 take a look at our upcoming calendar for March, which will be posted very shortly. It'll be on our public meeting section of our website. As a preview, we will be spending a bulk of our time next month reviewing the FY24 hospital budget guidance. So the board will be putting a lot of time into that with staff. You'll be hearing from Sarah Lindbergh quite a bit more next month as well. I also wanted to announce a couple of public comments. After today's meeting, we will be posting a public comment on the FY2017 UVMMC enforcement action. As I said, we'll discuss it today. We'll keep a public comment period open until March 8th, where we have a potential vote scheduled. Both Sarah Lindbergh and Russ McCracken will give you more details as they get into their presentation shortly. I'll also remind you, as I do every week, that we are accepting ongoing public comment on a next potential all-payer model. Any comments we receive, we share with the Agency of Human Services and the Governor's Office, as they are leading the current model work as well as the potential next model negotiations. And with that, I will turn it back to you, Mr. Chair. All right, thank you very much. Before turning to Ms. Lindbergh for the UVMM Medical Center Enforcement Action, we'll take up the meeting minutes from February 8th, 2022. Is there a motion to approve the minutes from February 8th? I'll move approval. Second. Is there any board discussion? Hearing none, those in favor of approval of the minutes from February 8th, please say aye. Aye. Aye. Aye. And the vote is unanimous. I'll turn it to Sarah Lindbergh. Ms. Lindbergh. Good afternoon. Sarah Lindberg, Director of Health Systems Finance, and I'm joined with Russ McCracken, Staff Attorney, and Russ will actually be the one to talk with you first this morning. I'm an afternoon, sorry. Great, thank you all. Russ McCracken, Staff Attorney with Board. I should be seeing my screen because you make sure you see that. All right, great. So before we get started, I do want to just make clear at the outset I guess a couple of housekeeping points. There's no vote today. The board is not taking any action today. There was no vote noticed for today. That was done intentionally. We have a potential vote notice for March 8th, but because of our format, we wanted to get the discussion started. So we're presenting that for you today. As Susan mentioned, we're also opening a public comment period that will run until March 8th or maybe the day before so that we have time to make sure the board can see all public comments that come in about this. There is some motion language in the slide. That's for completeness and for you to kind of see but no motions on this issue are going to come up today. So I'm going to give a little bit of background and history as best I can as an overview of this FY17 enforcement action particularly for board members who are new to it or who weren't here over the summer when we discussed this in the context of hospital budget reviews. So most recently, UBM Health Network sent the board a letter was at the beginning of February, near the beginning of February, giving us the current status of the self-restricted funds which initially were 21 million. It's now at about $18 million. UBM Health Network reports that the $18 million is still in self-restricted funds. Board's intended use to address the mental health needs in patient mental health capacity and they welcome conversations with the state to consider the best use of the funds. That letter also goes through to talk about some of the other mental health initiatives that UBM Health Network hospitals are doing in the state. Let me hit our staff recommendations here and then I'll go back and do a little bit of the history. What we're gonna recommend is that the board make a slight modification to the FY17 enforcement action so that the self-restricted funds can be used to support an increase in capacity and mental health services in the state without it being limited to inpatient mental health beds. The initial order permitted UBM Health Network to self-restrict those funds as long as they materially increased the inpatient mental health beds in the state. We're suggesting that those funds could be more beneficial and more immediately used for the state if that restriction were broadened to include mental health capacity beyond inpatient beds. So the second part of our suggested approach here is that we require UBM Health Network to develop a proposal in consultation with the Vermont Department of Mental Health that outlines the planned use of the remaining funds to address the mental health needs in Vermont and submit that to the board by May 31st. Here's a bit of the historical timeline. This action is from fiscal year 2017. The enforcement was deliberated and voted on back in March of 2018. I'll go through the specifics of that action on the next slide, but part of it was to require quarterly updates on the status of mental health project from UBM Health Network to the board. Those updates took place from 2018 and through really through 2020 on a quarterly basis and then they were suspended for COVID and the updates became less frequent. In April of 2022, the Health Network came before the board told the board that the project was not financially viable and that they were not at this point in time able to move forward on it. In June, the board sent a letter asking the hospital, asking UBM Health Network to consider some broader alternatives, including but not limited to adolescent or youth inpatient facilities and also giving the health network notice that not sufficient progress was being made on the project to increase mental health inpatient capacity. During the summer and then into the hospital budget deliberations in the fall, the board looked at these funds again and considered whether this was possibly appropriate to apply these funds to reduce commercial rate increases. The board did not order that during the hospital budget deliberations. The board did cite these funds as one potential path that UVMMC could pursue to make up a reduction in the commercial rate increase that between what UVMMC had submitted and what the board had approved for FY23. That process would require the hospital coming back before the board and asking for the board to order those funds to be used for commercial rate. Which has not happened in which UVM Health Network said in their letter, they did not intend to do at this point. So going back to the FY17 enforcement action, this is the text of the motion that was ultimately approved by the board following deliberations. The board provisionally allowed UVMMC to sell for strict $21 million in surplus funds with the condition that those funds be used solely for investments that measurably increase inpatient mental health capacity in Vermont. The order then required quarterly reporting. The enforcement action then went on to say that UVM has to continue to report quarterly until either sufficient progress is made on the plan that reporting was no longer needed or that UVM Health Network had failed to make sufficient progress on the plan were under the second prong of that part of the order at this point. And finally the order said if the board determines that insufficient progress has been made, it may order that UVMMC use all or portion of the $21 million to benefit rate payers through a commercial rate reductions. And I think it is important to take that fit in context of the board's hospital budget rule, which does set out a process for review of a hospital's actual results against its approved budget and sets out some guidelines for how the board may adjust a hospital's budget if its actual results are buried from the approved budget. That would be at the request of a hospital. The rule gives a couple of options. One of them is changing the hospital rates or prices by the amount that revenues exceed the budgeted net revenues. Another option is changing revenues or expenditures of future budgets. There are a couple of other items here. The last one is a broad catch all that covers any other circumstances the board deems appropriate. But I think that we see the tie in between that budget rule and the idea that the 21 million, if not used for a project to benefit mental health capacity, gets returned to rate payers through a commercial rate reduction. And just to be clear, if a hospital is operating under a approved budget but not in compliance with that budget and the hospital fails to seek an amendment, the board does have broader enforcement authority to go to court and require the hospital to comply with a ruler statute. Sarah, do you want to jump in on this? Yeah, sure, happy to. So you know some of the thinking behind our recommendation is that the need for mental health resources, not only in Vermont but probably globally, have only increased since 2018 as have expenses associated with capital projects. So this funding is at risk of being of less value the longer time goes on. And it also allows the opportunity for it to potentially be used in conjunction with other fund sources or projects by making it a little bit more flexible and by involving our partners at the Department of Mental Health, we think that it gives us an opportunity to increase funds and triage all the substantial need so that we can try to maximize the return on these funds for Vermonters. And so turning to the next slide, this is just a very high level indicator of the increased need looking at the unfortunate increase in deaths by suicide, both in pure rate and pure number of suicides but also the rate of suicide. This is through October of 2021. We also know that folks are showing up in greater numbers to emergency departments, which is not an ideal care setting for those problems and that they are spending a lot of time there that doesn't feel beneficial to the system or to the individuals who need help. So I know my own life has plenty of examples of the unfortunate deterioration of mental health. I think most of us have things to point to, unfortunately. So I think that's pretty well established and just at a very high level again, the next slide shows the increase in the producer price index in the industry of new healthcare building construction. You can see that huge jump from 2021 to 2022 in those material costs. So again, as construction projects become more expensive due to supply chain constraints and other inflationary expense growth, again, it might not get the most bang for those bucks by building something per se. And so here, as Russ mentioned on the next slide, what we have is just a potential motion for you to consider. There will be no vote today, but this is the language that we had come up with as we'll point out in the next slide. We do have a special comment period devoted to this as well as the potential vote will be noticed from March 8th. But if you want to click back to the suggested motion for a moment, please Russ. I can just practice my reading skills by saying move to modify the UVMMC fiscal year 14 enforcement action to permit the self-restricted funds to be used to increase capacity of mental health services in the state, not limited to inpatient capacity and require the University of Vermont Health Network to develop a proposal and consultation with the Vermont Department of Health for planned use of those funds and submit the proposals of the GMCB by May 31st, 2023. So again, just for you to kind of maul. But I think at this time, we're happy to answer any questions you might have about the recommendation. Thank you, Mr. McCracken and Ms. Lindberg very much for the overview and the history. I had a couple of quick questions before I turn it to the other board members. First, though, I wanted to commend UVM for indicating that this money could be earmarked and used for mental health and recognizing the acute need for mental health that we have here. Given the history, I know there had been some discussion about using it for budget gaps or margin. I wanted to thank UVM for recognizing the importance of addressing the mental health issues that we have here. There's a couple of questions I had, though, that will help me in voting. And one is, as I understand it, it was UVM MC that originally had the $21 million of unbudgeted revenue, right? It was the medical center. Is that correct? Yeah, we were trying to reconstruct some of that history as well. Russ, do you want to speak to it in a way that a lawyer might understand better than I would? Yeah, like Sarah said, we were trying to reconstruct the history. The motion language from 2017 refers to actual performances at University of Vermont Health Networks, Vermont hospitals, plural. The actual restricted funds were University of Vermont Medical Center and I don't know if that was simply because it's the largest of the three hospitals by a wide margin or if there was something else specific to it. I couldn't run down all the details on that. It was University of Vermont Health Network that was given the task of providing the regular updates and kind of leading the project, the potential mental health inpatient project. And historically enforcement would follow a hospital. So I think while technically a UVM MC action, it was intended to address the network. Okay, so a little clarity on where the funds came from, where they went to and where they were held, I think would be helpful. And what I'm getting at is from the history, as I understand it, which might be off, it was mostly or it was UVM MC that had the extra revenue, but then the health network undertook the planning for the project to be at CVMC. And my question is really was where was the $21 million held? Was that the medical centers, days cash on hand, the network somewhere? The medical center, yep. And the other question I had was the money's been held for a while. And is there any investment in the fund in which it was held? Is there any investment return that Vermonters should see in connection with the money that was there for four or five years? And if so, what is it? Yeah, so the way that the order was written, it was an amount certain and that the order was to self-restrict it and it was self-restricted in their cash on hand, in their unrestricted board designated assets. And that's where it's been this whole time. And so it's above, below that kind of level of booking for our regulatory purposes, we would just have to ask UVM for more detail. Okay, that might be useful to know. The only other question I had was, is there any way to salvage anything from the $3 million investment in planning for the CVMC facility, or is that at this point a sunk cost? We want to make sure this money is used efficiently and that might mean something in Burlington or something in Middlebury or something somewhere else. But I guess I'd like to understand if there is anything we can salvage from the $3 million investment. And maybe the answer is that wouldn't be feasible because you'd have, it wouldn't be the right way to use the money. And it's just a sunk cost at this point, but that would be something to be useful to understand. I have nothing else, so I'll turn it to any other board members. I just wanted to jump in and say, I really like the collaboration with the Department of Mental Health. I think that will bring in the state expertise in terms of what the greatest needs are potentially right now around mental health. So I think that's a really good addition. So thanks for thinking of that. I guess I'll just add to that and just say that I hope that inpatient isn't completely off the table and that maybe in conversations with DMH, part of the issue I understand was the viability with the CVMC project was reimbursements. And so to the extent that DMH is involved and can see and understand and think about the viability of that project, to Owen's point about, is anything salvageable? I'm just still holding out that we know that inpatient beds is still a need. I recognize that there may be other more pressing uses of the money that will return investment sooner and we have a mental health crisis. And so perhaps there are better, more immediate uses of those funds, but I guess I'm hoping that it's not completely off the table. If I cannot, I just want to jump in. I think that's a great point and I wanted to confirm that the proposal that staff is offering certainly does not limit the use of those funds for inpatient capacity. It expands the potential use of it, but inpatient mental health capacity certainly remains a possible use of the funds. If I could just build on to that for a second. I too have concerns about, I hope we don't let go of building inpatient capacity. The fact that our emergency departments are clogged with people needing mental health care services, sometimes residing in the emergency department for weeks at a time tells us there's a desperate need for inpatient services. They are in the hospital, in the hospital in the highest cost possible setting as we speak. But so I want to thank UVM. I want to join the chair and other members in thanking UVM for thinking about this and I appreciate the collaboration with the Department of Mental Health and the expansion of our thinking about how can we best use this. I think those are all good things. I want to follow up briefly on chair Foster's question about where has the money been and what is there any way to recoup the 3 million that's been already spent. I'm interested in learning more about where the money's been. If it had been, if it's been invested, which is common in hospitals, that days cash on hand or other dollars, if not days cash on hand, money is invested. That's an important part of a non-profit hospitals financial strategy. If $18 million had been invested in 2017 or 2018 and received just a 3% return that would have made over $3 million. So it's likely that the 21 is still possible if we want to pursue that line of thinking. I'm concerned with the proposal. This has been ongoing since most of us have been on the board. Enforcement, when there's been no action, has been lacking. And I'm not sure that, well, I'd like to see more thinking by us and our colleagues on what enforcement mechanisms we would pursue if progress is not sufficient in the very near future. This process started in 2017, 2018, and nothing has happened. So I think we just have to push back a little bit on that, Tom, because there were reports that came in that showed a lot of planning activities that did happen between 2018 and 2022. And I think for those of us who were here, we felt like there was progress being made. It did take time because there was, you know, there's a lot of desire for mental health advocates involved in the process, which I personally think is a good thing. And, you know, I think that having that community involvement was important, but also time-consuming. And we did not, until 2022 post-pandemic, find that there was insufficient progress being made. So it's true there's no result, but this kind of project is, you know, takes years to plan and implement as well. So I just take a little bit of umbridge at your statement because I think in my, I don't agree. And I was here. I welcome the conversation, Robin. Thank you. We do disagree, but that's okay. I would prefer to see stronger enforcement language going forward so we don't have several more years go by where we consider a submission of a report sufficient progress. I think just to respond to that, I think that, you know, as I get acclimated to this new rule, I think that enforcement is one of the key pieces in rethinking our regulatory process, and it's not an easy puzzle to solve. But I think, you know, taking actuals and applying them, you know, two years past the violation probably is not an ideal way to regulate. And so that's on, you know, my punch list for the next 20 years. No, it'll be sooner than that. But the other point just about the value of those dollars today is that there may be investment gains, but also, you know, the value of a dollar in 2017 versus 2023 has also changed. So, you know, I think those, there's different forces kind of working toward that. So I think it's, you know, probably not a straightforward answer of what that money is today. And I think the other thing is that we didn't, you know, it wasn't segregated in a specific fund. It was just required to be self-restricted in the cash on hand. So I don't know that there's like a specific $18 million left that they could necessarily point to, but we will make the inquiry and I'm sure they'll, in good faith, present their best estimate of your questions. Any other board questions or comments? I think the only thing I'd add to this is that I, you know, I do really appreciate the idea of moving this to not being just brick and mortar oriented. I think we have a need as everyone has expressed and we all experience and I've experienced in my clinical work and anything that we can do to increase access for mental health services in the state I think is anything we do to promote that I think is a great thing. So I appreciate UVM's willingness to engage in this and I think this is a good step forward. Sarah Russ, would you mind going back to the suggested motion language real quick for me? I'll turn it to the healthcare advocate. Awesome. You might hear some, we're doing some parental changing of our child in a second. So that's some sound in the background. Apologies. The healthcare advocates supportive of the recommendation and the motion before you. I just want a brief comment and many of the questions and really questions that we had have been asked by board members and board staff. So thank you for the good thoughtful conversation. But one comment just to consider would be adding something to this motion about consulting a community mental health provider and or a community member slash patient as a part of this consultation process. Cause I think that that would provide a really valuable input and I'm aware that, you know, we don't want too many cooks in the kitchen, but I think perspective from those stakeholders would be really valuable for such an important project. So thank you. Thank you for that comment. That's a good, that's a good recommendation. We can talk about that. And with that, I'll open it up to public comment. Please use the raise your hand function. I'll call on the order in which I see them go up. If any, the hands clapping from Mr. Walter Carpenter. Say you, Walter. That's me. Hey, I'm clapping. Standing ovation right on. You know, Walter, it's a good thing. That's one of the only emojis or whatever they're called that we have available to the public commenters, I think. Well, hey, standing all right. I just, you know, I agree just to back up the enforcement is the key. And I back up your question earlier, wondering where that money was before all this. That's it. Thank you for raising your hand and participating Walter. Any other public comments. Mr. Rick Vincent, please go ahead. Afternoon everyone. Since I'm on, I thought I might answer the one of the questions that came up about the ability to reuse that $3 million investment that we've made. So largely that planning work that's been done in all the detailed work in terms of projections of patients and those types of things and just how big of a facility might be needed is should largely be able to be reused. It just may be that the facility may not be located on the CBMC campus so that the money that has been spent will certainly certainly can be used. Great. Mr. Vincent, just for the others, I think I saw your name on the letter just to identify you. You're the executive vice president and CFO at the health network. So thank you for raising your hand and answering that. Thanks for being here. Any other public comment. Great. Ms. Lindberg and Mr. McCracken, thank you very much for your work on this. Next we will turn to Vital and a potential vote relating to their budget amendment. And today we'll hear from Jessica Mendesable, who is our director of data management analysis and data integrity here at the board. And we also have with us Marine Gilbert, who's the director of client engagement at Vital, and Ms. Beth Anderson, the president and CEO of Vital. Jessica Mendesable. I just wanted to hop on. I'll be speaking after Vital's presentation today. So Beth and Maureen, I just wanted to let you know when you're ready, if you would want to go ahead and share your slides. Thank you. Thank you. I'm going to start us off, but Maureen and I will share this presentation today. So thank you for the opportunity to present again today. Today's presentation has just a couple of topics for you. One is the command care board team has asked us to do a high level overview of the HIE and some of the work that we do, which Maureen will kick off in a moment. I think the highlight of today's meeting is our request for your consideration of our amendment to our current fiscal year or fiscal year 23 budget, which I'll walk you through. And then we'll present some highlights from our quarterly report that we present to you. Just to acknowledge on the call today, in addition to Maureen, our director of client engagement and myself, you have Bob Tornel, our CFO, Sufritz, our director of technology, and Christine and Chokat, who is our director of operations. So we will together answer any questions you have so to kick it off and to turn it over to Maureen to walk us through a little bit of the HIE. Hi there, Maureen Gilbert, director of client engagement at Vital. I'm going to get us started way back at the beginning with a few abbreviations. We know that one of the unfortunate realities of health IT is the number of acronyms that end up in so many of our presentations. And so we are going to first try and avoid doing that and second, tell you in advance about the ones that we will use today. So to get started, Vital, we actually talk about ourselves as Vital. Think of that as our name, but it is short for Vermont Information Technology Leaders. And if we say VHI, what we mean is the Vermont Health Information Exchange. We've got a number of partners and programs that we also may refer to by their acronyms. So the Vermont Agency of Human Services, AHS, the Department of Vermont Health Access, DEVA, and VDH for the Vermont Department of Health. Beth will take us through our finances and sometimes you'll see CY for calendar year, FY for fiscal year, and M&O when we couldn't fit maintenance and operations and to talk about our maintenance and operations budget. So as Beth said, we were encouraged to do a brief overview of Vital and we'll keep this short recognizing that many of you have heard this before, but it's always great to ground the conversation in a little bit of background about what we do. So Vital is an independent nonprofit organization founded in 2005 and we operate the Vermont Health Information Exchange in accordance with Vermont statute. We have a board of directors, independent board of directors representing hospitals, healthcare providers, health technologists, payers and businesses around Vermont. One thing that I would encourage everybody to do is take a look at our annual report. Our 2022 annual report takes a look back at some of the achievements from the past year and has a few notes about what's ahead as well. That report is available on vital.net and linked in this report as well, which I believe is on the Green Mountain Care Board website. So thinking about the work that Vital does and how the Vermont Health Information Exchange works. It's not just about moving data back and forth. We do a lot of work to that data to make it usable, to make it meaningful in healthcare and in health reform. So we collect data from contributors and I'll show you a slide next that shows who is contributing data to Vital. We match that data, so taking all the records that exist for patients all over the state and bringing them together. We know a patient's longitudinal health history and it's made up of all the many places they've received care in their life. And then we standardize that patient data, taking it and translating it from all the local languages and local conventions that exist in the electronic health records of our data contributors and making it standard so that it can be used comparatively across the population. For our data contributors, we're a hub for efficient data sharing. What we do is we enable them to connect to us and then we send their data downstream to many of the places they need it to go. So instead of building multiple connections, data contributors are building one connection to us, which is more efficient and then we're able to send the data downstream for purposes of public health, patient care, number of uses which I will get into in just a second. Really at the foundation of all of this for us is protecting patient data through robust security practices and ensuring appropriate access. That is at the heart of everything we do. This doesn't work without trust and it's something that we are committed to. Ultimately, this data that we take in and we match and we standardize is sent downstream to inform patient care, quality improvement activities, health care reform initiatives, public health activities, population health, and case management and care coordination. So our data contributors, we have a wide range of data contributors from all over Vermont and a border hospital as well. All the hospitals in Vermont contribute data as do all of the federally qualified health centers. We've also got good coverage with independent specialty and primary care practices, although more than twice as many independent specialty and primary care practices are accessing data as are contributing data. We've got recently increased coverage with pharmacy chains and with labs during the pandemic really ramped up to bring in vaccination data from pharmacy chains and test data from labs. And I won't go through the entire rest of this contributors list, but it is available on our website in this report as well. So importantly, how we're funded is we're about to talk about our budget amendment. The majority of our current funding comes from a contract with the Department of Vermont Health Access within the Agency of Human Services, and we have sort of two funding streams within that. One is maintenance and operations funding, which supports the ongoing operation of the Vermont Health Information Exchange, and then there's design development and installation funding, and that supports the implementation of the community and capabilities. So state health information exchange priorities and funding, those investments that the state makes are guided by the Health Information Exchange Steering Committee, and that's a multi-stakeholder group convened by the State of Vermont Agency of Human Services, and they document their priorities in a five-year health information exchange strategic plan, which is improved annually in November here by the Green Mountain Care Board. So that's the quick overview of who we are at Vital and what we do and how we're funded, and with that, I'm going to turn it over to Beth to talk about our budget amendment. Thanks, Marce. So, as I mentioned, this is an update, I'm so sorry, to our current fiscal year budget, which you did review and approve in June of last year, and our fiscal year goes from July 1st through June 30th of this year. And the changes reflect really two things, and the reason for re-forecasting the budget really is driven from our signing a new contract with the Department of Vermont Health Access for our January through June work. Traditionally, we've worked on a calendar year contract with the state, which then sometimes makes changes to our fiscal year budget because it's a mid-year where that goes into effect. So this forecast will reflect new items in that contract, as well as just our experience over the past six months of the fiscal year, so it's a more accurate reflection of where we expect we'll end up. So next slide, please, Maureen. Overall, there's not a very significant impact to our budget. We are projecting that net assets will be about $1,300 higher than we thought they would be in June when we did our budget. Overall revenues are increasing by about $543,000 and expenses by about $541,000. So just to give you a little, I'm sorry, next slide, please, a little context on the revenue changes. They're largely driven by new contract work we have. So One Piece is extending the funding for the Buy State for the Vermont Royal Health Alliance to do some data quality and quality improvement work. So there's $280,000 in revenue for that. You'll see on the next slide there's an offset of expenses where that goes to them to do the work. We've expanded the monies available for us to build bi-directional connections for healthcare organizations to the immunization registry. So we've been working with the Department of Health on a pilot whereby healthcare organizations can, through their EHR, their electronic health record, actually access immunization data on the patient that might be in front of them. And we are looking to expand that out to more healthcare organizations over the coming year. We have some work to work with the designated mental health agencies to aggregate what's called 42 CFR Part 2 data, which is really substance use data, which has different protections and privacy required around it. And we've been working with AHS and the DAs to find ways to aggregate their data in. So it is available for some purposes. And then with the ultimate goal, though this will be a longer-term goal, of making the data available or what data is appropriately available for different needs of different providers to support their patients. And finally, there's another increase. We shifted some revenue. We thought we would recognize in 22, but based upon the way the projects ended the year, we're going to recognize some of that revenue in 23. We also have a decrease in what we had projected on our budget for this year of M&O of about $470,000 lower than projected, which is offset by some lower expenses, which will take us to the next slide. Please. There's some key changes in the expenses. And really the changes in expenses are aligned to the projects and the changes I just talked to you about. So increased outside support to complete the projects and fill some vacancies that we have open, or positions we have vacant right now. We have some specific project expenses outside the outside support to support those projects. As I mentioned, the moneys to fund the VRHA in doing the quality improvement work. We have some additional costs we've included for recruiting and training. We do have some open positions. And we also do know that our staff, our existing staff and some of the new staff will need some training, particularly as we've implemented the new platform over the past couple of years to get some advanced skills and some of the new technologies we're using internally. And finally, for the increases, we have some unfulfilled contract costs so that some costs that we incurred last year, but the revenue is going to be collected this year. So it's kind of just an accounting thing. Well, we will have additional expenses recognized in this year. And then some decreases in expenses to offset some of those increases. And we are with staffing lower than budget due to some vacancies. We, as I mentioned, have some decreased maintenance costs based upon some project timing and we've decreased the contingency line in the contract. Now that we're further through a fiscal year, we just leave, we don't expect to need the same kind of room for things to change or shift. And so those are the big changes that kind of feed into that $1,300 change in our overall budget for the year. And I'm happy to answer questions now if it's easier or at the end. I think it's fine if we go all the way through to the end and members can hold their questions. That's fine. Thank you. Then I will give it back to Maureen to review your quarterly update. Thank you. So we do a quarterly update to the Green Mountain Care Board in alignment with our budget guidance. And that document is available on the Green Mountain Care Board website. It's a little bit more robust than what's in the remainder of the slides here, but we were encouraged to focus on two areas. One is patient education and the other is our quarterly metrics. So just know there's more information available should you need it, but we will go right into patient education. So VITAL is continuing its direct outreach to Vermonters through our current education campaign. So we've talked in the past about our commitment to educating Vermonters about their, how their data is shared and about their options regarding that sharing. So we do direct outreach. Last campaign was June through September 2022 and we're planning the next iteration for this summer. We also ask participating organizations, data contributors and organizations that access data to partner in an ongoing way in educating their patients about how their data is shared. So in order to do that, we have a toolkit of education resources we make available to the participating organizations and we encourage them to use that in many different engagements with them. So onboarding when we're doing check-ins with the organizations and we also do periodic outreach email campaigns to participating organizations, encouraging them to use that toolkit and also offering our services to help them if there's anything else they need to support patient education about data sharing. So our quarterly metrics are just a few snapshots of data about how data is accessed, how much data is accessed, who it's accessed by in the Vermont Health Information Exchange. I'm going to start by talking about the percentage of Vermont patients opted out of the Vermont Health Information Exchange today and our quarterly metrics go through the end of 2022. That rate is at 1.1% of all of the records in the Vermont Health Information Exchange are opted out. Vital access queries. So this is our clinical portal. This is the web-based portal where providers and staff can go in and look up patients' records one by one and find information to support healthcare operations and so forth. And you can see here some distribution across a number of different types of organizations. We have many different types of organizations using this service. So ranges from strong use at hospitals and independent practices to the Vermont Department of Health, a lot of public health use in there and emergency medical services too. So ambulance crews are using this as well in their work. Interesting distribution of usage. And vital access queries by month. So what do I mean by queries? Queries are a chart access, whether it happens through a search or we have a few organizations that sign on directly from their electronic health record and they can go right from the patient in their electronic health record into vital access. However, they get into that patient's record, that is one chart access and we count it up to one time per hour. So our chart accesses are holding steady. Right now it does look like there's a drop from 2022 but there was really big use around COVID by the Vermont Department of Health specifically and when you take that use out you see sort of strong steady use of this tool with a little bit of growth. Queries of the Vermont Health Information Exchange from eHealth Exchange. So eHealth Exchange is a national data sharing network. Initially before we switched platforms we were connected directly to the University of Vermont Medical Center and to the VADOD through point-to-point connections on the eHealth Exchange. They were using this regularly to pull data. When we switched platforms there was a need to rebuild with eHealth Exchange because they no longer permit point-to-point connections and only allow connections through what's called a hub model and we are putting that functionality in place right now. So results delivery is an interesting service that we offer in that it is used by a really large number of providers in the state of Vermont but almost none of them know that they're using it. So this is where we take lab results, radiology reports and transcribed reports. So notes and deliver them to the ordering provider right in their electronic health record and this avoids phone and fax based workflows. It's much more efficient than the alternatives and we have 586 providers currently receiving results directly in their electronic health records. To a large degree and we'll see now the results delivery by the receiving organization type, this is federally qualified health centers and independent practices who were supporting by delivering the results into their electronic health records. But I think it's also worth remembering that this is a supportive service for the organizations that are sending the results as well. So for the hospital labs that are sending the results. So that's a quick snapshot of our metrics over the course of the last quarter of 2022. And I will stop there and see if there are any questions. Ms. Mendeswell, do you want us to ask questions first? Are you presenting as well? And would you, if so, do you prefer to go before the board? I don't have a preference. So. Why don't you go ahead? That'd be fine. Okay. Sure. Thanks. Let's pull up my screen. Can everyone see that? Yes. Great. Okay. So again, I'm Jessica Mendeswell. I'm a member of the data and analytics team here. And I'll be presenting the staff recommendation today. Prior to providing the recommendation, I just wanted to walk through some background in the board's role in vital's budget review. So as part of its oversight and policy making activities related to the health information exchange, the board is required to review and approve vital's budget annually as well as any amendments. And so this authority came to the board in 2015 and was first exercised in 2016. And the board's oversight is intended to provide strategic guidance and policy parameters. As Beth mentioned, the board did vote unanimously to approve vital's current budget. So as required by the guidance today, vital presented their budget update because there was a change that exceeded the threshold as specified in the guidance. Our legal council recommended that the board vote on the modified budget so that there wasn't any uncertainty about whether vital is operating under an approved budget by the Green Mountain Care Board. So GMCB staff have reviewed vital's budget amendment for FY23 as modified and agree that it continues to comply with the four principles that are stated in the guidance. And those are transparency, incorporating public and stakeholder comment, alignment with the health information exchange plan, and alignment with the vital and diva process. In addition, vital will continue to comply with the conditions that were included in the FY23 budget order. Those are going to remain unchanged. All other aspects of the budget approval would also remain unchanged. So I just want to mention that at the end of this presentation, those conditions that were included in the budget order are in a reference slide. So just regarding public and stakeholder engagement, we did hold a public comment period. It began on Monday, February 13th, and it went through noon today. We did not receive any public comments related to the budget amendment. And we have some proposed motion language, which we can revisit after questions, but it's here for your consideration to move to approve the amendment to vital's FY23 budget as it was presented today. So we can go ahead and go back to discussion. Great, thank you. So congrats, Miss Gilbert and Miss Anderson on receiving no public comment. That is a rarity here, so good job. Others are going to want your secret. I'll turn to the board for a couple of questions. I have a couple real quick ones. I went through some of the financial statements, and I'm new to the board and the vital process. So I just want a little bit of background. And the financial statement that was submitted with the 23 budget amendment, it said collections for fiscal year 22 audited financials was 10.8 million, and disbursements were 9.1 million. And then there was a line for starting cash for the fiscal year 23 approved budget, which was about $5.1 million. That's sort of similar to like days cash on hand. That's just cash that's held at vital, is that right? Bob, do you want to take this one? Do you want me to? Let me just get to the, I believe that you're correct in your assumption. So what I, you know, the collections versus the disbursements is runs pretty close in your budgets from what I can see, right? Like there's not a lot of excess revenue above costs. So I had a question about how the cash position came to be around the $5 million level. It's an accumulation of the change in that asset. So for the past four or five years. There's been some years where we did have some funds at the end of the year in surplus, more than we had anticipated what we've tried to do. Now that we have built up. What I would say is a sound amount of our amount of cash on hand. So we can cover our shifts in costs and when the revenue comes in relative to the expenses, because the expenses are more consistent month to month. The revenue comes in a little bit more at peaks and valleys. As we complete deliverables. But what we've started to do is use some of the funds. You can see last year was an example where we did have a higher surplus than we had anticipated. And when the budget that was approved in June by the board, we reinvested or we are reinvesting some of those monies this year into the platform to enhance some efficiencies and capabilities in the platform. So we're trying to find the right balance of having enough cash to kind of weather the ups and downs and be prepared for those and then reinvest where we can to put them to good for the HIE. Is there sort of a target level that you've concluded is sort of where you want to be in terms of cash on hand? Great question. It's a conversation we're actually working through with our board. Now with the finance committee of our board to get put a formal policy in place, but you know, Bob, I think we've really aimed to have six to nine months. Feels like a comfortable place again, given given what we know about how there can be variation in the receipts. I had done some rough math last night. I thought it was about $29,000 per day based on the number. I'll mess this up. Sorry. You can scratch that question. Okay. That's pretty close. Yeah, chair. Oh, I mean chair foster, that's pretty close to around the usage of cash. So. And we have an open CFO position if you're interested. No. Bob would like to retire. Okay. Are there any sort of benchmarks or comparisons or guidelines that the board should look at in the future, not for this particular isolated thing, but in terms of what it costs to run. In HIE of this size and scale. Yeah, that's an interesting question. There's not a good benchmark and I'm not trying to be cagey. And, you know, I know that the state is looking to try to do some benchmarking against other HIEs, but because each HIE is so very different in each state, right? And has been built to meet state, state or community needs. They're not all state run. Some of them are more regional. There's not one that I could say look at that one. That's a great comparison. We. Some only move data and don't house it. Some only get certain data types and don't work through it. Some really just serve more as a provider portal. And that's it. And don't do some of the reporting and the kind of digging into the data that we do to make it available for some of our stakeholders for more robust reporting. So I think there are ways we can and this, this work with the states, the planning and taking on will give us some good guidelines, some definitive answer about what that looks like. But we do participate in a, sorry this is the long answer, but we do participate in a national collaborative of HIEs. It's called Civitas where we do, do have these conversations across HIEs. So we share org charts. We share how we do our work to at least help us understand how we're doing or where we can learn to do things better or differently, more effectively and efficiently. So it's maybe some more informal ways of doing it, but we do try across the board because we're all largely nonprofits, working with our states with public funds and trying to be good stewards of those funds and deliver as much as we can. Yeah, that makes sense to me. I mean, what you all do is quite different depending on the HIE. Okay. And so in this year's budget, there will be minimal contribution towards the cash on hand. And I presume that's because of just where your expenses lie and that you have a sufficient cash position. It did strike me as kind of large for a $5 million cash position on revenue of nine or 10 or $11 million, right? I mean, half the revenue is held in cash. It's just jumped out to me as potentially significant. Okay. I had no other questions. I appreciate those answers. Thank you. I'll turn to any other board members. Quick question about the immunization directory work that you're doing. Could you just give us a sense of how many organizations were participating in the pilot and how many you're hoping to expand it to? I'll answer if anyone wants to help me feel free, but we have one in the pilot. We have, I think, 10 that VDH has on their kind of next list to start to try to work with. And then I think the population is just limited by the number of healthcare organizations in the state that will want that access. So thank you. And the other question I had around the DA, the work you're doing with the DAs around the part two data. What kind, I'm just curious since obviously until you work out the longer term issue and the federal regulatory issues around sharing the specific data, what kind of uses are you anticipating the aggregated data would be available for? So this is support and I don't know all, I don't have all of the specific details. So I'll share what I know is the state as a funder, right? So as a funder of some of this work really through their partnership would like to work with the DAs to do some, to understand better the services, right? So the goal is to really be able to combine the part two data that they hold with the, I'm going to say the other clinical data that we have in the HIE and really join it together to get a more robust picture of kind of patient and population health. So I think the goal and the more near term is to have that more complete picture of those patients for some of their work. That's right. Thank you. It sounds like it's largely state driven and the, or AHS driven and that they would be the user of that data. Yes. Yes. And hopefully, yes, hopefully the DAs will be able to get them better analytics too on their patients, but pulling it together. Great. Thank you. The only comment that I have to add on this, I support the budget amendment, but is that I and I, we've had these conversations and I just want to continue to, to encourage whatever provider usage we can of this data. It seems of the user interface. It seems like an incredibly useful resource for Vermonters and providers in Vermont. And just I'd love to see those numbers grow and more utilization. I do. I think this has come up in other conversations too. I do. I think that at least several of us at the board would love to see one of the various organizations that works with the various types of providers. Such as large groups of providers, be it ACO or, or you all have a provider faced dashboard for patient oriented metrics. And I know that's a step away from what you have been doing so far, but it just, it's something that it just seems like when you look at the utilization by independent providers and FQHCs for results, it's almost like the perfect place to have some aggregated information in there for providers. But again, scope creep for this discussion and I appreciate the work you do and you coming here today to present the budget amendment. Okay, and it's an idea that we definitely are, we have on our roadmap, so we will talk more. Okay, unless there's any other board questions or comment, I will turn it over to healthcare advocate for any questions or comments they may have. Sure, we don't have a position on the budget amendment. I do want to say for historical context, and it deserves to be recognized. HCA was very critical a few years ago about the match rate of records and VITAL has substantially improved that. And I think it's a very good example of demonstrated success that we should hold everyone to. And as board members who have been on for longer note, we took a position different from the board and from VITAL for opt-in or opt-out of the system. Obviously a different direction was the parties decided to go towards opt-out. But I think VITAL did a very good job of explaining that to consumers. And although I would imagine our position on it hasn't changed about the harm, the risks of an opt-out system, I would say all of our concerns were addressed by VITAL and I think they did a wonderful public education campaign. Thank you. Mr. Schulte, thank you very much for your comment in recognizing the improvement that you saw. I think that's important to do, so thanks for doing it. With that, I'll turn it over to public comment, okay? Seeing none, Ms. Bindisbel, would you mind pulling up the suggested motion language again? Sure. I'll move to approve the amendment to VITAL's fiscal year 2023 budget as presented today to the GMCB. I'll second. Is there any board comment or discussion on the motion and all those in favor, please say aye. Aye. Aye. And the motion carries unanimously. Thank you very much, Ms. Gilbert, Ms. Anderson and Ms. Bindisbel for your presentation today. Thank you all. Thank you. I think that is all we have on the agenda today. Is there any new business? Any old business? Ms. Barrett, did I make any mistakes? Okay, all right. Is there a motion to adjourn? So moved. Second. I guess everybody else wants to stay. All those in favor, I don't. So I'll say aye. Aye. Aye. Aye. All right, thank you everyone and have a nice day.