All right. It's 930, so I'll call the Green Mountain Care Board's meeting of November 16th, 2022 to order. We have a long day ahead today. I hope everyone's enjoying the first beautiful snow that we've had this year. It's really lovely here in Montpelier. Today's meeting, we are going to have the executive director's report. Sarah Kinsler, a director of health systems policy, is going to review the Vermont all-payer model extension. Then we're going to hear from the staff relating to gather their health, which has undergone a name change since we last met them. And then we will have Vital and a break. And then we'll have the health information strategic plan and connectivity criteria for 2023, presented by Catherine O'Neill here from the board and Kristen McClure from the health care reform integration. She's a health care reform integration manager at AHS. And with that, I'll turn it over to Ms. Barrett for the executive director's report. Thank you, Mr. Chair. Good morning, everyone. So I reminder that there are several open public comments open right now on our website. If you go under the public comment section, you will see all the details. We have the HIT plan, which HIE plan, excuse me, which Chair Foster just mentioned. We have the one care Vermont budget and certification. And we also have the potential next model, which is of the all-payer model, which has been ongoing for a long time. And any comments we receive regarding that issue, we will share with the governor's office and AHS as they are leading the negotiations on the next model. I also want to announce some scheduling updates. So the next couple of weeks, we'll be meeting on Monday instead of Wednesday. And happy Thanksgiving to everyone for next week. And then an exciting announcement, the board is going on the road. We're going down to the Retland community on December 5th. And we'll be conducting our board meeting in person in Retland. So stay tuned for more details on that. We'll be sharing very shortly. And we're excited to get out in the community and hear from patients and providers and businesses. And really excited to be in person for that time. So with that, I will turn it back to you, Mr. Chair. Thank you. And we'll take up the minutes from November 9th, 2022. Is there a motion to approve the minutes? So moved. Second. Is there any board discussion relating to the minutes? Hearing none, those in favor of approval of the minutes of November 9th, 2022, please say aye. Aye. The minutes are approved. And with that, we'll turn it over to our Director of Health Systems Policy, Ms. Sarah Kinsler for discussion of the Vermont all-pair model extension. Ms. Kinsler. Thank you very much, Mr. Chair. Let me get projecting over here. One moment, please. Are folks able to see the document I got up on the screen? All right, great. All right. So for the record, as Chair Foster stated, this is Sarah Kinsler, GMCB Director of Health Systems Policy. And I am here today to present the terms of the short-term extension that the Vermont signatories have negotiated with our federal partners at the Centers for Medicare and Medicaid Innovation, or CMMI. The extension agreement has been negotiated but not signed. So the board will need to consider the extension contents, hear public comment, and then make a vote on the extension agreement before it can be executed. As Susan mentioned, we're currently accepting public comment on this matter. And I'll be back before the board on November 28th to report out on any comments we receive and make a staff recommendation. And we also have a potential vote noticed for that day. So before I jump in, any questions about process? All right. Hearing none, we'll get to it. So for a little bit of context, the Vermont All-Pair Model Agreement, or APM, was originally slated to operate from 2018 to 2022. It is signed by the Governor, the Secretary of Human Services, and the Chair of the Green Mountain Care Board. In light of the COVID-19 pandemic and the transition to a new federal administration in 2021, the AHS Director of Healthcare Reform, Ina Bacchus, and I came before you late last year with a proposal to request a one-year extension of the current APM agreement so that we could allow for fuller stakeholder engagement and an additional year of data to inform our proposal for a subsequent model. At that time, the board voted in favor and the chair with the Governor and the AHS Secretary formally requested that one-year extension in December of 2021. In response, our federal partners at CMMI offered Vermont a one-year extension plus an additional transition year at Vermont's option. So CMMI has indicated that this two-year extension would best fit with their timeline and could act as a bridge to a future model potentially. So for the past six months or so, the Vermont signatories led by the agency have been negotiating with CMMI on what the actual contents of that extension would be and to come to terms, come to agreement on terms, excuse me. So what is in that extension agreement? And I'll say for folks on the phone and board members and anyone in the public following along, I do not have slides today that I'll be presenting on the screen. I've got a summary of the amended and restated agreement that kind of describes the changes and goes through them in more detail. We've posted that. We've also posted the amended and restated agreement itself. So those are both part of the meeting materials. And I'll just scroll through here and kind of walk us through the summary document. So again, led by the Scott administration, the state signatories negotiated the extension agreement. If signed, this would extend the model for a year with CMMI being required to offer Vermont an additional transition year. If Vermont accepts the option year, that would put the current agreement through 2024. So what are the major themes? There are a lot of technical updates included in this. A big part of a big part of this is updating the agreement language, the legal language to accommodate the change in time period. There are also changes to recognize that COVID has and likely will continue to impact Vermont's performance on the agreement targets and to appropriately allow CMS and Vermont to consider COVID and other factors that are outside of the state's control when we look at this performance against the agreement targets that go over the lifetime of the agreement. And finally, there are some technical changes to the population health and quality measures to reflect changes to national quality measure sets and specifications. The table on the second page of this document, which I'll scroll down to now, please let me know if the kind of document projection is moving a little slowly and I'll slow myself down. This really outlines the changes that were negotiated and I'll kind of walk us through those. So first, there is a series of recitals added to the introductory language of the agreement that would be added to describe the amendments. It's also a great summary of what's changed and a helpful place for folks to review if you're trying to follow along. The agreement would be updated to reflect the new end date, so 2023 or in the event that we take that second option year at 2024. And that impacts both the term of the agreement specifically, but it also flows through to calculation methodologies related to the targets and other things like that. Next, we've added language related to the waiver of scale enforcement to both explain why that was granted in 2021, provide that context on why the targets were waived. And in keeping with that waiver, there would be no targets during the extension period, but Vermont would be required to continue to measure and report on scale performance as we have since the start of the model. And I do just want to say all of the reporting that would potentially be done during the extension period that we're contemplating would continue to be public and we continue to report those things publicly. As I mentioned above, we wanted to make sure that the agreement considered the potential impacts of COVID on Vermont's healthcare system. So an exogenous factors clause would be added to the population health outcomes and quality of care section, bit of background here. In the original agreement, there was a clause in the statewide financial target section, that's section nine. We commonly refer to that just as total cost of care. And that allowed the state to reflect that to request that exogenous factor. So factors outside of the state's control be considered in assessing the state's performance against the model's financial targets. And in determining any enforcement action by CMMI. When the agreement was signed, we were thinking about natural disasters, heavy flu seasons and things of that nature. Obviously, we've had a significant exogenous factor that I don't think any of us would have anticipated at that time. So the negotiated extension agreement would allow for an identical process related to the state's performance against the statewide quality of care and health outcome measures that are included in the agreement. And it specifically adds a mention of COVID-19 as one such factor, both for quality and health outcomes and for financial targets who are explicitly recognizing that COVID is an exogenous factor. In addition, in Appendix one, which provides the detailed specifications for all of those statewide measures, it waves enforcement for failure, for the state's failure to be kind of on track to meet those agreement targets for performance years three and four, so 2020 and 2021. Next in section eight, which outlines the state and federal responsibilities related to administering the Vermont Medicare-ACO initiative, we would add clarifying language to reflect the process that the board uses to determine the total shared savings advance payment amount. And this is the dollars that go toward the blueprint for health payments to patient-centered medical home practices to the community health teams and to the sex program. This amount is proposed to CMS annually by GMCB in a letter that the board sends with its proposal on the Medicare-ACO benchmark, the ACO program spending target. Next in sections 11 and 12, the extension agreement would add requirements that CMMI collaborate with Vermont to inform future models and would require CMMI to continue to work with Vermont to explore ways to allow additional provider types to receive Medicare reimbursement for mental health and SUD treatment services to better align with the provider types that Medicaid is currently able to reimburse. In addition, the extension agreement would adjust some of the model reporting requirements during the extension period, so adjusting the frequency of total cost of care reports from from quarterly to semi-annual just because we were seeing limited utility to the quarterly reports, streamlining required content of the reports submitted in the extension period and updating the report deadlines to align with when we're actually able to produce them based on data availability and also like eliminating future payer differential reports, HHS's report on integrating mental health SUD and home and community-based services with the model financial target services and requirements for Vermont to submit a proposal for a subsequent five-year model. I do want to note that again in the event that we execute an extension all those reports that we do produce will continue to be public and posted. So finally, Appendix 1 would also be modified to include technical revisions to the quality measure specifications. Those reflect changes to national measure sets, changes to reflect Vermont's specific reporting mechanisms, and also to amend the approach to identifying whether measures are deemed to be on track toward the final kind of end-of-agreement target as well. I do want to briefly note that there were some areas that Ina and I presented last year that we requested in our additional proposal that CMMI was not able to accommodate during the extension period. Chief among those were payment model changes to the Medicare ACO program which was at the request of participating providers and changes to how the Medicare contribution to blueprint and SASH funds would flow. So what happens if we agree to an extension? With an extension, providers can continue to participate in the Vermont Medicare ACO initiative which is the Vermont modified version of the Medicare Next Gen ACO program. Through the extension, Vermont providers continue to have access to the potential for shared savings and shared risk with the payment model consistent with prior years of the APM agreement. Providers also would continue to have access to the Medicare waivers that kind of come with participation in that program including the telehealth waivers, home visiting waivers, and the three-day SNF rule waiver noting that providers have been able to implement some of those more easily than others. Providers also continue to be exempted from additional reporting requirements and quality based payment adjustments associated with MIPS Medicare's merit-based incentive payment system because participating providers are considered to be participating in a Medicare advanced alternative payment methodology. In addition, Vermont continues to receive Medicare funding for the blueprint payments to the primary care practices, CHTs, and SASH. That was about $9.1 million in 2022. And finally, Vermont would continue to maintain a high level of contact with staff and leadership at CMMI which we hope to use to advocate for future models that can benefit Vermonters and Vermont healthcare providers and that can really work for us as a state. I do want to remind folks that the results we have to date from the most rigorous analysis of the all-pair model which is the federal evaluation of the model have been positive. The initial evaluation report from the independent evaluators at NORC covered 2018 or 2019 and provided an early picture of implementation and impact and they did find positive early indications for the Medicare ACO program and Vermont as a whole compared to other states including savings for Medicare. Conversely, without an extension, Vermont providers rejoined Medicare fee-for-service unless they're able to enter a different Medicare advanced alternative payment methodology. They would be subject to MIPS and its quality related payment adjustments unless they would otherwise be exempted and they would lose access to those waivers associated with the Vermont Medicare ACO initiative. Vermont would also lose that $9 plus million contribution to the blueprint PCMH, CHT, and SASH payments and would no longer have kind of the same level of access in relationship with CMMI. So in closing to my remarks, I'll say Secretary Samuelson sent a memo to the board yesterday stating their support for the extension and that letter has been posted to our website and included in the meeting materials. I want to thank Secretary Samuelson and Director of Healthcare Reform, Ina Bacchus, for their partnership in this and for helping the board understand where the co-signatories stand in position to this. And as I mentioned, we're currently accepting public comment on this matter so I'll be presenting any comment we receive and a staff recommendation to the board on November 28th prior to a noticed potential vote on this topic.  Great, thank you very much. That was extremely informative. I see on our agenda that our general counsel is listed is Mr. Barber also presenting on this topic today? Not presenting, I'm just here to answer questions if there are any. Great, thank you. With that, I'll turn it to any board questions or comment and we'll start with Ms. Lunge. Thank you, Sarah. That was a wonderful summary. I really appreciate all your work on this. I don't actually have any questions. Thank you. All right, Mr. Walsh, do you have any questions or comments? Sure. Good morning, Chair, and thank you. Good morning, Sarah. Great job summarizing what has been, I'm sure, a lot of work, a lot of conversations, a lot of hard thinking. I appreciate the summary. I have one question. I'm wondering, it seems often conflated, but the all-pair federal agreement and the ACO that we have in the state, and I'm wondering if you could say a little bit more about that relationship and what's the core function for an ACO in this agreement? Thanks for that question, Member Walsh. I'll try to answer it in parts and I'll look to Mike to jump in if he would like to. I do want to stress, and I think this is great context and something I probably should have mentioned at the beginning of my remarks. When we talk about the extension agreement, when we talk about the all-pair model agreement, we're talking about the contractual relationship between the state of Vermont and CMMI that allows us to kind of have this slightly special relationship, slightly special model for Vermont. No ACO is a party to that contractor relationship, but it allows Vermont and CMMI to offer an ACO or ACOs who would want to participate, a slightly Vermont-tailored ACO model for our state. As you know, we have one ACO currently participating in the Vermont Medicare ACO initiative. That is a relationship really between that ACO and CMMI. There is a participation agreement that governs that relationship, so the ACO federal contractual relationship. It is CMMI that deems whether an ACO possesses the core competencies to participate in that model and those requirements are laid out in that participation agreement, which again the state is not a party to, so two separate contractual relationships. Mike, do you have anything to add there? No. Thank you for that background and context. It's very helpful. I guess the second part, I'm just digesting that information, but the second part is in our agreement, what's the core function of the ACO in this agreement? What's the key thing that they are supposed to be able to help the state do to fulfill its contractual responsibilities with the federal government? I'm mute, so I want to let him answer first. I would say that the core function is to take responsibility for the cost, quality, and overall care of the populations that they're contractually responsible for caring for. The all payer agreement doesn't really get into the details about core functions of an ACO like care coordination and data and stuff like that that is typically covered in the payer agreements. Like Sarah mentioned, I don't know, Sarah, if you want to add on to that. My only addition would be that the part of the agreement that most closely relates to this is the part that describes the state and federal responsibilities in administering the Vermont Medicare ACO initiative. Under the agreement is the state's responsibility to support Medicare in offering this Vermont-specific ACO model. I would say that's where the all-payer model agreement leaves it. Thank you both very much. I've professionally worked with more than a handful of ACOs, but not in Vermont. This context, the state-specific context, is really helpful to my thinking, so thank you very much. Thank you. Ms. Holmes? Yeah, thank you. I actually don't have any questions, but Sarah, Mike, and the others on the team, I just really want to note my appreciation for the hard work that you did over the several months related to these negotiations and the planning for the negotiations. So, thank you. No questions. Great. And Dr. Berman, do you have any questions or comments? Additionally, no questions, but an additional appreciation for all the hard work that everybody has done through this process and advocating for Vermonters through the process. So, thank you so much. Great. And I participated in some of these negotiations and work, so I got to see firsthand the effort that this took, and I'll express my appreciation for the Secretary, Jenny Sandelson, and Director Ms. Bacchus for their efforts in collaboration with us on this, and our staff's great work, and I have no questions. With that, I'll turn it over to the healthcare advocate if they have any questions or comments. Thanks, Chair Vosler. No, nothing for most. Just appreciation for Sarah and the team, and happy winter days to everyone. Wonderful. Thank you. And with that, I'll turn it to public comment. Please, as usual, use the hand function, and I'll call in the order in which I see them raised. The first one is Ms. Aranoff, Ms. Susan Aranoff. Please, go ahead. Sorry, Ms. Aranoff, sorry, you're on mute. Yeah. Good morning. Nice to see everyone. First of all, Sarah, thank you so much for all this work. And as you can probably really anticipate the change I am most thankful for is that Medicaid-funded home and community-based services, the other side of the Medicaid house, seems to no longer be in the crosshairs. So this is, I guess, I don't know if I can ask questions. I just want to really confirm that, but I can read. It seems like it's really off the table. My real comment, and this is really goes to the new members, but I'd ask the ones you've been there before to just think about it. Just as some feedback, I do policy work for the Vermont Developmental Disabilities Council. I'm a state employee. I'm housed in the Agency of Human Services Secretary's Office as an Affiliated Council. All 50 states have a Developmental Disabilities Council. We're entirely federally funded. We exist to really, to bring the voice of people with disabilities and their family members into all these important policy discussions. In order to get the federal money that pays my salary, for which I'm very grateful, Vermont has to sign a set of assurances. Jenny Samuel since signed the most recent ones that guarantee that the Developmental Disability Council A gets to advocate whatever policy positions we want, whether they align with or depart from the AHS. So that's first and foremost. Just want to give, I always try to lay that out for people when they see my email, vermont.gov. I work in AHS. Why do I get to sit here and question the wisdom of Jenny Samuelson or Ina Bacchus or anyone else? So because of these special assurances and this special unique role we have. A little bit of my own personal background, as Sarah and other folks know, I worked on the healthcare transformation grant that kind of gave birth to the all-pair model agreement. Very familiar with it and with how it's operated. One of the things that really undermines people like me that are faith in it, is that the agreement and care board is a party.  You guys sign it as a party. Under the agreement, you guys have responsibilities as a party. The chair has to submit an annual letter saying that he's working with the ACOs to achieve scale targets. Throughout the agreement, even the new agreement, wherever it says the state, the state shall do this, the state shall do that. It's not just the agency of human services and the governor, which is an appropriate role for them. It's also the green rotten care board, the regulator. So you guys probably know it's not a new question. Are you a promoter? Are you a regulator? Are you a reformer? Are you a regulator? In my personal experience, we can just take the issue like administrative expense. Originally, one care was going to have to show that in its budget, their administrative expense, that the benefit the state got every year, either through savings or improvements of quality, outweigh their administrative expense. But the board in its wisdom did what I call literally move the goalposts and said, no, no. We could never just functionally calculate in any given year what the administrative expense was after the fact to what the savings were. It just was like a mathematical puzzle that just couldn't really be worked out. So as you guys know, because you discussed last week, now that administrative expense is going to be matched up against cost affirmance or other vague things at the end of the project with this extension, it's not clear when that reconciliation is ever going to take place. So the board as a regulator might think moving a goalpost or changing a target or changing something in the budget order is a smart thing to do, but when the board is also a party and when the board, when I've sat through meetings after meetings, hospital budgets, meetings, hearings, where the board convinces, controls, coaxes, encourages, changes policies to really incentivize hospitals to have every possible program in the ACO just all along the way, done everything it can to promote this all-paramodal success of the all-paramodal agreement because you guys are a party to it, people like me lose lost faith, a lot of faith along the way. Are you doing this because this is what's good for Vermonters, what we'll keep down costs, etc. Are you doing this because it's good for this agreement? What's good for the ACO? What's good for you via healthcare? So I would just encourage you amongst yourselves and with Michaels Wise Council and other attorneys amongst you to consider why you think you need to be a party to this agreement. Most other states that have agreements with Medicare, they don't have an entity like the Green Mountain Care Board. I did a lot of research way back when to see if the Green Mountain Care Board as an entity could even enter into such contracts. But as you all know, lawyers and others amongst you familiar with administrative law probably know that the Green Mountain Care Board is just this empty vessel and the legislature breathed life into it and the legislature I'll say gave you guys a bum deal. They told you to develop regulations that balance support for innovation with oversight. They also put you in tandem with the agency of administration, with the governor, to negotiate with CMS for an all-payer model agreement. And honestly to this day, I just don't get it because I think it is really undermined your legitimacy as a regulatory body. And when you have the kind of monopoly or close to it system that we have in the state, you need a strong independent regulator with credibility whose chair doesn't go and become the next big earner at UVM. I mean, there's a lot of reasons why those of us out here don't have a lot of faith or respect for certain parts of this process. But one of them really is you're just isn't the kind of regulatory objectivity or distance for project of this undertaking. There hasn't been to date. It seems like maybe there's a sea change. So I would just implore you to reconsider the question of, do you need to be a party? And if so, why? And if you're going to be a party, how can you mitigate against the appearances of conflicts of interest and conflicts of roles? Some of you may or may not be aware. About five years ago, the Legislative Committee on Administrative Rules had a little conversation with Chair Mullen when he was a new chair saying, hey, Mr. Chair, we're a little concerned about this apparent EB-5 conflict. They use the language EB-5. That's why I'm using it, conflict between promoting and regulating. And the chair then was kind of open to having the conversation. None of the committees of jurisdiction at the legislature ever taken up that issue. But to my knowledge, publicly, Agreement Care Board has never taken up that issue. If you guys could take that issue up offline, so to speak, I think it would be really beneficial to the system overall to get some clarification of your role. Promoter, regulator, reformer, all of you above. We've really, in our world, we are really looking for a strong regulator. Thanks. That's my comment. And I'll be putting some of the stuff I'm writing. And again, Sarah, so I'm trying to learn to do the compliment sandwich you guys and really excellent, excellent work on the redraft and the elimination of the home and community-based services being in the total cost of care, all that kind of stuff. Super tremendous.  Thanks. Ms. Ernoff, thank you very much for those important points and for raising those. And thanks for your close participation and your work at the Developmental Disability Council. Glad you raised your hand and raised those. And there are certainly issues that we think about and that are important to Vermonters and to us, of course. So thank you for doing all that. And I don't see any other hands raised at this point. And so with that, we will turn on to our next subject, which is the staff presentation on Gather Health. And I'm forgetting their new name, but I'm sure our staff will remind me. And our Associate Director of Health Systems Policy, Marissa Melamed, will take it from here. Thank you. Thank you, Mr. Chair and members of the board. I'm actually going to turn it right over to Senior Health Policy Analyst Julia Bowles to walk you through the slides. Thank you, Julia. Yeah, thank you. Good morning, everyone. Can people hear me and see the slides? Wonderful. All thumbs up. Thank you. Great. So like Marissa said, my name is Julia Bowles. I'm a Senior Health Policy Analyst. And I'm joined today by Marissa Melamed and also Russ McCracken who will be available if there's any questions. And, yes, so Mr. Chair, the new name is Lower Health, formerly Gather Health, which is who we're here to revisit today. So in terms of the agenda for this presentation, we will briefly review the scope of this review as well as some new information that we've received from the ACO, provide a summary of the recommendations, and then we will have time for board questions and discussion, public comment, and then the potential vote. So this slide should look very familiar to people at this point, but we wanted to bring it up again just to remind people of the scope of this review in that we are looking at a Medicare-only ACO with fewer than 10,000 lives, which is highlighted on the right-hand side of the screen. So it's important to remember that this is a very different process from the One Care Vermont process that kicked off last week, which is reflected on the left-hand side of this crazy flow chart. So some of the main differences between today's ACO and One Care's review is first that Lower Health is a Medicare-only ACO, meaning that they're not subject to certification. Second, due to the ACO having fewer than 10,000 lives, the review is guided by a different section of Vermont statute. Third, the GMCB is in a different regulatory posture relative to lower, and this is because Lower Health is participating in a standard Medicare program called the Medicare Shirt Savings Program, which has many preset terms that are all established under federal rules. And additionally, lower is a multi-state ACO, so the board is balancing its review of the ACO with the jurisdictional limits of regulating their operations specific to Vermont. So this next slide is just sort of a summary of everything that I just went over for reference. And moving on, we just have two short slides reviewing information that we have received since we last presented on this topic on November 2nd. The first, as Chair Foster mentioned, is that we heard from the ACO about their name change, so formerly Gather Health, ACO LLC, the legal entity submitted a legal name change due to another entity using and trademarking Gather Health shortly after their initial use, and their legal entity is now named Lower Health, ACO LLC, which I will refer to as more or lower health as we move through this presentation. So GMCB staff will work on updating the website materials to reflect this change with the prior submissions that we received with their budget. We'll still have the name Gather Health. The second part of the new information is that the GMCB received information from Lower Health providing further details about their corporate structure and confirmation of what they shared during the hearing that they will not sell or share beneficiary data. Finally, as it relates to new information, we have not received any written public comment about Lower Health FY23 budget. So with that, I will move on to the summary of the recommendations. In the following slides, anything in red text is going to denote something that has changed since we last presented these recommendations on November 2nd. There's also key points below each recommendation, which are also from the past slides that the staff presented on November 2nd, and they have a snapshot of the evidence supporting the staff's recommendation. So I will go through all five recommendations and then come to a slide that summarizes them so we can see everything together. So the first recommendation is that Lower Health provides to GMCB its shared savings or losses segmented for Vermont. The second recommendation is Lower Health provides an updated version of their Vermont financial summary with actuals, including a breakout for in-kind incentive spending, and that GMCB staff are to develop the template and set the deadline. The third recommendation is for Lower Health to provide to GMCB its quality reporting segmented for Vermont, if possible, with appropriate restrictions to protect patient confidentiality. The fourth recommendation has a lot of red, so I will do this one a little bit slower. I know it's also a smaller font, but the red reflects additions that were made in response to feedback that board members gave at the November 2nd meeting. So the recommendation reads, Lower Health provides a copy of the terms and conditions given to beneficiaries upon signing up for the Lower Health platform, as well as any other marketing or informational materials shared with beneficiaries. So moving to the sub-bullet, Lower Health shall notify the GMCB immediately if the intended use of beneficiary data changes from what Lower Health presented to the GMCB in connection with the review of Lower Health FY23 budget. There's some text that has striked through on it, which is just taking out the old date reference. In continuing in red, if no changes are reported to GMCB, Lower Health shall provide a certification under oath with the submission of its FY24 budget that no changes have been made to Lower Health intended use of beneficiary data. And when we get to the summary slide, this one will be nicer to look at. So I'll keep going. The fifth and final recommendation is that Lower Health provides a bi-annual update with the first report submitted with their FY24 budget submission on October 1st, 2023, about how Lower Health's care model is working in Vermont, including the number of Vermont attributed patients registered to the Lower Health platform and any unique Vermont challenges. And the development of this template report is delegated to GMCB staff. So this slide has a summary of the recommendations, which I will plan to leave up on the screen as we move into board questions or comments. But I also just wanted to show that we have suggested motion language on the next slide, which I can return to when the board's ready for that. But for now, I will pass it to you, Mr. Chair, and go back to the summary slide for your reference. Thank you very much. I'll turn it over to board questions or comment. In the same order, we went through the all-payer model extension. Sorry, Ms. It looks like you're Robin. Are you speaking? Got it. No questions. All right. Tom, do you have any questions or comments? No, no questions, no comments. Thank you, Julia, for the summary. I don't either. Thank you for the clear presentation, the updated recommendations, and I have no further questions or comments. Same for me. No questions or comments at this time. And thanks for all this. I don't either. And with that, I'll turn it over to the healthcare advocate for any questions or comments. Nothing else from us. We appreciate the opportunity to air our concerns and the opportunity to work with Marissa, Julia, and the team, and we support the recommendations before you. Back to you, Chair Promster. Thank you. And I'll turn it to a public comment, again, using the raise your hand function. Seeing none, and based on the concise and clear recommendations, is there a motion? I'm happy to make a motion. I move that the Green Mountain Cabinet approve lower health ACO's fiscal year 23 budget as submitted to the board subject to the conditions reviewed by the board today. I'll second. Hopefully you can hear me now. Great. So Jessica moved and Robin seconded. Is there any board discussion of the motion or any members wish to comment on the motion? Hearing none, is there any public comment or HCA comment on the motion language? Hearing that, all those in favor of moving that the Green Mountain Care Board approve lower health ACO's fiscal year 23 budget as submitted to the board subject to the conditions reviewed by the board today. Please say aye if you're in favor. Aye. Aye. The vote is unanimous and the motion carries. Thank you very much, Ms. Bowles and Ms. Melamed for your work on this and Mr. McCracken. And for the first time, I think in my 10 years chair, we are ahead of schedule by a healthy margin, which makes me happy. Next, we have a presentation by Vermont Information Technology Leaders and Vermont Health Information Exchange overview. And that will be provided by Ms. Maureen Gilbert, who is the Director of Client Engagement at Vermont Information Technology Leaders, commonly known as Vital, and Ms. Beth Anderson, who is the President and CEO of Vital. And I see that they're both here and ready. So thank you guys for attending and being here. And with that, I'll turn it over to you. Thank you very much for the opportunity to talk to talk to you today. What we're doing today, you all have seen the agenda, but we're going to do a bit of an overview of the HIE, particularly it's been a while since we've done it, cats the new members up about what we do. And then later in the agenda, we will give you our quarterly update so we can talk in a little more detail about the work we've been doing since the last time we talked with you. I'm here, as you mentioned, with Maureen Gilbert, who's our Director of Client Engagement. And also Christina Chokat will be part of this conversation, and she's our Director of Operations. I just wanted to take a minute to start off and tell you about the conversation. Should we display the slides? I don't know if we coordinated that up front. I can go ahead and share my screen. Is that great? I didn't know if we could do that. Thank you. So just as you mentioned, vital Vermont Information Technology leaders, we have the designated operator of the Vermont HIE, and that has been a case for a while, designated in the HIE plan to be the operator. We are an independent nonprofit, we're 501C3, we're based in Vermont, we have about 27 staff members. We are governed by a board of directors who represent across the healthcare and business ecosystem in Vermont, represent hospitals, healthcare providers, health technologists, payers, and independent businesses across Vermont to guide the organization. Next slide, please. Our mission is to securely aggregate, standardize, and share the data needed to improve the effectiveness of healthcare for Vermonters. We walk through the slides today, we'll talk a lot about the work we do to make sure that the data really is standardized, aggregated, matched to individual records so we can have one individual patient record really help to inform care and the work that goes into that to really make the data usable and meaningful for providers and other purposes that we have. And with that, I will turn it over to Maureen to talk through some of what we did. So we're going to start right at the beginning today with what is health information exchange, and I'm going to rely here on the Office of the National Coordinator for Health Information Technologies definitions. So health information exchange, you can use it as a verb, the exchange of health information appropriate and confidential sharing of clinical information among authorized organizations, or you can use it as a noun. So an organization that has agreed upon operational and business rules that enable electronic sharing and secure exchange of health related information. And that's what the Vermont health information exchange is. That's what vital is. We operate the noun of health information exchange. And we'll talk a little bit about the benefits of health information exchange, and I'm going to go right to the next slide to talk about benefits sort of stakeholder by stakeholder. And we always start here with patients. So for patients, one of the goals is that they don't have to carry their records with them from provider to provider. They don't have to make these record requests. There's less burden on the patients. There's also the benefit of better care at their providers because they've got more complete information to work with. For providers and provider organizations, and we work every day with providers who are participants, we see that they have access to more complete patient records that can support care delivery and form care coordination and reduce duplicate tests. It's also about efficiency. So this is about getting data from other providers accessible in their electronic health records and not by fax. It's amazing how much faxing is still happening in the healthcare system today. And we're really working to try and reduce that and get data flowing electronically. We also serve as a hub for efficient data sharing. So without Vital, without the Vermont Health Information Exchange, there would be much more requirement of point-to-point connections between healthcare providers and between healthcare providers and, for instance, health reform initiatives or the state. We serve as a hub to reduce that duplication of connections. We're also a source of patient data during planned or unplanned system downtime. And we've seen that a couple of times in the last few years where health systems or organizations have had unexpected downtime and they've relied on patient data in the Vermont Health Information Exchange to continue providing informed care. There's several other stakeholders that are important and that use our data in their day-to-day work. I'm going to start with public and private payers. For them, access to data can support operations like case management, prior authorization, and potentially quality measurement. And we are seeing that happening today, particularly the case management work. For public health, the Vermont Department of Health access to patient information supports case investigations and supports public health programs. And it also provides the opportunity to aggregate immunization and laboratory data. And we'll talk a little bit more about how we do that because it's something that we've been working on a lot lately in a way we've supported public health recently. And then data is also used for population health purposes, so to support operations and measurement of health reform and population health initiatives. So I'm going to turn it over to Christina Chouquette, our director of operations, who's going to tell us a little bit more about how we do what we do. Hi. So I'll just start with kind of repeating what some of what's been said before and maybe digging a little bit more. So the power of the VHI is collecting the data real time and not having to collect data that's weeks or months old. And then once we get that data, being able to actually aggregate it, match it across the state and then standardizing that data for several purposes, some of which Maureen has already walked through. And again, serving as a hub so that you get the data one time and you can use it for many purposes so that we can share the data, providers can access the data. And it eliminates that need of having to create point to points. If we have the data, we can use that data several times for several purposes. At the same time, protecting that data and honoring patient consent, as well as having security practices in place and policies that we follow, we take the privacy of the patient's data very seriously. And then when we are able to share that data using it for the many purposes that Maureen walked through, supporting patient care, helping with quality improvement programs, and those types of activities as well as case management, having providers and users of the data access it in order to better care for their patients. Next slide, please. So after we do all of that collecting and aggregating and matching, we do have that one longitudinal record for Vermonters that can provide meaningful and usable data to those who need it. So we don't simply just take the data and move it all around. Behind the scenes, we do extensive work in order to do all of that matching and standardizing of the data, understanding the data that we are getting, making sure that it's put into code sets that can be understood by electronic health records or other types of analytic systems. Those systems are expensive. We want to make sure that the organizations that purchase those systems actually can leverage that data. Plus, we also need to make sure that it's translated into ways that providers can actually read the data. It needs to be human-readable. And so we do that work as well as working with those data organizations that are actually providing the data to make sure that we're getting it in a way that it can be used. Again, we apply the patient consent and honor that and it's done so that we can protect the data and share it appropriately. You'll hear about this a bit more later. The connectivity criteria that we use, first of all, to establish whether or not a data contributor is able to make a connection. So we're using the money wisely in making those connections and working with vendors and healthcare organizations, again, who are spending money on their EHRs to make a connection that can send the data that we know that we can actually match across the organization and work with them if there are some issues with their data. We do have a best-in-breed patient matching system, and that has enabled us to have a matching of greater than 96% across the V-High. We also use, we also work with organizations to understand if they are sending a local code to be able to map that to a standard code set. You might be familiar with SNOMED and Loink. We're able to do that. So, again, the data is meaningful and usable, whether it's human-readable or for another system that likes codes and numbers, and we do that using terminology services once we know what those mappings are to translate the messages that are coming in the door for storage and then usage. We also maintain the original code and code set that is supplied to us, so we never lose the integrity of that initial data, and then we store that data in a FIRE data structure. Our platform was implemented in order to support that FIRE framework, which FIRE is Fast Healthcare Interoperability Resources. It uses some techie-speak JSON objects so that systems, especially EHRs, it's a framework and a standard that can be used to share data transactionally. That's it, and I think, Maureen, you're next. I am. Thanks, Christina. Sure, thanks. The next question folks usually have when they're learning about the Vermont Health Information Exchange is, who's contributing data? What data is available through the Vermont Health Information Exchange? And over the years, we've built connections to most of the large healthcare providers in Vermont and many of the smaller ones as well. So all of the Vermont hospitals are contributing data, as is Dartmouth Health, and when I say the hospitals, I'm also grouping in there their inpatient and ambulatory services, their emergency departments, their specialty and primary care practices. All of the Vermont Federally Qualified Health Centers are contributing data. We also have 32 independent specialty and primary care practices sending data into the Vermont Health Information Exchange about twice that used data from the Vermont Health Information Exchange, and we'll talk more about data use later. There's six home health agencies, 12 pharmacy chains and individual pharmacies. That doesn't sound like a lot until you think about all of the kidney drugs in Vermont, all of the CVS locations in Vermont, many of which came on during the pandemic in order to contribute immunization data. 17 labs, state and commercial, again that includes chains with multiple locations and one state agency. And the way data contribution is funded is through the state contract, new and replacement connections, we call them interfaces, are funded that way. And these connections are prioritized with the Health Information Exchange steering committee's connectivity criteria subcommittee. And again, as Christina said, we'll talk more about the connectivity criteria later in the day and it defines some tiered requirements for data contribution. So tier one, you can get connected, you can tell the Vermont Health Information Exchange who the patient is, tier two, you're sending a lot more of that essential patient information, A1C's blood pressures and so forth. So what data do we have? Data comes in, I think when I first walked in the door at Vital, I just assumed you kind of hooked up a pipe to the electronic health record and it just all came through. It's a little different than that comes through in some specific feeds, some specific data types. So the ones that we get currently are admission discharge and transfer messages, ADTs, this says a patient was seen in the emergency room, a patient was admitted to the inpatient unit, patient was discharged from the hospital, it's where is the patient, where are they receiving care. We also receive laboratory results, radiology reports, so we don't have the imaging but we do have the radiologists reading of the images, transcribed reports and this is many types of notes, doctors notes, nurses notes, discharge summaries, quite a variety. Immunization messages just carries information about an immunization, about a vaccination. We get some home health data and then continuity of care documents and continuity of care documents are these point-in-time snapshots of a patient's medical record. This is the closest thing to what I was saying I was envisioning when I walked in the whole medical record, but it is a point-in-time snapshot. This contains information like patient history, medications, allergies, procedures, much more than that I won't go through the whole list right now but one of the things that Vital is great at and known for among HIEs is the ability to extract data from these continuity of care documents and store it in a way that's searchable. So how is this data accessed? There are 150 organizations that are currently using Vital's data access services, so really providing benefit for a large number of healthcare providers in Vermont and that data is made available through the Vital Access clinical portal. This is the one that's sort of easiest to actually envision. It looks like an EHR. It's accessible through a web browser provider or a staff member who is authorized can go in. They can look up one patient and see their longitudinal health record in this portal. We also work to deliver data into electronic health records and this is really long-term. This is the big goal that you get more of the data from the Vermont Health Information Exchange into the place that the providers are working every day so they don't have to toggle between systems. Right now that's laboratory results, radiology reports, and transcribed reports. So this is one of the ways we are working to eliminate faxing as many lab results in the state are delivered into electronic health records by Vital. Also, under development, APIs, this is application programming interfaces and smart on fire. This is a strategy for delivering more data types directly into EHRs and to any EHR apps. So we're actively exploring that right now. Event notification is another data access tool. This is something we do through a third party partner and it's a way of getting notified when somebody on a list of your patients, if you are a provider, has been seen in the emergency department or hospital. And then we also do custom reporting and analytics. So in addition to the data access, one of the real benefits for providers, especially for data, this is for data contributors specifically, is the delivery of their data through the Vermont Health Information Exchange to a variety of stakeholders. So this is all about streamlining required data submission and reporting for providers and ultimately informing public health and population health efforts. So this is the, instead of all the point to point connections, the provider organizations build one connection to Vital and then Vital delivers data on to other clinicians and organizations that provide care. We deliver data to the Vermont Department of Health, to one care Vermont, to the blueprint, and then also to the Vermont Chronic Care Initiative for their care management work. So how data sharing is authorized. This is essential. This is at the heart of what we do is authorization of data sharing and really honoring patient consent preferences, operating in accordance with state and federal law. So I'll start by saying that since March 2020, the Vermont Health Information Exchange has been an opt-out health information exchange. The way we authorized sharing is through entering into data use agreements with contributing organizations that specify how the data may be used and this is always in accordance with state and federal law, with HIPAA, and with the protocols to access to protected health information on the Vermont Health Information Exchange that's included in the Vermont Health Information Exchange strategic plan. So we're committed to educating the public about data sharing and their options and ultimately to honoring people's decisions to continue sharing their data or to opt out of the health information exchange. Today, 98.8% of people's records are viewable in the exchange, well 1.2% have chosen to opt out. We've talked about this briefly. Christina mentioned it earlier, but really want to spend some time here protecting patient data. This is also a foundational piece of the work we do, maybe the foundational piece of the work we do. And that's the security of patient data, ensuring appropriate access and honoring patients' rights and preferences. So this is a commitment we've made and practically it means that we will continuously review and update our security and recovery practices to ensure they align with best practices and to mitigate the ever-changing threat landscape. We're also committed to ensuring transparency about how Vermont Health Information data is shared, to monitoring and aligning with regulatory changes, and to maintaining agreements and controls to ensure appropriate sharing of health data. So now I'm going to talk a little bit about our patient education because the data that we think every day about how the data that we share is ultimately information about an individual, about a person, whose rights and whose preferences we work to respect and to honor. And one of the ways that we do that is through public education. So years ago, I was doing focus groups as a consultant to Vital with patients about their data sharing preferences and needs. And what I heard over and over again was that they wanted to hear about data sharing, about how their data was going to be shared from the organizations where they received care. So in order to support that, Vital has developed a whole toolkit of consent education resources that those organizations, the data contributors can use to help educate patients.  And we expect that they include information in their notice of privacy practices. And we encourage them to share flyers, which we've got translated into nine languages, brochures, posters. We've also got social media resources and videos that they can share. And we've built a website that's specific for patients. And that really, you hear us today being careful about acronyms. We'll say an acronym and then we'll try and spell it out because it's so easy in this world to talk in language that is not patient friendly. So we work really hard to maintain patient education resources in plain language. And you'll see that on our patient website. We've also recently, and we'll talk about this more in our quarterly update, done some direct to patient outreach and communications through YouTube, Facebook and Instagram, recognizing that that is a really positive way to supplement the education that providers are doing with their patients. And I'm going to turn it over to Beth for the next slide, which is about how vital and the Vermont health information exchange is funded. Thanks, Maureen. Just to give you a sense of how we are funded and how we do the work that we do, we about 95% of our current funding comes through an annual deliverable-based contract with the State of Vermont through the Agency of Human Services. That funding comes from a combination of state funds, which are used to match and leverage CMS funds to support this work. And you'll hear more about that later today when Kristen goes through the HIE plan. We get funding for two components of work, both maintenance and operations work as well as development work. So the maintenance and operations supports our work to keep the platform running, keep the data secure and runner security program, ensure the data is flowing in and out, keep the connections live with the healthcare providers submitting data, make sure we are getting the data out to the purposes that it is intended to get out to provider portal feeds. Also provides for training and education, both for healthcare providers about how to use the data and accessor services as well as for the patient consent education that Maureen was just talking about. In addition to the M&O funding, we get varying funding each year for what CMS refers to as development design and installation or DDI programs. And that's really to invest in creating new capabilities for the HIE. So some of the work we did this year, for an example, were creating a new provider portal, which is more user-friendly. It could be putting in new reporting capabilities, implementing a new MPI to do better patient matching and having a much more complete patient record. In addition to the state funding, we do generate about five percent of our budget from other work that we do, and that is a combination of services. Some is where we do custom reporting and provide custom data needs for stakeholders in the state. We also support some event notification services that providers and hospitals use to access patient data that they want, very specific patient data that they want, and we do bring in some additional funding through those needs. We continue to explore what our funding model looks like. So the state continues to fund implementation and maintenance of the VHI. And as you'll hear later, really expanding that into the unified health data space and really a more robust platform for serving the needs of stakeholders across the state. We continue to explore opportunities to ensure that we're allowing vital to continue to innovate and meet needs of individual or smaller sets of stakeholders that might have needs or valuable uses of the data and figuring out how we have really strong business model, an operational model that can support those needs and ensure that we can continue to deliver the needs of the state and maintain a kind of diverse and sustainable business or an organization to continue to continue. Thank you. Was that and we'll turn it back to Maureen. Great. Thanks Beth. So now I want to zero in on some of the really important work that we've done in the past couple of years. And when I think about that time period, one of the things that stands out is vital partnership with the Vermont Department of Health. During the COVID pandemic, real opportunities emerged for health information exchanges across the country to demonstrate real value and support of public health. There was opportunity there before. I think this accelerated the realization of that opportunity all across the country and certainly in Vermont. So very early on, we worked to connect new testing sites with COVID testing data and we continue to onboard new testing sites. We also have been working to collect and deliver more immunization records from from more places. I mentioned pharmacies earlier, many new pharmacy contributors in the last couple of years. At this point, we are delivering about 78% of the immunization records that are in the Vermont Health Information, sorry, the Vermont Immunization Registry maintained by the Vermont Department of Health. About 78% of those get to the Vermont Department of Health through vital and the Vermont Health Information Exchange. We make that automatic, so the flow from the practices or the pharmacies to VDH happens automatically through the Vermont Health Information Exchange. We also are delivering daily reporting about hospitalizations and resource usage and we are supporting through vital access case investigations and contact tracing. So there's been quite a lot of use of vital access by Vermont Department of Health staff for this purpose. And then right now, there's some new work that we are doing and that includes development of bidirectional Immunization Registry connections so that not only can the providers send data to the Immunization Registry, but they can also query data back from the Immunization Registry and say, all right, tell me all of the immunizations that my patient has had without going and logging into another system. They can do it right from their own EHR once these bidirectional connections are in place. We're also working on health equity strategies with the Vermont Department of Health. There's some promising early work during the pandemic where initially the Department of Health, when they were evaluating COVID cases, had race and ethnicity information for only, or for, it was unknown in 73% of cases. And then they were able to incorporate Vermont Health Information Exchange data and it was reduced to only 8% unknown. And that was really important for evaluating the impact of the pandemic and how that impacted different communities differently. We're also expanding our lab reporting. We know that that COVID is not the last thing that we're going to have to work with the Vermont Department of Health on. So Monkeypox is something that we are now beginning to make sure that there's connections to report on. And we're doing some strategic planning for closer integration of Vermont Department of Health and Vermont Health Information Exchange data systems. So also in 2022, we developed a regional collaboration of health information exchanges. This is a connection between health information or health info net in Maine and not a literal connection. We'll get to that in a moment. This is really about connecting the organizations. Health info net in Maine, the Rhode Island Quality Initiative, Ricky, and us at Vital. So we'd been talking casually for a while and learning from each other and realizing that having a really formal agreement in place would allow us to better share what we're doing, freely discuss the work that we're doing, and best practices share innovative thinking, learn from each other, and explore opportunities for joint initiatives. This is really about looking for efficiency. We are all small states with small health information exchanges, and we want to think about how we can learn from each other and support each other, take what's best at each organization, and leverage it. There's also some opportunity here to access data, to work together to access data from regional specialty centers. So we hear again and again that especially for folks with really complex conditions, especially for children with really complex conditions, data from Boston specialty centers would be helpful in their care, and we think we're going to be better able to access that together than we might be alone. And that is where I will end it. Our last slide is just some highlights from our last annual report, some numbers about what we do. But I'll stop there. Thank you all very much. That I'll turn it over to the board for any questions or comments that any board members may have. Mr. Walsh, you're the only one not shaking your head. Do you make questions, Tom? Sure. Well, I'm interested in the quarterly update. But I appreciate the overview as a newer board member not having been through this. The acronyms are difficult. And I really appreciate what you're trying to do. And in some of my other work, I learned HIEs are having some difficulty. The Idaho HIE just went bankrupt in April of this year. And finding a funding source to continue this work after the federal funding kind of dries up is difficult. And I really appreciate the effort that you've all made to secure some of that. I was reading through the report about some of the Medicaid funding that had been secured, which I think is terrific. I think there's a note of caution that goes through my head as I'm reading through this material. A lot of the improved care coordination, improved communication reminds me a lot of what was being said about electronic health records when I was a clinician. And those promises never were fully realized. And instead, they've kind of been hijacked to be used to improve revenue. And they get overly complex and overly burdensome, and we can't do some really simple things. And so I just caution folks with these efforts before trying to get bigger and more complex and include more and more data sets and fancier and fancier analysis, like highlight statistics that's kind of fun to pull in data streams and run fancy regressions. But from a clinical standpoint, just being able to identify how many of my patients have diabetes, and of those, how many have an A1C level greater than 9? Who are the really sick patients? And being able to do that type of thing with all ambulatory care sensitive conditions. Who has COPD or CHF? Who have a positive test that indicate that they're really sick? And then who hasn't been seen in the last six months for diabetes? That's a standard interval. So if the patient is beyond that interval, their care is not really going to standard. And that can be an indication of other things that are making it difficult to comply with recommended care. And assigning treatment protocols that may not be appropriate for a person at that time. So who hasn't been seen in six months in the past six months? How many people with that diagnosis have ended up in the emergency department because of that diagnosis? And how many people have been had an unplanned inpatient stay because of that diagnosis? And none of that is particularly difficult. It's not hard math, right? It's division. But it's really hard to pull that information together and to be able to give a provider system a report on 12 ambulatory care sensitive conditions on a routine basis. But if I were running a healthcare system, I'd want my health information exchange to be able to produce that for me anytime I asked. And it's really hard to do. You can talk about it and it sounds easy, but it's really hard. But I worry sometimes we get so interested in the forest and growing a big forest that we can't execute on those simple things. So I'd really like to see Vermont succeed on being able to deliver that crucial information to providers so they can use it. And we can monitor the effectiveness of our system with data like that. May I respond to that? I know it wasn't a question, but I think information that may be interesting. I'd love to. Thanks. Well, I very much appreciate your point about thinking about how we make sure we're kind of meeting the foundation and the point of care work in our work. And one of the things, and you'll hear a little bit more about this later, is the state's investment also guided by an HIE steering committee, which does represent across healthcare organizations and providers. So they try to ensure that there is a voice in making the decisions about where we go forward, which I think is really helpful. And I absolutely hear what you're saying about the providers and something. And I know Maureen hears it and frequently in conversations with the healthcare organizations that we work with. And it's something we are looking at doing, going forward. Some of the work I think we have on our roadmap is really building dashboards for providers and some of that I think would be things like the risk analysis. We have data sets that allow us to tell things that you can't do just out of one EHR. If you, someone's due for their mammography, you might not know that they want Dartmouth for it, but we might have that information to be able to do it. And that's absolutely things we're looking at being able to do going forward. And it's going to be an evolving process. We will not be able to solve it all day one, but prioritizing and trying to take steps forward to make the information available for all of the providers too. And I think that's an important piece of our work, not just the ones who have the money to spend on the big CIS fancy systems, but how can we make it usable and approachable for everyone. Thank you. Yes. I agree. I had a couple quick questions. You spoke about the patient consent preferences. As a patient, when do I get that? And from whom do I get it? When I go into, let's say, urgent care, my primary care, they give me a form of some variety. Is that where I consent to my information going to vital and how it's used by vital?  I can take it. So, typically when you establish care at a organization, you will have to, you'll receive a notice of privacy practices. And that information should be included in your notice of privacy practices that data will be shared with the Vermont Health Information Exchange. We also see many organizations doing things like posting notices, next to registration desks, like making brochures available. There's a variety of different ways they do it, but the foundational one is in the notice of privacy practices. Great. So you get that from whoever, wherever you established your care, not from vital itself. That's right. And then, if I just go to an urgent care, let's say, randomly, how do I know if vital got my information? Does it just depend on whether or not you have a relationship with where ever happened to go? That's right. And the urgent cares that are affiliated with the organizations that we mentioned earlier are sending data. I know you're not asking really specifically about urgent cares, but there are some that aren't, some of the national chains we are not connected to. So it does depend on who's contributing data. And then slide seven, you spoke a little bit about having, I think it was called terminology services to translate some of the required vocabulary codes, RxNorm for medications and prescriptions, snow med for diagnoses, Loink for labs. And that caught my ear because I think here in Vermont, there's been enforcement actions of over $400 million against four national leading EMRs for failing to comply with those requirements. Are you seeing, are you seeing gaps in those required vocabulary codes being included in the information translated over to you? I think sometimes what we see is, especially in historical messages where the codes might not have been applied in the past, and we need to do those mappings. It's a, it's a really great question about, you know, what we might be seeing and patterns. Most of the time it's that historical data. And there are, we might get new codes that have not been mapped. It might be a code and code system that we recognize. It just might not be a code set that can be used across for specific custom reports. So for example, an organization that might want to have data in snow med instead of Loink, we might need to make sure that we translate it over to that so that we can share that data. Those are the two that jump to mind. Do you folks keep track of, you know, the statistics on compliance with those requirements of the information coming over? Because I think those vocabulary codes, the big ones that you mentioned, have been required since the 2014 edition under meaningful use. So eight years ago, do you guys have stats on which ones are on gaps that people are having? No. Again, an evolving HIE. Yeah. No, I understand. Yeah. Okay. I didn't have any other questions myself. Thank you guys very much for, for doing this. This is same as Tom. This was really helpful for me. I'll turn it over to the HCA for any questions or comments they may have. Thanks much. Just one question and thank you. I'll start up by thanking everyone for the presentation. As a self-identified data nerd, this is, oh, it's a fun conversation to have. I wonder if you could speak just broadly to the data safeguards in place, particularly for health equity related data. This is a really important priority, obviously, but I think it'd be good for just the general public to know what safeguards are in place. Thanks. So I'm not sure. I fully understand your question. So let me try an answer and tell me if I don't get it. Okay. My team will help me here. So we protect all the data as protected health information. It comes from health care organizations and it's covered by the traditional HIPAA regulations and service agreements and business associates agreements we have in place. We are not getting any data outside of traditional demographic data that comes with those records or information right now that would be considered difference. As we go down the path of thinking about new data types like social insurance, health data, substance use data, things like that, we are having conversations, very careful conversations about what the right approach is and that's from the start with the patient consent and education so they know what's happening, but then also what the right way to kind of protect and share the data would be when we get to those places. Thank you. Super helpful. Okay. Great. And with that I'll turn it to public comment via the raise your hand function. Great. I'm seeing none. We're scheduled to go to 1145 with this segment. Why don't we take a quick five-minute break just so you guys can get set up again and I think we'll just go on to your next segment which was supposed to start at one. We'll just keep trekking through. So we'll be back in five minutes. If you guys need more time than that, let me know. Are you good with five? Okay. Great. So back to 1106 and we'll proceed. Thank you. Okay. It's 1106 so we'll continue on. Ms. Anderson, is everyone present on your side or do you need another moment? I know Maureen is back on her way and I can get us started because I have. I see Maureen. Oh, there she is. Perfect. Great. Yes. Others made, yep, we have our team. Thank you for checking. Great. So I'll turn it over to you in a second here but we're going to be going through Vital's quarterly update and I see we have two additional new faces being added for this and if you guys could just introduce yourselves to us all we'd appreciate and take it away. Great. So I'll just point them out. Oh, thanks, Bob. I'm Bob Ternot, CFO for Vital for the next couple months. Okay. Sue Fritz, the Director of Technology. I've been here for a little over a year now. Pleasure to meet you all. So we will dive in. I'm going to do my displaying again. Thank you. So I'll start us off again. I wanted to take just a few minutes to give you a little bit of an overview of some of the work we've done to date since our last update and then talk a little bit about our contract going forward or our thoughts on the contract going forward for the next fiscal year or calendar year. Sorry. So just to talk through some achievements because we haven't been in front of you since June, we successfully completed launch of the new provider portal out to all of our providers and more have had some really great feedback on the portal being much more usable and user friendly. The data is much more accessible so we're really excited about that and the opportunity there for providers really to get insight into the data that we have in the HIE. Some other work the team has been working closely with the Vermont Department of Health to build what's called a bi-directional interface with the immunization registry which is going to allow provider organizations to query the immunization registry through us to get up-to-date immunization data. The first steps are to get the immunization records after we will be looking at adding additional functionality, things like allowing them to get forecasts. We had a big public education campaign which Maureen will talk with you about in a bit. We did successfully retire our old platform which we were very excited about and we were going to make the transition fully to the new platform. You try to talk a lot about that in the past. We're taking steps to really expand our reporting platform out so we can do some of those custom reports in the dashboards that we talked about and we have been working with the team at the Medicaid agency to help them have the data they need to meet their Cures Act final rule requirements around information blocking so some exciting work going on. We jump to the next slide. As many of you know and others of you will get used to is this is usually the time of year where we were talking about our new contract with the Agency for Human Services or with the Medicaid agency. We typically do an annual contract which is on a calendar year basis and so usually at this time of year we're submitting the contract to the Centers for Medicare and Medicaid for their approval with the thought of signing a new contract for the January 1 calendar year. What we're looking to do actually this year now is to align our state contract with our fiscal year and the state's fiscal year as it stands now we have a mismatch. We are on the same fiscal year as the state but our contract is on a calendar year which makes it hard sometimes to do planning and certainly to do our budgeting because we're often budgeting based upon a guess at what the next year's contract will be. So what we are doing now is talking about a six month extension to our current calendar year contract which will take us through June 2023 and then signing annual contracts aligned to the fiscal year starting July 2023 going forward. So what you will expect from us is or you should be seeing from us in January and what we'll be doing in January with our board and bringing to you in February is an amendment to our current year budget which will reflect the changes that we expect for that six month contract. I mean so I'll walk you through into the minutes and exciting opportunities to do some work that we hadn't anticipated we'd be able to do which will which will impact our budget. So Maureen if you don't mind jumping to the next slide please. The contract that has been submitted to CMS has not been approved we usually as you know don't find out about that until December but it usually is pretty aligned with this we'll be continuing the maintenance and operations funding as we had this year to continue to operate the VHI like I mentioned earlier. We will continue to have funding to create data connections to get new data into the HIE. We're really excited about this because you've heard us mention in the past that we weren't sure that CMS funding would be available to allow that work and it's looking like the moneys can be made available to continue to expand the data that we do have available. We'll be putting some work into making building capabilities to provide de-identified data sets. First use case is really for public health's needs so right now we cannot provide de-identified data it's only with patient demographic information in there and what we're really hoping to do is be able to provide that data so it can be used for more purposes for their analytics work and then potentially in the future this hopefully open some new use cases around research and other needs as well. We're working with AHS to coordinate with the designated agencies to get their their data into the HIE and as many of you know that they're currently covered under 42 CFR part two substance use disorder guidelines which provide for very different capabilities to share and access that data and we'll be working very carefully with the state and with the agencies to make sure that making that data, securing that data in the appropriate ways and ensuring patients understand what is happening and where their data will be. We have additional funding to continue some work we're doing with the state on social determinants of health data really looking at getting some of the state data sets integrated into the HIE to help inform a more holistic picture of the patient and the patient's health situation so information from the VCCI, potentially economic services so we can really understand not just the patient's kind of current diagnoses and situations but the external factors that may impact their health to help make sure that their care is kind of guided and coordinated in the appropriate ways that that is make them successful. We will continue our work to build connections to allow providers to access the data and the immunization registry which I mentioned a moment ago and we will also continue our work with the five states Vermont Rural Health Alliance activities. So as I mentioned we expect to get the CMS decision back in December we will do our final contracting hopefully by December 31st with the goal of having an updated budget for you to review with those changes. Additional piece of work we continue talking about that we've mentioned in the past that will not be in that change but we'll potentially follow that as we continue our conversations with the Medicaid agencies to have the HIE serve as part of its new data and analytics capabilities and infrastructure. That is conversations we continue to have in negotiating what that work might look like into designing capabilities or expecting that that contract would likely come to be in the spring as well so that's something we will keep you updated on as we get closer and more clear on what that looks like. One thing I do want to mention Bob kind of alluded to this and he's telling you he'll only be around for a few more months but I do want to let everyone know that Bob has unfortunately decided to retire.  So you will likely see him or potentially see him again when we come back with a budget amendment but I wanted to let you know that we will be having a transition in that position. And with that I will turn it over to I believe Maureen who will talk to you in a little bit of detail about the patient education that's been happening. All right so the last couple years of presenting to you we so often had to say or we repeatedly had to say now isn't the time for broad public education about the Vermont Health Information Exchange. Of course notice of privacy practices of course messages in provider's offices but we didn't think during peak COVID it was the time to be broadcasting information about the Vermont Health Information Exchange and I'm so pleased to be in a place where we're able to do that again where it feels right to be out doing the direct to the public education again. So between June and September of 2023 we did an education campaign on YouTube Facebook and Instagram with messaging focused on how health data is shared. This is a statewide campaign targeting all age groups. 4.3 million video plays on Facebook and Instagram and about half a million video views on YouTube. Now the goal here is really about awareness there's not a conversion we're looking for we're not looking to drive opt-outs certainly unless that's people's preference so the the metrics that that we have to share with you are really about reach and about awareness and this is a continuing commitment for us so we will be back here talking about about our public education efforts again and again I hope. So the next topic is going to be a projects update and I'm going to hand it over to Christina. Thanks Marie. Next slide please. So I'll give you an overview of some of the exciting projects that we are working on. Obviously having data in the VI is extremely important especially getting that data real time so we have been working very closely with the Department of Health in order to prioritize the data that's needed especially during the time of COVID in order to get vaccination reports and laboratory reports so that we can keep for monitors healthy. So we've been working with them to prioritize that and that really is our highest priority at this moment. We have been working with healthcare organizations because we don't want to have gaps in data as they may switch electronic health records. After we establish data and we have that data coming into the system if an organization decides to move to another platform we want to be there in order to minimize the data gaps and have that data flowing in through their new system. So we're doing that while not risking the public health interface data coming in. We've also been working with Medicaid. They needed to be in compliance with the CMS interoperability in patient access rule so that members of Medicaid can access their data and they needed custom clinical data sets to be provided to them and we continue to work with them on that work so that they have that data to provide. And Beth gave you an overview of this and I'll add a bit more flavor about the immunization registry work. So working with the Department of Health we have implemented an approach so that providers right from their electronic health record would be able to query right through vital on to the immunization registry to request immunization data so that they can see it right within their own EHR. It's exciting to me because this is a very dynamic type of interface. It's not setting up a connection and just receiving data and then turning around and sending it somewhere. It's very dynamic in that it is within the provider's EHR and it's you know within their own workflow they'll be able to get that data and care for their patients. And we've completed that configuration testing and we're already working with one hospital to ensure that this is a repeatable process and we can continue to roll that out through the funding mechanism that Beth was talking about earlier. Next slide please. Oh this one has some acronyms in it so we are planning a design and implementation again of that fast healthcare interoperability resource. It's an application programming interface or API. This is also very exciting to me because this is really the reason why we implemented a fire native platform, that next evolution of HIE so that you can set up APIs to access data in a very very standard and usable format. And we hope that this will set up for patients and providers to be able to access data more easily within their EHRs and use it at the point of care and beyond. We're also working with the agency of human services in order to ingest social determinants of health data that's being collected by the Vermont Chronic Care Initiative. We've worked on templates that can be used in implementation design and now we're working with them in order to collect that data and work through an ingestion process and determining how it can be shared in the future with consent and education in place. We're also working on our reporting infrastructure now that we've implemented the new fire platform. We have a reporting infrastructure and we've already used it to deliver two blueprint for health reports and we're using that for other purposes as well. We're working with the Vermont Department of Health again on reassessing their needs for COVID reports using that new reporting infrastructure. And we're also upgrading to the latest fire standard. There's a version four that is needed for those APIs that I was talking about earlier in that first bullet. It's a standard way and a standard version in order to send data through those fire APIs and we want to get on to that new version. And lastly, we are making updates to our clinical portal. We're looking at a medication fill history service so that we can get information about whether patients have actually filled their medications and have that available within the provider portal. And we're also working to connect to national health exchange networks. The eHealth Exchange right now is one of them that we are testing with in order to expand nationwide so that we can query for data. I think that's it for my slides. On to a security update and Sue will speak to this. Thanks, Christina. You can go on to the next slide, Maureen. Thanks for the opportunity to give you some little details about what we've been doing with security over the last quarter. Call out to the slide. You've heard us say it multiple times, the privacy and security of the state is really important to us. And we engage in a continuous program to always monitor and improve the work that we're doing. At the core of that is policy and standards. And we've actually been doing quite a bit of work with policies and standards recently. As the funding model and regulatory environment is constantly changing around us, there's always this need to look back. So we have a great security framework that has historically been based on the NIST CFS. The National Institute of Standards and Technologies has various different frameworks. And we've been following the NIST CFS framework for many years. We are starting to morph that program more towards the NIST 853 framework and subset of controls specifically with a view towards the Marzi minimal acceptable risks for health exchanges or for exchanges. That's just the nature of where we're going as an HIE and our involvement in the Medicaid space and our future work. So that's a lot of the work that we're doing is reviewing and updating our policies to set ourselves on a great path for that moving forward. As most organizations recognize, there's always this new changing dynamic with creating a remote workforce. So we've been doing a significant amount of work. Streamlining, we made the move to COVID and work from home very effectively and very securely because by the nature of our work, we had to do that prior to COVID. But now we're trying to streamline the processes, be able to deliver services to our workforce that meet all those security standards in a much more streamlined and fast way. So we've been doing a lot of work in that space. We've also had a great cybersecurity and awareness training program, but it didn't have the streamlined formatted documented processes that we really wanted to achieve to cut down on the work efforts and the manual work efforts. So we've procured a platform that can deliver automated trainings to the staff, track and monitor the program throughout the year and make sure that we have good data at the end of the year to evaluate progress and make a good plan for the next year. We have a security and event monitoring system for those who aren't technical. This is a system that actually digs into the AI and all of your logging from your systems to try and analyze and correlate events across your network infrastructure to see if there's malicious behavior going on. That's a key tool that all IT platforms or IT environments use to help make sure we're staying abreast of the bad guys in the world. And we continuously update and add new logs to that look for new ways to enhance that AI. We went through our it's almost funny that renewing cybersecurity insurance has to be something that's worthy of mentioning to you all. But for those who have to do this, then you know that this is a big accomplishment when you're able to say we renewed our cybersecurity insurance this year. So that's something that I wanted to draw to everybody's attention. And in addition, my last bullet was an annual penetration testing. We go through a series of assessments throughout the year. The one that's relevant and up to date are coming up on our roadmap is the penetration test that we go through every year to see if that guys can hack into our network. And so that's been contracted and scheduled. I think that's everything that I have. And I think who are we going to next? Bob's up next. I should think you're stuck with me doing this presentation. That was part of the negotiations of keeping Bob around for longer. So this will be a quick update, because we're very early in a new fiscal year. But so you know, we're Bob's team is working out to wrap up the fiscal year 22 audit. We will have that to you when that is completed. Our early signs are Bob's team did a great job. No findings. We're kind of where we expected performance is actually going to be better than we anticipated when we spoke to you in June, which is which is good to not have any big surprises, but more details on that to come. Fiscal year 23 as I mentioned, we are presenting or the next page next slide has our performance through September 30, which is really just three months into the new fiscal year. And you know, nothing really significant to know what we are behind on revenues. It's a combination of two things. One shift in project priorities. We did our budget based on some assumptions about order of projects and how they would happen this year. But after some work with agency of human services and looking at some different needs, we rejiggered kind of our schedule of projects. And so the shift in some of the revenues is really just due to the timing on projects like guys, you'll see the expenses are below again, due to some of the project priorities and where we're spending on the projects. Some of the change or some of the kind of lower performance on revenue is actually not lower performance. It's on recognized revenues. We deferred in FY 22 that we will recognize or expect to recognize this year, but we wait till the audit is completed to make sure we've accounted those properly before we recognize them in a new year. So that is more just an accounting activity more than anything else. So I think that is most of the highlights to report as of September. And I will then I can pass it back to Maureen who will go through some of the metrics that we provide. Thanks Beth. So in these quarterly reports, we always present the same set of metrics about kind of high level how things are going at the Vermont Health Information Exchange. Always open to looking at this differently. But these are sort of the core things that we've been reporting on in recent years. One is the percent of Vermont patients who are opted out of the Vermont Health Information Exchange. You can see this is fairly steady. There was a drop in April, which was due to the addition of a large group of new patient identities from the import of historical data from a large COVID testing laboratory. So as you bring in large new data sets and then new people really to the Vermont Health Information Exchange, you do tend to see a bit of a decline. The next one is about queries of vital access, our clinical portal by organization type. This is really a story about who's using the Vermont Health Information Exchange through vital access. And there's there's a diverse group of organizations who are using that tool. So we've got many independent practices. You've got some hospitals, though I would say more reliance from independent practices relative to size on the tool. Quite a lot of use by the Vermont Department of Health. We actually have emergency medical services who were initially brought on early in the pandemic and they are using the tool quite frequently. Federally qualified health centers are visibly in the mix there as well. So this is vital access queries by month. This is really just for the past year. I will say that this is an ongoing upward trend. We are are pleased to see some growth over time here. What the story for this past year is really about big use by the Vermont Department of Health during COVID to do those case investigations and that contact tracing. So if you put a line under this that just shows use without the Vermont Department of Health, if you see real steadiness here. So it's great that the Vermont Department of Health is able to use this when needed. And there are some other uses that the Department of Health has for vital access as well. The purple line here is the new vital access. The blue line is the old vital access. Pilot of the new vital access began in February. We did some really, well very early co-design work and then some piloting with a group of people who were especially interested in the tool and were able to give us some great feedback. And now you see that the new vital access is the only vital access and there's some steady use there. A little under 10,000 queries per month. This is about queries of the Vermont Health Information Exchange via eHealth Exchange. We were driving eHealth Exchange access off of our old data platform. We haven't talked a lot today about the transition in our data platform. But there was a change there and we decommissioned our eHealth Exchange connection in June of 2022 and can't get reconnected in exactly the same way because eHealth Exchange requires that any new connections be through their hub model and we are excited to be part of that hub model. But it is a different way of connecting and we're currently working on technical and process planning for delivering data through the eHealth Exchange hub. This is results delivery by results type. I think the number here that's most interesting to me is actually in the smallest print which is the number of providers who are receiving results directly in their EHR. Down at the bottom that's 592 providers in Vermont who are getting results for the lab tests they ordered or the imaging that they ordered in their EHR through the Vermont Health Information Exchange. And you can see here in orange that the majority of the results we deliver are lab results. Then there's radiology results and transcribed reports are also delivered in this way. Some steadiness here as well a little under 100,000 results delivered right now per month. This graph is about who receives these results, who's relying on results delivery, and what you see here is it's really two types of organizations who are relying on this service and it's the federally qualified health centers and it's the independent practices because typically they are ordering these lab tests from a laboratory, a commercial laboratory or from a hospital more typically, and then we deliver those results back into their EHR. So big service here to the independent practices and to the federally qualified health centers. And that is my last slide. We do have some abbreviations for reference and I will stop it there. Great. I'll go a little out of order and just congratulate Mr. Turner on first his shrewd negotiating to get out of the financial performance and second his upcoming retirement. Congratulations, Bob. I'm sure it's well deserved and an excellent career. So congrats. I'll turn it over to my fellow board members for any questions or comments they may have. I can go ahead and go first. Hi all. Nice to see you again. So I've had a couple of questions. One is Beth, you mentioned in terms of the work that you're doing with VDH and the bi-directional immunization data that you're starting with the records first and then you're moving on to forecasts. Can you talk about what is a forecast and why are they helpful for you to ingest those? I'll start and Christina is going to correct me where she doesn't like my answer, I'm sure. So the forecast gives literally a forecast of what immunizations would be coming due for a patient. So based upon the record that they have of what they have had, their age, all the things that go into deciding what immunizations a person should have, it then turns back to the provider what should be anticipated. So it sounds like that would be particularly helpful for providers that don't have an EHR for example but might be seeing a patient. Yeah, I think that's it's you know an EHR that doesn't have that capability and I do believe many providers can get this out of the immunization registry now by logging into it but then they have to go into a separate section and depending on if it's someone within the provider's office like a nurse as opposed to the provider needing access to the data I think it can create some challenges of making sure they have it. Great, thanks. That's helpful because quite frankly I think my provider has that already in their EHR so because I get questions about it so thank you for explaining that. Yeah, I think the value here I'm sorry not to interrupt is that this is then based on the immunization registry data too right. So if you had an immunization at a kidney drug or something it would have pretend like all of that information to give the most complete forecast. Great. Yeah, so my second question is about the social determinants of health data. It sounds like you you've started already with VCCI. Do you have any policy updates related to security or privacy related to the VCCI data and is it appropriate to have separate policies for that data or are you thinking that it's covered by your existing policies? That's a great question. So the initial focus on that project and again either Christina or Kristen they want to add here we are the focus really now was on testing that we can get the data on what it would take to map it in. Do we have the right infrastructure to capture the data with the full intent that before any of that data was really used for any purposes or shared we would definitely we need to address the kind of what the data is what the expectations for the patient not always a patient at that point but the person the individuals should be and what kind of education we need to do so we are we know we need to do that work but we haven't completed it all yet. Okay and would you expect to have a similar process do the testing figure out the data mapping and then those follow-up steps for new types of data that you would be expanding to? I'm not sure that's always the order it would happen in sometimes you know it's particularly for more more complex data types we you know the patient in education and consent would be more of the upfront work around the data governance work that we would do I think a little you know we're going to have to take that more in a dataset by dataset basis on this is just another very similar to what we already have or this is really something new that we really need to dig in on and make sure we have addressed the all of the components that go into it. Thanks so is that work that vital will do independently or is that work that will happen at the HIE steering committee level? A combination of work so we would do it with either the steering committee or a subcommittee of the steering committee which is often where this work done so a group of people with specific knowledge or interest get together to focus on the different topics and that's how the social determinants of health work is working and to dig in but we also engage oftentimes we'll engage the making sure that the organizations providing the data are involved in that conversation obviously we take legal both from this the providing organizations perspective but are legal at the VI to to make sure that we are keeping in compliance with the laws from a you know there is a practice and we really want to make sure that we are meeting what we need to do. Thanks. I think in terms of the vital access query data are you expecting to stay around that 9,000 mark for for queries are you expecting that to go up or down in the next year where are you where do you think that's headed? Mori do you want to take that one or do you want me? Sure I would expect to see it about that mark unless there's a reason why there needs to be a surge like VHH's use during COVID I think there's always opportunity for for growth there but it is sort of steady work of going in educating the practices we find that they tend to use it a lot more if they've had recent education so there's there's some work behind growth there and we do think that there is opportunity for growth but I don't see it being sort of large dramatic growth I see it being sort of steady incremental. Do you have any way to measure kind of how much of the universe you've captured so for example on the next slide after that there's an indication that FQHC's and independence tend to be a big utilizer of that particular functionality do you have any sense of how many independence that you've educated and are currently using it compared to the total universe or similar for FQHC's? We can make some guesses on that we don't have the the precise number of practices in Vermont I think that's a challenge for for all organizations knowing exactly which practices are currently operating but there's been opportunity at I think most of the practices and I think there's always opportunity for more education I will say there's certain types of practices that we're seeing more use from recently I know naturopaths who do primary care are using it quite a lot so there's some growth there. Great and then I think my last question is in terms of the e-health exchange reconnection to the hub do you have a sense of timing that you can give us? We're targeting that for the end of this year December 31st. Great that's it for me thank you oh I guess one other question I do have some questions that are more I would say related to the HIE so I think it's appropriate to hold those until after that presentation I'm assuming you you will still be around to do the connectivity criteria yeah great I'll be here thank you. Thank you Mr. Walsh. Yeah just thanks again a couple a couple things came to mind it just everything sounds very complex right there's so much that's going on and I just want to reiterate the point I tried to make earlier about focusing on very actionable straightforward things like being able to identify patients with who have a condition that should be amendable with standard visits to primary care but when it gets bad they end up in more expensive care that type of data is just really helpful for health reform efforts because those are the patients that end up becoming the most sick right and similarly when we're thinking about reform efforts and changing payment policies and or reimbursement plans there's always a worry that if we tweak something about it patients could be worse off and so we need timely outcome data in order to make sure that a population isn't getting worse when we're trying to come up with a better model and the quarterly reports that you went over I had these thoughts going through my head at the same time you know in addition to the queries and the other information showing how often the HIE is being used it'd be really helpful from a state standpoint to understand how many patients across the state have a positive depression screen and then of those with a positive depression screen how many are able to be seen by a behavioral specialist within a week or within three weeks or three months or six months because we have this problem with wait times right and then if you have those categories you could then stratify by what proportion end up in the ED for each of those categories what proportion end up with an inpatient admission and then sadly we've got very high and rising a very high and rising suicide rate what proportion of those people are end up dying by suicide that type of data would help us understand the how the changes in our systems are affecting Vermonters and then with the social determinant data that all the things we can add in from from your work we then know how to focus those so it's it's very necessary work that you're doing and I'm very supportive of it I do have this nagging worry that it's it these type of projects can just grow in expense it grow and grow and grow before we can do some really basic things with it so that that's my my recurring thought today but thank you for coming and and giving us this update I look forward to seeing you regularly back to you chair foster thank you go please go ahead miss Holmes thank you so much and thanks again for coming today I actually have a couple questions that are similar to board member lunges questions but maybe let me just ask a little bit differently I am curious a very deeply about the social determinants of health data and the pilot there and I understand it's VCCI data but I think there was also mention of economic services data so I'm curious about I just want to understand a little bit more about you know how many patients data this might be what types of data this exactly is and I know it's a pilot right now just to see if you can do the matching and get it in there but I would love to hear more because I do I'm going to have more questions I think in the HIE presentation this afternoon about how that data is going to be used who's going to access it and what the plans are you know about how it'll be used so I'm wondering just from your perspective if you can give us a little bit of more information about that Christina do you want to give a little bit of specifics about what you're doing with the VCCI then maybe I can address yeah so at this moment right so at this moment in time it's still early on working with VCCI to understand exactly what you're talking about the eligibility data is the first thing that we're looking at mapping that to taking their questionnaire and mapping that to ways that we can ingest the data we are also working very closely with diva who's working with their state's attorney to make sure that we have use cases for this data and again the protections in place what we do on the V high side is also working with our platform vendor to plan out how we're going to securely tag that data or at least put the right security layer on so once we have the right use case for exposing the data we know exactly how to protect the data and expose it in a way that can be done so we're still very early on in that process so I guess and maybe you know when you come back I guess we'll be what February or so it'd be helpful to understand a little bit more about this but I presume that there must be some expected use cases for this or else there wouldn't be a contract in place to explore bringing it in so can you just give me an example there too of a use case that you're anticipating ristina I don't know if you have that yet I think we're still waiting for the VCCI team and the state team to that is correct I'll communicate that yeah okay well maybe I'll I guess I'll ask this afternoon maybe there's some some well hopefully we'll hear more about that okay my second question I guess was around similar to board member lunge's question and I noticed actually in this afternoon's presentation I'm not sure if you've seen the PowerPoint slides that are coming our way but there is a final slide that has KPIs on it and there were a few lines that stood out to me one of them was the number of vital access users tracked between September 21 to June 22 and the number of vital access users peaked in 21 at about 3500 and now it's down to 1980 and then there was a the second line was the number and this maybe gets a little bit at board member lunge's question but maybe not so I don't know I appreciate more depth on this but the second line was the number of HCO vital access users and I'm assuming HCO is healthcare organization but I may be wrong about that acronym there's a lot of acronyms here but the sex so it was the number of HCO vital users divided by the number of potential HCO users and so in June of 2022 it was 237 divided by 1593 and that was about the same rate in September 21 that's about a like 15 percent take-up rate so I'm just wondering you know if you could speak a little bit to those numbers and those would be great metrics you know I was really happy to see those a different way of looking at the use of vital and just you know maybe in future presentations would be great to see that as well but I was wondering if you could just speak to both of those I saw okay I can take the vilex that's users thing to begin with I think that one is there's a really clear an easy explanation for that which is during the UVM cyber attack they provisioned a very large number of user accounts in order to meet you know in order to have data to information about the patients they were seeing to support care appropriately they then removed access for most of those users so that because they didn't need it after the cyber attack we do go through an annual audit process with the organizations that use this and say okay here's here are all your users who do you want to remove and so UVM did took advantage of that appropriately any thoughts on the the access users divided by potential users is that is that what you would expect I mean I'm just I'm sort of is there a target goal for what that might be I'm just kind of curious it's diff it's it's the first time I've seen it laid out like that so it struck me I just want to give a piece of context on that so that is those are the so everyone understands that those are reported differently from the way we report and we can absolutely talk about how to get how to get this in our package those are the outcome spaced certification metrics that we as a state are providing to CMS under the new certification program that you heard us you've heard us talk about in the past under which the HE was certified in May so that's some very specific numbers and I know Kristen may talk about these later so I don't want to steal her thunder either those are really relevant to the Medicaid provider population I'm really you know making a making presentation to CMS for Medicaid providers the service is being provided being offered to them and usage there so I just want to explain a little bit about why those numbers might look a little different to about some of the stuff that we are presenting we can absolutely talk about putting these I think Kristen we can figure out a way to make sure that these are going with our regular packets to the board I want to be careful because these are this is data that the state calculates and presents to CMS so I want to make we'll work out a process to make sure we get the accurate and current data available but to the question of are they the numbers we would hope to see I mean I think we always want to see more usage right and but we also know that for a provider portal perspective um providers don't all want to go into another yet another platform right and log in and so that's what you see are kind of focused for going forward is both looking at the provider portal and expanding that because we do have providers that don't have robust EHRs they don't have EHRs that they can get other data sources into so they will want to use this that that provider portal but really where we want to put some new focus on is how do we get the HIE data into or accessible through their EHRs so they don't have to log in to another system and that's an area where we want to focus so I do want to I mean we always want more people to use the portal I will absolutely say them you know to know that it's there and have access to it but I don't want I don't I think it'd be short-sighted of us to think that is the solution and I think we need to think about what that use will be holistically to and how we balance that out great I appreciate that um and so so if I understand it then that denominator is Medicaid providers if it's his Medicaid specific data that's probably the denominator is Medicaid providers versus all potential okay and and from your perspective getting the number of practices would be hard to figure out you know a different denominator say for the other populations other payer populations that might okay yeah um okay um and I get my last question actually is um we often hear and I heard it through the wait times investigation focus groups and I hear it from providers largely primary care providers expressing frustration that they don't get consult notes often back from specialists that sometimes it gets lost and you know it doesn't get faxed from the specialist's office back to the provider's office or it doesn't get integrated into their EHR and um it just strikes me that it should I'm guessing right or I guess is what I would love to know is how do those consult notes show up in the V high um and and is that a place where I could be answering you know I get emails sometimes um and I get comments about that frustration and is it would it be fair to direct people to the V high and say the consult notes should all be in there or what percentage of the consult notes should be in there or what what um you know is is that a place a source of that data that's being underutilized and and and primary care providers are waiting for the faxes but actually should be you know relying more on the V high for those consult notes help me I just don't know I don't know enough to know whether it's there or not there or you know to be saying hey have you looked in the V high when people talk about it Maureen did you come off a mute because you wanted to answer that? Sure yeah definitely available to answer that no I think have you tried looking in the V high is a great um question have you tried looking in vital access and we are certainly available to help people navigate that to provide some education there are a couple places that could show up we in the transcribed reports that we receive in the continuity care documents we receive I think there's always some potential work to be done um to to improve sort of the through rate there um so if they go in and they don't find it that's good data for us as well um because then we can help look at at making sure that connection is delivering all of the data including the consult notes but absolutely encourage them to try please so vital access should be a source potentially for many of these primary care providers to be yes getting that okay wonderful I appreciate that and thank you for the presentation if you know that it's if you know that it's from specific locations that are common commonly that they're not finding it it's certainly some conversations like something we can explore too so I don't know if you see themes like please don't hesitate to share with us who who's did it might not be available that we can try to work with yeah okay I will I'll think about that thank you very much I appreciate it Dr. Merman do you have any questions or comments yeah this is a this is a great conversation I it's interesting because I feel like I'm learning a lot about something I didn't know about but as a provider in the state I feel like I should know about vital more but as the conversation's gone on it makes sense to me that as a hospital based provider that I probably don't have the opportunity or need to to use the services as much as as I think might actually make sense to use them so I guess my first sort of comment is a anecdote relating to to member Holmes's comments and questions regarding the numbers of individual providers accessing the data and just you know conversations with colleagues over the last week or two of people realizing that nobody not nobody very few actually have have accessed vital access and most the ones who I spoke with actually were UVM folks during the cyber attack and I do think that actually I work at Central Mont Medical Center that you know we are we are probably over reliant on epic but and the care everywhere component of that but but we do take care of patients that receive care at multiple different hospitals and multiple different clinics and primary care providers that are not associated with with the UVM health network so I think actually utilizing vital more and actually if you can figure out that integration into our EHR you know as you mentioned logging into multiple different platforms at the same time is it's more irritating than it is onerous to be honest but but it doesn't it really decreases the likelihood that someone's going to access that data so I think if it could be a plug to encourage you to pursue that that that that's I guess that's the point of this comment but also it is kind of maybe not surprising to me but it seems like there could be a lot more utilization of this by hospital based providers especially in hospitals where you you're taking care of patients that are transferred in from nearby hospitals or receive care nearby and all across the straight state there's examples of that. The other thing that I'm struck by that I'd like to just hear a little bit more on is the potential overlap between the goals of one care and the goals of vital and some of what member Walsh's comments are regarding getting performance metric data back to providers about aspects of their patient's care. A1C's hypertension goals it sounds like that is probable and likely to be able to be done through vital access if it's not already being done but it seems that the data that you guys have and is more clinically relevant and less claims based and that might actually provide more timely data to providers to do these quality improvement goals that we would have in the state so could could you comment on the likelihood of that occurring and and and if it is occurring more about that too thanks. Sure so um again I will let my team chime in where they where they have anything to add so we do actually work with one care and they you they do receive data from us to help inform some of their work so we do not do the analytics you know we try to make the data the raw data raw data is not fair I'm sorry we do a lot of work as you've heard to kind of clean up and match and standardize the data to make it usable for these purposes and do make it available for one care to use in their platforms to do some of their work. I think the challenge that we we have in the state is not every patient is under a one care program right and we have many many providers who um have data from one care for some of their patients but not all of their patients and how do we make sure that that data there's kind of data available across the board so we are not looking to recreate what one care does but rather think about ways that we can make sure all providers have access to the information they need for all of their patients and not just their one care patients and some of that you know could be working with one care and some of these um some of it will be making some basic data views and analytics available for those providers who either who don't work with one care who have patients not covered under one care so we I think it's um an area that we definitely try to focus so we're not trying to duplicate efforts that that exist in the state but also making sure that there is a bit of kind of equity and availability of the capabilities in the analytics for providers who might not have access to it otherwise. So do you provide that basic level data now to providers? We don't so the providers have access to the portal and the results delivery and kind of more the clinical point of care we don't have ways that the providers get that data from us now otherwise and that's what we are going to be exploring with the state over the next year year and a half about how what are some basic dashboards and information that we might be able to make available to help inform patient care. And could you provide those dashboards to uh providers one care patients in addition to their non one care patients? Yes yes and you know I should say the HIE steering committee that I've talked about a couple times that I know Kristin will be talking about later um does one care is our participant in that work so as we think about the work we're going to do in the future as the HIE and and to meet these needs one care is part of those conversations so we do have the opportunity to really explore what they might do where we can partner together where we can make sure we're not completely recreating or causing confusion and the work in the data we provide. Thank you that's really helpful. I'll turn it over to the HCA for any questions or comments. Nothing from us thank you. Great and is there any public comment please again use the raise your hand function if there is. Okay um it's 12 of five um and so we'll take a break till one o'clock and at one o'clock we'll hear the 2022 health information exchange strategic plan and connectivity criteria for 2023 so we'll see everyone back at one o'clock. Thank you very much.