developmental disabilities and who are helping to support individuals in receiving their health care through programs like the refugee resettlement program. So we, I think that we will have to pick and choose in this first year who those messengers are to ensure the quality messages and focus. That said, we do believe that in order to gather the information through the stakeholders, it is important that we engage a large number of stakeholders and advocacy groups in hearing those best messages. That makes a lot of sense, okay, thank you. So I know you have some questions on the mechanisms, so we'll turn it over to Andrea from Vihl. Thank you. I only have one slide. Okay, so this is primarily the focus of Vital's work is to expand the opportunities for remodlers to easily opt out of the Vihai or opt out of having their information viewed through the Vihai. The work that we've done so far, I believe Governor Scott signed the bill on June 10th. On June 20th, we assembled the team and have been meeting on a weekly basis, at least weekly since then. We developed a comprehensive project plan that includes the critical elements to a complex project like this, including updating our policies and procedures to reflect and support the new legislation on March 1st of 2020. We're currently identifying use cases, workflows, and really ensuring that the proper security measures are taken to verify identity and those kinds of things are cared for. We also need to update our consent education materials. Very important, and we will be collaborating a lot with Diva, Maureen, and Jenny, and Terry on these types of things. And then moving on to the next bullet, maintaining continuity of previous consent decisions. This is super important for patients that have previously chosen to opt out of the Vihai that after March 1st of 2020, they remain in an opt-out state. When it comes to solutions, design, and documentation, there really are two parts here. There is a technical configuration in our current provider portal that currently supports the opt-in policy. On March 1st of 2020, that technical configuration needs to be changed to then support an opt-out consent policy. So that's the first piece. The second piece of this is to allow the Vihai, or vital, to collect patient consent and to expand the opportunities for patients to easily opt out of the Vihai. Currently, the only way a patient can choose to opt in or opt out of the Vihai is by visiting a participating healthcare provider. In the new world, on March 1st of 2020, this really ties back to expanding the opportunities in addition to participating healthcare providers. Our goal is to provide other opportunities such as with engaged stakeholders that will be informed about the process and to provide guidance to the people that visit them and then get information to vital to then care for that patient's consent decision as well as offer the opportunity to visit the website that we have available and make a consent choice request. This is really very much in development and as we get more feedback, we can adapt. But we are on target at this point in time. We're on target to be ready for February 1st, which is one month prior to the effective date, which I believe is in Act 53. I said a lot, but do you have any questions? Questions. Continue. I'm sorry. Go ahead, Robin. I know you mentioned, it makes sense that in the web-based portal where providers are going to vital access to look at it, that you'd have to reconfigure that. Will you have to change something in the EHRs that have been configured to have direct access as well? You're talking about the electronic consent collection. Yeah. Yeah. So that's part of this. Great. Thank you. So very briefly, let's talk about the evaluation methodology. So the Act requires us to identify a methodology to evaluate the extent to which all of the public outreach that we've just been hearing about, we have to gauge the extent to which that has been successful. So to do that, so far we have identified the four core questions that you see here. Very fundamental to the process and to the purpose, which is have we reached people? Is the message clear and is it understood? Are the opt-out options easy? And which providers are offering opt-out? So to pursue the methodology for getting to these questions, we've identified so far the Statewide Patient Experience Survey as one source of being able to measure this. And we've established a planning group inside Diva, an ad hoc committee basically. And the plan will be developed and will be incorporated into the health information exchange strategic plan that is due to you on November 1st. So that's how we'll be communicating the evaluation plan to you. Can you tell us a little bit about the makeup of the eval committee that we'll meet in September? As part of our stakeholder engagement process, we are asking folks who they believe would be able to help inform us in terms of our evaluation methodology. Right now, this is our work stream that has the least amount of development. And we've convened an internal team to define the stakeholder process that includes vital. Vital has been a key partner throughout this entire process. It includes representation from the evaluators from the blueprint for health, we're drawing from the staff that we have internally and the folks that you see here. We have yet to engage stakeholders, but we'll be doing so shortly. Do you have an optimal size? Something that's manageable. Sounds awesome. What do you believe that is? I believe that that optimal size is probably around 10 to 12 individuals, but also similar to the way that we have sought stakeholder feedback through the rest of the process, engaging the rest of these organizations to vet the plan. I should build on that for a quick second. I'm just thinking, if the primary vehicle through which a lot of the consent education is gonna take place really is the provider community, as you all have mentioned. I'm thinking that engaging organizations like the Vermont Medical Society, Health First, VOS really early on in the process, and particularly in the testing of the messaging and in this evaluation process would be really helpful. Then you probably have done that, but I just wanted to throw that out there. Yeah, I think that that is really helpful. One of the things that I will say that we have not mentioned to date is that we are giving regular, the Health Information Exchange Steering Committee meets every other week, and we have representation from a broad set of stakeholders there who are also providing us guidance and feedback. So I think that that's worth mentioning here, and we definitely will take back the question of how to even further engage the provider community. Thank you. Are you fully confident that you'll have a solid plan for us on November 1st? Yes, we are on target. Okay, questions? I had a question about the, and you may not have gotten this far in your evaluation planning, but what you were thinking in terms of the timing of the evaluation, because obviously I could be free to ask you to prevent the methodology by January, but you won't have actually gone through the implementation to do the evaluation of the implementation at that time. I don't wanna presume what the evaluation process will look like at this point in time. What I can say, and the reason we put one of the predominant mechanisms up here is the Patient Experience Survey, is that during the legislative process, we started to ask this question of how do, rather than checking off whether each provider has informed each patient, which wouldn't necessarily answer these four questions, are there other mechanisms? One of those mechanisms is the Patient Experience Survey, and we will have initiated that before the January 15th report, and are hoping to have some baseline results, maybe for the January 15th report, if not, I think you can expect us in our other reporting to you to come back with those results shortly thereafter. There will be additional evaluation mechanisms. Another evaluation mechanism that Vital currently has is right now, they're asking which providers provide opt-out, and they're tracking that, that we will also be able to report relatively early in the process. And I invite any members of the committee also who wanna help, I know a couple of you have a lot of experiences in this arena to provide us input and feedback. I'm not so sure that it would be proper since we have to- This is true. Decide if it's been done thoroughly, so, Tom. Yeah, I just wanna emphasize something I've raised, which is I recall from the Health Tech Solutions Report, many states have gone before us in this arena, and to me that's an important context to have our arms around what that means. This issue here has been controversial here in Vermont, and I think that context and experience of other states is valuable to have. I also wanna ask is what if you get to the end of this process, and there is still no consensus? Consensus, I just wanna clarify the question, consensus on the mechanisms that we should undertake? Right, consensus in terms of how to approach the education of the public and the involvement of the public in helping them make a decision as to whether they opt in or opt out. Yeah, so I wanna clarify one element. In our stakeholder engagement process, we are not arbitrating whether we should have an opt in or opt out policy. We believe that that was handled through the legislature last year. What we are asking is what are some of the mechanisms and are committed to a multi-pronged and multi-sector approach? There seems to be consensus at this point that that multi-pronged and multi-sector approach is the right approach. We are working with each of the different advocacy groups to get to understand what they feel would assist for their populations and the general public. We feel like that gives us enough bounds to say that we have at minimum kind of met the intent without having every organization have to agree on every mechanism that we will be putting in place. So I do think that there is consensus already that a multi-sector, multi-pronged approach is the right approach. Some may say a mailing versus no mailing, but most of them can at least agree that there are at least some things that are helpful. So that is our approach. I think you've got a very tough road ahead of you because I think where the consensus problem is going to lie is whether or not you've reached that each of them honor threshold, and that's going to be a tough one. It's going to be a problem because I'm born and raised in Arlington, Vermont, because Kevin's from roughly north of me. He doesn't consider me a room honor. Do you think you have that? I brought a brother up. Other questions? Any closing remarks or can we open it up to the public comment? I actually have a couple of other questions on the report, but I was saving this till after the end, but maybe I can jump into those now. Do you have more to present, Jenny? We're good, thank you. Okay. So I'm looking at the legislative report and there is in the beginning part of the report there's a discussion of promoting meaningful consent as described in the gold standard, which is the goal set out by the Office of National Coordinator for Health Information Technology, and that that's the gold standard that you're sort of striving for, but that the act requires, in my reading, HIPAA plus the part two, so the current federal requirements. Those don't necessarily to me seem like the same standard. So I just wanted to get your sense of how you're thinking about those two things. So meaningful consent is, as you said, the gold standard. So it's basically aspirational and moral principle, and it's clearly not something that we could dictate or require. I think what we're recognizing already in some of the conversations that we're having is that there is confusion around consent even in the context of HIPAA, and especially 42 CFR. So even just addressing that part of the act, which says we're supposed to align the rollout of this policy in the context of HIPAA and 42 CFR, that alone is going to be very challenging, but in terms of developing tools and information kits and trying to reach providers to better consent conversations with their patients in the context of care delivery is something that we can do that moves us toward this goal. Thank you. It was interesting to me because I read the HIPAA consent forms, but I'm a lawyer. I don't think most people read them. I think they just sign them, right? Much less understand what is a business associate, how does that all work, and that kind of thing. So I think you have a tough road to hoe giving the current state of understanding as I think you're seeing in some of your stakeholders or engagement. I was also curious if you could talk a little bit more about some of the alternative communication approaches that you're considering. In the report you mentioned visualizations and audio or video messages, and I wondered if you could just talk a little bit more about those sorts of issues. Sure, so we've already found in the process of doing the early focus groups that having an animation about how the Vermont Health Information Exchange works is tremendously helpful. We know that people have lots of different learning styles and that visual learning is something that we want to support in this process. We also know that there's folks who have low levels of literacy or they're literate primarily in another language besides English and we want to support them with audio messages. For instance, one of the recommendations we've heard both from a woman who runs the cultural brokers program and from the Vermont Department of Health is to consider having people who are from other countries and other cultures and who English is not their first language record a message in their first language and share that with other people in their community and that we know that translation can be a challenge and that can help overcome that. So that's just two examples of how we're thinking about alternative communications approaches. Can I follow up on that? Yeah. Because in addition to all those bearers, what about the time challenge? Sorry, say that again please. I'm thinking of the individuals that are just never going to take the time to actually have a meaningful consent. They may sign something quickly, but they're just always in a hurry and a lot of us are. So as communicators, that is a challenge that we think about all the time is how do we get this message across to people in the context of their busy lives, often in a health care environment where they are concerned about something having to do with their health and that's more pressing than what's happening with my health information. I don't have a solution for you on that yet, but it is absolutely one of the challenges that I'm considering in this process. And then I just had a couple questions about the engagement with health care practices and provider organizations. In the report you mentioned, a provider survey that is designed to inform the state Medicaid HIT will include some questions around this as well. And I was just curious about the timing of the survey. Yeah, the survey, we actually initiated the survey on July the 12th, and it will end on August the 19th. And we hope to have some summary conclusions published by the end of August. So that should be in time to inform this. Great, and I'm curious if you've gotten any pushback from the provider community around the consent issues, just in terms of workload or anything like that? Well, we know it's going to be an issue in terms of work flows. We're simply anticipating that and hoping to be proactive. In terms of early results from the provider survey, I think what we're learning there is that consent is not a major topic of concern that in a lot of cases people are not even familiar with the opt-in policy as it currently exists. And I'm talking about the provider community itself. There's a large percentage of the provider community. And remember that this consent policy has to do with information that's in the V-high. Right. So that's a more limiting concept. 25% of the providers don't know about the V-high that it even exists. Thank you. Yeah. Other questions from the board? Can I add to that? One of the things that at our steering committee, in fact that we had today, is that both Vermont Medical Society and BOSS are very interested in one care and helping us to communicate the messages to providers. And so while they represent a provider network, those networks are excited in the change in the policy and they've provided feedback to us that their providers are also, those who are aware are also excited. So just wanted to put that out there. Anything else from the board? If not, we're going to open it up to public commenter questions. Dale. I have two. The first one is a clarification because it reads which providers opt out. So that had me a little confused. Is it mandatory that providers opt in? And that provides, is this that whole scenario where the consumer goes with the provider? Consumer status, can it be determined by what the provider chooses to do? The short answer to your question is no. It's the patient's decision. Consent is the patient's decision. Whether the change happens in 2020 or not, consent is still your choice. So, could you just clarify? I think I understand. You do? Okay. So Dale, I think we're confusing kind of apples and oranges in terms of consent with the ACO, with OneCare Vermont and consent with the VHI. In the VHI, if a provider is able to and is feeding information into the health information exchange, that is not necessarily tied to the individual person's consent to have the information go into the health information exchange. What we are asking for in consent in this case is can their health information then be shared among the provider community? And that really is the decision of the client or the patient in order to have an information shared. Regardless of whether their provider, if their provider puts information in, that's not part of consent. That's upstream of that. Okay, so they're clarifying. So which providers are offering opt-out? So all of the providers in the health information exchange at this point are in an opt-out status. On March 1st, sorry, an opt-in status. On March 1st, they will be moving to opt-out. And that is across the board. Providers may choose to put their health information into the health information exchange based on their technical capabilities of their electronic medical record. It's not related to opt-in or opt-out. Okay, that helps. The one that was actually after the purification is if a person decides to opt-out, what kind of guidance do they get, what that is like to navigate the health care system when they, if they opt-out? And the other one would be quickly, in terms of educating them, can you do a head talk where they might be able to pick what language they hear it in or what sort of universal graphics that helps us send the message in terms of, well, I think you know that one. Yeah, the head talk is an interesting strategy. We will definitely put that down on our list of things to consider. What you bring up is the core of what we're trying to achieve, which is meaningful consent. The stakeholder process that we've outlined today is really designed to identify how people prefer to receive their information through their health care provider online, how they prefer to receive it, and what messages they feel like will adequately represent what consent means. And so we're working through that process now of developing that so people do understand what it means if they choose to opt, if they choose to allow their information to continue to be shared, or they choose to opt-out. And so that's currently under development. Thank you. Yep. Other questions or comments from the public? You see anybody? Seeing none, I want to thank you. Oh, did you, sure, after I turned my head. Sorry, I just have a comment which is that I was present when worrying that with a number of people with intellectual disabilities and parents of children with disabilities in complex medical needs, and as you guys know, I'm a recovering lawyer and I've been doing health care along with people with disabilities and dealing with consent for more than 20 years, need to say it. And I'm worrying your presentation with the patients and the exes and Dr. Wood, Dr. Two, Dr. Three, is one of the best pieces I've seen and I can't wait to see more and put your ability to explain these complex concepts to people with visuals to get to a number of colors. Question, one of you guys asked questions about visuals was so effective and every single person in that focus group participated, and they participated in their own way and their own level of human being that possible, so who knows. Thank you so much. High praise. Other questions before I thank this excellent panel. Proof of being the pudding, but it looks like this is off to a great start as far as a solid implementation plan. So thank you, I know this is a lot of hard work and you have been given a very high bar to achieve. So thank you for everything that you're doing. Thank you for having me. At this point, we're gonna take a short break. We will reconvene at 2.45 and if Sarah and Michelle can be ready to go promptly, that would be super. And whenever the two of you are ready, go ahead. Right next, oh, do you want to show me? Somebody did that. Okay, awesome. So Sarah and I are here to talk to you today pretty briefly about some of the performance here, one quality scale and total cost of care results to date is like the key phrase there. This is obviously not final as of yet. So we're just gonna walk through some of the information that we do have access to and give some more background on where we hope to end by the end of this coming year. So I'm gonna kick us off and talk about some of the statewide health outcomes and quality of care results. Just a quick refresh, it's been a while probably since we've looked at this slide on the quality frameworks before we dig into some of the results. So as you're all very well aware by now, I'm probably sick of listening to me talk about this. Vermont is responsible for meeting quality targets on 20 measures under the model and they fall into three buckets. We've got process milestones. So those ensure that the state and the ACO are striving towards improvement on quality and population health. We have healthcare delivery system targets. Those are measures and targets that evaluate ACO performance and quality of care. So for these measures, the population is people attributed to the ACO and these measures can be multi payer or payer specific. And then lastly, we've got our population health outcomes. These are statewide measures and targets related to the health of the population, regardless of whether this population seeks care or not. So the population here generally includes all of our monitors and something that I like to point out is that these measures are unique to Vermont's model. We're one of the first initiatives to commit to these big kind of statewide health improvement goals as part of a major delivery system and payment reform model. Each of the process milestones and healthcare delivery systems targets support the achievement of one of the statewide population health outcomes. Hence the lovely triangle. So, oh it looks so tiny. I want to sort of preface this with a reminder that our first annual report will be released later this year and we'll have complete 2018 quality and health outcomes results at that time. I'm only presenting results today for those measures that we currently have data on so you will not see all 20 all payer model measures represented here. So a quick touch on the behavioral risk factor surveillance system. So again, this is conducted among all Vermont's aged 18 or older and you have to be a Vermont resident for 30 or more days out of the year and Vermont's average survey group is between six and 7,000 people annually. So if you look, we don't quite have the 2018 results yet. They become available towards the end of September or early October. Again, that's a CDC run survey so by the time our health department gets the results we typically can get information from them before the final report is released as a department, but that's not something that we wanna present before they do. So here we're just looking at the 2017 data that we have and if you look at that, as you can see we're currently on track to meet all of our performance year five targets based on the 2017 information. In terms of vital statistics measures, I just wanna make a note that even though I saw our first annual report will have 2018 data, vital stats measures are at least one if not two or more calendar years behind. And so for each annual report produced we won't actually be reporting on the mortality of that prior performance year. It will be whatever performance year is most current and the performance period will be in alignment with that calendar year, but it will be again, the most current information that we have from vital statistics at the time that the report is produced. So just something to keep in mind as these results continue to be updated. There we go. So we'll look at some of the other measures here. So we have the Vermont Uniform Hospital Discharge Data System measure. This measure again had a phased approach to get to the performance year five target and we're currently on track. This will be updated with the 2018 discharge data when that annual health outcomes and quality of care report is released for the Vermont Prescription Monitoring System. Use of the VPMS has steadily increased while opioid recipients have decreased, which leads to that quite dramatic increase in the ratio. It's nice isn't it? It is nice. So I spoke with our colleagues over at the Alcohol and Drug Abuse Programs Department at the health department to just kind of get some background on this and they had stated that some of the drivers here are those new pain rules that were instituted through the legislature. And VPMS system enhancements that include things like prescriber insight reports and clinical alerts in addition to education and training opportunities for prescribers. And then there's also been some media and education outreach for the general public that could factor into this quite significant progress. Again, this is really good for one year but our target is still for performance year five so we don't want to see this go down. For the hub and spoke information here, we're doing quite well. So we're surpassing the target that was set, which was the 150. So we're more in line with this quote unquote rate of demand measure here, which will be hard to ultimately measure the rate of demand. So we're looking good there. I'll just say that. And for the ACO line beneficiaries, this comes straight from our scale target report that was produced earlier this year. Sarah will talk more about the scale report earlier this year. And Sarah will talk a little bit more about the scale report. I do want to touch briefly on some potential quality framework technical changes. So we've been in contact with our federal partners regarding these technical changes to the framework. This will not change any of the 20 measures included, rather as an effort for all of us to better align the performance year targets, performance year five targets with available data sources and timing of the report to this data availability. So I just kind of wanted to touch on that, that those conversations are currently underway. Do you want to ask me questions first or do you want to wait until the end? I think we can wait until the end. Good afternoon. So we just submitted our Q3 2018 financial monitoring report to the federal government. There's a lengthy leg on these results due to claims run out and waiting for some complete data. We do expect lengthier delays for our initial Q4 report. We've had some challenges in getting data from some of our payers into V-Cures. And so, we'll deal with that challenge, but just giving you a heads up. We also now will be producing a final annual report with six months of claims run out, which means that we'll be rerunning our baseline information to account for that. But all that is to say that these results are going to change, but this is the best guess we have for how we're doing so far. So the all payer total cost of care is something that we're bound to try to limit the average annual growth to 3.5% or less between 2017 and 2022. We like to see how we're doing and whether or not we're quote unquote on track in the meantime. This is all for monitors, whether or not they're attributed to the ACO, as long as we have their information in V-Cures. So again, we're missing a good portion of our self-funded plans that have access to an exemption and don't have to give their claims. So on the top here, we have the quarterly per member per month costs and the year to date. So that's Q1 through Q3 for the baseline year. Again, we're gonna rerun that with six months of run out. So that'll probably go up a bit when we do that. And then we have the 2018 results to date. Now you'll note that this number is pretty low and that is deceptive. So that's only with three months of claims run out. So that number also will go up. So we have a year of a growth of 5.5% in Q1, 5% even in Q2. And that 1.7 in Q3 is a number that we know will increase. But the year to date results are sitting at 4.1. This number is clearly above 3.5, but not above the corrective action trigger of 4.3%. We were from a lot of things all the same time in Vermont. And so it's come to our attention that some really exciting and important work that is being conducted by our partners at Medicaid may be affecting the claims as we see them in vCures. So it's hard to know how much these numbers are gonna change due to the baseline changing. And also we know that the growth rate we're seeing for Medicaid is too high for what should be included in the total cost of care. So we need to do a real deep dive on our code to get that right. So I don't think that we're probably really at 4.1%, but it's hard for me to estimate exactly how much lower it might be. I will tell you that these numbers also take into account the section 10D of the agreement, the so-called hold harmless provision. And that one is the one that says if you're increasing Medicaid reimbursement in order to get it closer to Medicare, we're gonna give you a break on that. And so that ended up docking this percentage down by a 0.4 percentage points or about $8.3 million. So that is a combination of two different adjustments. For our claims-based measures, we asked our partners and they generously complied to reprice the 2018 claims as if it were 2017 without those price increases that the federal government said, yeah, we buy that. That's getting you closer to Medicare or improving access. And then we also did an adjustment to the non-claims-based portion of 4.2%. The reason we're using that number and we need to make sure that that's the right number is that since we're using the actual capitated amount in our total cost of care, that means that we're not counting the savings or losses or we don't have the luxury of that offset. So we wanna make sure that any assumptions that went into building that capitated rate are reflected here. So that's our best guess today about what they built into the 2018 capitated rate for these pricing increases, the major one being Dartmouth. Yeah, all right, next slide. So these things evolve over time. So the way to read this, so here's the payer group and then the rows represent previous quarterly reports. And then the columns are the estimate for that. So for instance, the all payer rate for the Q1 report we thought was 2.1 that jumped to 4.0 in the Q2 report and is now at 5.5. So these things increase with more run-out. This again, this negative 1.5 going up to 5.7 in negative 4.8 to 4.2, this is more evidence that something wonky's going on with our Medicaid data that we need to sort out. So we're well aware of that and we'll get that sorted to the best of our abilities before our next report. I know that it's frustrating not to have that information today, but the analogy I keep hearing that feels true every day is flying a plane while, they're building a plane while it's being flown. But we're sorting this out and we're lucky to have great partners both at the state level and at the frontal level as we try and sort this out. So yeah, this is just the quarterly trend. So just kind of generally what we tend to see is Q1 and Q2 being relatively higher, a dip in Q3. There tends to be less utilization then due to a variety of reasons and then an uptick in Q4. So this Q3 number again is gonna go up we think, but that's where it stands today. And this is what it looks like by payer. So Medicare is the average cost per person per month. Commercial splits the difference with the Medicaid. And again, not only is there an adjustment for the whole harmless provision for Medicaid, but we're only including about half of the Medicaid spend in the total cost of care. It's just funds that flow through Diva. So there's other services that will be incorporated eventually into this measure, but this is just basically claims based measures that are part of the contract with the ones here tomorrow. So totally different numbers. They don't match for a good reason. So in the first few years of the agreement, our Medicare total cost of care is tied to the ACO population. So due to some limitations and data availability, we unfortunately will not be able to get, we don't think any quarterly estimates for the baseline year. And what this is designed to do is say, okay, this is the population in 2018 who is actually attributed to the ACO. Who would have been attributed in 2017 based on the 2018 provider list? And let's see what their expenses look like. So that's a cohort over cohort comparison based on the provider list. So it's less about the people and more about the delivery system. I think that's the intent of the way it was drawn up. But all that to say, this growth rate now says 1.3%, but because we set the benchmark, we know that this growth rate will end up being 3.5%. So we're gonna have the rest of the information trickle in. We're gonna have any shared savings or losses. So we know it's gonna grow by that amount close to it. But this is the best data we have available. And this is the one that's been kind of the trickiest to get at. So fun fact is that you don't have to necessarily live in Vermont to be attributed to the ACO. It's based on where the provider's located. So if you live next door and you're provider's in Vermont, you can be attributed. But as of today, we don't have those claims in B-Cures. So we're pursuing a different kind of data use agreement that might help with some of those data gaps. But one advantage of doing this on kind of a per member per month basis or a per member per year basis is that we think a lot of that will come out in the wash and that we don't think that there's a substantial population difference between people coming over the lake. It's mostly in the New York area that people are, we're in this situation. So yeah, scale. So again, kind of have like the quality targets, the financial targets, then we have the access targets. And the best way we can measure that is through how many people are aligned to this ACO. And so it's definitely getting more expanding over time. So the light blue are HSAs that aren't participating. Orange is Medicaid only. And the pink is the odd, not odd, but the unique situation we have with Dartmouth where it's Medicaid and Blue Cross only. And then the bluish-purple dark, this area, is participating in all programs. So we have more and more kind of growing into this darker kind of show of participation in all programs, which means scale is increasing as well. Yeah. But, oh, it's been canceled. I was like, what is that? That's what I'm sure you don't know about that. Okay, sorry. So as it looks, these again are estimates for the 2019 plan year or calendar year. So Medicaid's got a very healthy penetration rate met and that might, is that low? I feel like this is an old slide, so it may not be quite up to date, but the major message still is that we have much greater penetration by the governmental payers and that the real room to grow is among the commercial market. And so we are hoping to see major gains in this area in 2020. And that is also, this one in particular, you can see how high it is. And it's the one where the regulatory levers for the board are maybe most restricted if you think about the rate review portion. So getting this, more of this bar, a lighter green would help maybe increase the strength of a lever in that particular market. All right, am I supposed to be talking about this review? Okay, great. So yeah, so as far as the targets go, so for Medicare, I always have a hard time reading this, so the target in performance year one was 60% in 2019 at 75%. We are still below our targets, but gaining. And we've also had some really encouraging progress with our federal partners because when we've started to look into the data, if you say, okay, how many Vermont residents would even attribute to a Vermont provider if every single Vermont provider were participating in the ACO? And spoiler alert, it's less than 80%. And that's because of either being attributed to a provider that's in another state because they didn't have any qualified evaluation and management services. So that might be, they didn't seek any care or they're like so sick that the type of care they're receiving isn't really typical primary care and stuff like that. So they're aware, unfortunately, they're not very nimble. So changing the alignment strategy is not something that we can do quickly, but that we're starting that process to figure out what a fair target might be and maybe there's a split between who we count for scale and who counts for the total cost of care or something like that. So we're just starting to kind of explore these questions but it was really encouraging that they kind of heard that message loud and clear because we wanna be ambitious but fair in our goals. For all payer, it was 22% with the performance which is below our target of 36%. We're still waiting on some final information in the current performance year and we get to count any programs that come online to the course of the year. So it looks like we'll probably fall short of that 50%, but again, we're making gains in kind of closing that gap. For 2020, the increase for Medicare is a little less dramatic than it was between performance years one and two. So it's kind of nice and that would be true for the all payer as well. So that'll be a nice kind of chance to hopefully gain some ground. A slide you're all familiar with. This outline through reports that were responsible for submitting to CMMI through the duration of the agreement. My favorite data point for you all is, let's see, 39 to go, 39 more between now and the end of 2023 because it ends in 2022, takes about a year to finalize all these things. So you'll notice that year two, which is where we are now is a big year for all the analytics and reporting activities. So you'll be seeing a lot more of Sarah and myself with a number of recurring reports that have started this year. So on this slide, we've only listed them at their outset. Sarah talked about total cost of care and she did reference that we are also adding an annual report to sort of account for six months of run out to hopefully get a little bit better of a picture. So that added five more reports to the total number of reports. We've got payer differential reporting. We had our first scale and alignment report that came out in June and our first quality report is due later this year, as I mentioned. In addition, we'll produce a handful of one-off reports on particular topics. So we've got different aspects of a payer differential analysis that you can see up there. There's a payer differential options report in performance year three. We have a public health system account of ability framework. That is led by the agency. And we also have a plan to integrate mental health, substance use, and home and community-based services within the all-payer financial target services. And again, that's led by the agency of human services. 39 more. That's it for us. But who's counting, right? Me. Questions. I just wanted to say thank you, Sarah, for explaining both some of the data issues that I wish I had known during the negotiation, but not including the Medicare attribution challenges because that was definitely something that was not on the radar. So we're learning a lot and I think that's good, even though it doesn't make the reports challenging to both do and understand as we move forward. But thank you for explaining that as we went along. I just have a question. If you can go back to page nine. And what, I guess, what our level of concern should be when you look across the top on the all, and we're at the 4.1, and I think you said 4.3 is when things could kick in. And Q1 through Q2, obviously we're exceeding that. Q3, if we look back at the past two quarters, we would expect pretty significant jump to where Q3 ends up. So the point is we're tracking above that. And I know there's some issues with the Medicaid data that might be artificially inflating that. But I guess what's our level of concern? What happens if we trigger? You know, if we were just through the first two quarters we'd be averaging, you know, five and a quarter. So we'd be a point above. So what are your thoughts on that? Yeah, absolutely. So it's hard to say exactly. So a corrective action plan isn't like an automatic thing. Like it's something the federal government, I think according to the agreement may request. And so what that would look like, I think would be, you know, a partnership and trying to figure out exactly what that would look like. But yeah, I wouldn't, it's just so hard to say this five, seven is just not right. Like then that's a big number to not have rights. So yeah, so I guess I just, I'm not sure. And I hope we can get this straightened out. As soon as possible so that we can have a better kind of litmus test for exactly where we're at and how concerned we should be. And yeah, I mean. And even without the issues with Medicaid, commercial and Medicare through the first six months. Sure. Are exceeding the 4.3. Oh yeah, yeah. And like the other thing like our spending can be a little bit noisy. So, you know, this is like a five year target. And so not being on track doesn't mean it's all doom and gloom. But yeah, no, it's definitely don't want to fall too far behind and get ourselves in real trouble. So yeah, I would say it's a concern about how serious of a concern. I just, I'm just not sure at this point. Okay, yeah. I also jump in on that because I think given the scale, it's not particularly surprising that when we're looking at spending, which includes a majority of fee for service that it would come close to or even exceed the 4.3. Because well, there's been a lot of focus on the 3.5. The 4.3 in and of itself was a stretch goal given that that was also tied to the economy and healthcare spending as we know traditionally grows faster than the economy. So. Yeah, one solid recession is gonna bail us out. Just kidding. But I think, you know, I think to me these numbers, again, recognizing that there's a lot of noise in them right now and we don't actually know what the right number is. Given how much is still in fee for service is not particularly surprising. So can you just remind me again, I think you said, but when you think this chart will be. I'm really hoping that we can get this right for the Q4 report. But when the Q4 report will be possible is uncertain due to, until we get the claims that we need, we can't get an extract or run any of this stuff. So. Okay. No problem. Yeah, and even when we get that data, the commercial stuff might be a little dicey, but yeah, it'll be much, I think it'll be in a much better shape than it is right now. Other questions? If not, we'll open it up to the public for any comments or questions. Dale. How many quarters do I need before I can really determine noise versus trend? And then, for the reason I'm asking that is if you go to the map, with all the nice colors on it, does that actually reflect that noise? Oh, sure. So the all pair, these guys, it's the whole map. Doesn't matter. Yeah, so that part. But that said, we are a relatively small state and so sometimes noise is the trend. When you're in a small, it is the value we have, but it can vary a lot year over year. So in terms of being relatively confident in the number that we have for that time period, we like to see six months of claims run out and then it takes us about another three months to actually get that data in-house, so nine months. Okay, so that's part of what confuses me sometimes because if I'm in California and see a shift like this, compared to the magnitude of what I'm dealing with, I'm stable. I'm here in Vermont, where I don't even qualify maybe as a town over there. And is it more, almost you've got an inside duration? Yeah. You'd be the best town though. Yeah. Once we get this right, you know, the plan is to get a historical quarterly trend and then at least we could get like an average with a confidence interval to be like, okay, well what is the average magnitude of change that we would expect on a quarterly basis? And you know, I think that would help put some guardrails around kind of the concern issue and figure out like what are kind of effect sizes for worry. Well, this is also why it's a five-year trend and not a year-to-year trend. Yeah, yeah, absolutely. Yes, Walter. Pick up on a little bit what Dale said. I'm just curious what all these numbers mean for the quality of care. We're talking about TCOC, but people still get claimed in aisles. They still have problems with bills. They still have problems with providers and everything. I hear about it every day. So I just, these are great for measuring this or that, but they're not measuring the human value good. Yeah, and we're actually actively working on trying to help tease out some utilization data, which still isn't going to be perfect for quality, but at least you can see if, and one thing that we don't have a great control group to compare these attributed lives to. So because, you know, we'll get how much is in here and finding even another state with a similar regulatory environment in situation is pretty tough to do. So one thing we're trying to think through are ways to say, okay, so let's look at the ACO population before they were attributed and see how different they looked from the population that wasn't attributed and then let's kind of track those two groups over time to see if we're seeing changes in their primary care utilizations, access to specialists, things like that. So on top of that, we have the quality-based measures, some of which are just tied to the ACO population, but I do think that, yeah, the triple aim is a heck of an optimization problem. Like, yeah, and quality in particular is a very hard thing to measure. Other questions or comments? Susan. So I've been having a hard time squaring today's materials with some of the numbers that were in the report dated at June 29th, the first scale type of report. That report itself had no internal inconsistencies that there were three or four different numbers for the total number of lives attributed in 2018. So specifically referring to the other report, the scale targets have two different numbers, 112 in one instance, 112,756 in one instance, and 109,748 in another instance. And then in this report, you're not using numbers, you're using percentages. So I'm just wondering, if I write you a email, have you helped me square some of these numbers since there's just internal, I don't know how when you go from a whole number to a percent, if you're using two different whole numbers, it would seem like a percent's would change to... Yeah, so I've been alerted to some differences in the numbers and sometimes it depends on whether, so attribution occurs before the performance year begins and between when that happens and when the performance year starts, we lose some folks, particularly with Medicare, they die in order to sign up for Medicare Advantage and stuff like that. So can certainly review the report. I don't know how soon, but yeah, we can certainly try to sort that. Any other questions or comments? Yes, Susan. So I noticed that in July, there had been a schedule, a presentation schedule that was for like that July 17th, meaning it was going to be on an all-care model update. And then there was another presentation schedule for your meeting next week, I was working at the same time. My understanding is that we won't have Medicare information until September, but I'm asking now, I'll ask you, Mr. Chair, can the green amount of care board have a credit system in September that has the quality and substantial performance for the three major payers, Medicare, Medicaid, and Blue Cross in this year-to-year data sets that we're used to looking at, the quality performance measures that are targeted, total cost of care, and the actual total cost of care. Because what seems to be happening now is we're getting reports at sort of your time periods for three. But I don't see the green amount of care board actually scheduling a time to really look at what is the AC of it, of Walter's question. We have information on quality. I mean, the Medicaid program is flexing information on quality on a whole bunch of points, so probably to this Blue Cross, and so is Medicare, so it'd be really nice to see those. In addition to the other stuff you're doing, which I understand are the quality measures for the all-payer model, but the quality measures by payer and the financial performance by payer year over year is really important and I feel like we're losing it, and we're losing the ability to track it, in part, because the numbers are changing, but we're also losing it because the presentation of the graphs and the information is changing. So I guess my answer would be we might, but it will depend upon the delivery of information from others than even though information is promised, it does not always arrive on time. Kevin, may I add to that? Sure. So as part of the ACO budget guidance this year, we did ask them to address through their payer contract, so again, some of those measures do align with the measures that the state is responsible for through the agreement, but they have varying measures through their payer contracts. Assuming that settlement has occurred by the time they come to present on their budget, we have asked them to include that information, so you would see that through the ACO budget process in the fall, in October. And that's great, but that process doesn't allow for an actual review by the board of that information and an explanation, why did you only get a zero for follow-up or substance use disorder, what is your quality improvement plan for that measure, that kind of presentation, which I think would be really vital to the success of this project. So I think that will be part of this year's process because in prior years that will be what I do, I think, through this year's ACO guidance process and budget process, and so in years past, we could have referenced shared savings programs measures and their performance there, but as we try to sort of tease these things apart, the ACO has payer contracts and we wanna start following the performance on those payer contracts from year to year, recognizing that they may negotiate new measure sets as they move forward and that's part of the deal, but so that will be part of the questions, very likely part of the questions that the staff will have back to the ACO that we will present publicly and that the ACO will likely respond to in a public manner or all that documentation will at least be available on our website. Other question. So we have had about two years with Medicaid, but we have not had the time to analyze and finalize our first year with commercial and our first year with Medicare. So it's not possible at this point to do a lot of year-over-year analysis because we don't even have our first year of data yet. So that was the only thing I would add in there, but yes, Michelle's also correct that that's coming as part of the ACO budget review process this year because we have the opportunity to do that and the data to do that. I believe you're making a distinction between a first year and a second year if you all care about it. I believe the way that budget guidance is worded is that information is being asked for from all payers, from all ACO contracts going to court. So this year, a saving contract with Medicare that we had to, what, five or six years and then three costs and with the state prior to the next one should all, those quality requirements really haven't changed that much in those programs. So being able to look year-over-year at those members just because it's now told all payers, the population hasn't changed, the measures haven't changed, the payers haven't changed one year on the piece is the name of the program history. I don't agree, Susan. I think that providers have changed, the population has changed, the payment mechanism has changed, which will have an impact. So I don't see the programs as comparable. That's my personal view. The population, all right. Well, I really hope that the remit of your board does its job and allows a good evaluation of the effectiveness of the stated money into the fairing quality if not to us again. We will do our best. Any other public comments or questions? Seeing none, thank you very much. 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? Second. We've moved in second to adjourn. All those in favor, signify by saying aye. Aye. Any opposed? Thank you everybody and have a great rest of the day.