Welcome everyone to the Green Mountain care board meeting The first item on the agenda is the executive director's report Susan Barrett. Yes. Thank you, mr. Chair welcome So I have a few announcements first some scheduling announcements next week. We are not having a board meeting It is canceled and then the next week, which is the 29th of May. We are traveling down to Randolph Vermont and having a traveling board meeting at Gifford hospital if there's any questions on that that all of the information is on our website I do have two announcements about rate filings The first is regarding the sigma rate decision that the board recently made So on February 7th 2019 SIGNA health and life insurance company proposed an average annual rate decrease of minus 3.6 percent For its large employer groups affecting 534 Vermont members on February 22nd SIGNA corrected an error in its filing which changed the proposed average annual rate from a decrease of minus 3.6 percent to an increase of 0.2 percent on May 9th The green green mountain care board Ordered SIGNA to reduce its profit margin from 3.5 percent to 1.0 percent And improved the modified rate Resulting in an overall average annual rate decrease of approximately minus 2.4 percent Regarding the Vermont health connect 2020 filing rates on May 10th 2019 Blue Cross Blue Shield Vermont and VP filed proposed rates For plans that will be offered on Vermont Vermont health connect for 2020 Blue Cross Blue Shield Vermont proposes an average annual increase of 15.6 percent Over 2019 premiums with proposed increases per plan ranging from nine point one percent to eighteen point five percent MVP proposes an average annual increase of nine point four percent over 2019 premiums with proposed increases per plan ranging from five percent to twenty three point seven percent The hearing dates for these rate requests are July 22nd for MVP and July 23rd for Blue Cross Blue Shield The board will also hold a public comment form on the afternoon of July 23rd beginning at 4 30 p.m Those hearings, I believe this year started 8 a.m. But I would double check the website on that I'm fairly positive starting at 8 a.m. and The anticipated decision date for the filings is August 8th And I would encourage folks who have questions about these rate filings to visit our website under the rate review page. I Believe that is all I have to announce. I'll turn it back to you, Mr. Chair Thank You Susan. The next item are the minutes of Wednesday April 24th. Is there a motion? It's been moved and seconded to approve the minutes of Wednesday April 24th without any deletions additions or corrections Is there any discussion? Seeing none all those in favor signify by saying aye aye any opposed and One abstention due to absenteeism With that one bite Mike and the team front Thank You mr. Chair My name is Mike Smith. I am the president CEO at the interim president CEO of vital I'll let the rest of the team here introduce themselves starting with Andrea Hi, I'm Andrea de la Brea our director of client services I'm Bob turno chief financial officer for vital Hi, everyone. I'm Frank Harris the strategic technology advisor for vital And in the audience and I'll just ask them to raise their hands We have Christopher shank who's the director of technology and carol and stone who's the director of operations? I brought the whole team here to get a sense of the process For the Green Mountain care board, especially in the budget process as we move forward I just wanted to do a short intro before we unleash Bob on the numbers and He can go from from there One of the things that if you've heard me lately in the legislature that that I have said as I've been testifying is What a difference a year makes I mean in FY 19 we established a strategic plan and revised our mission statement. We updated our bylaws We strengthened board membership criteria. We added new board members including Dartmouth as a board member We developed new ways to make it easier for providers to access and view the V high information We continue a data quality improvements We established connectivity criteria. We advocate advocated changing Vermont's consent policy And I think we've been fairly successful in that area The the challenge is to be now implementing that policy in a way that meets the criteria of the legislation And we implemented a technology road map now We did all these things and we sort of established as you remember last year a three-year fiscal plan because we think We believe we had to accomplish three objectives as we look forward into 21 this budgets on 20 But as we look forward to 21 we believe we had to accomplish three major fundamental objectives That was to stabilize operations The second was to reestablish credibility and the third was to put in tool put in place tools That allow us to add value-added products along the way We think we have done that and the reason we had to do that step approach We believe it was imperative that we stabilize our operations reestablish credibility and add value added tools first Because one of our major objectives in this budget although you won't see the concrete examples of it But we're moving towards that with the tools Is to diversify our revenue stream in FY 21? We also had budgeted objectives of Improved data quality reach out to clients make smart technology choices Evaluate our existing infrastructure will go all through this maintain a high level of focus on system security and maintain a Workforce we we have to start in this in this budget cycle Diversify our revenue base and although you don't like I said you don't see it in the results of this budget We are laying the foundation for that in there this budget an example is what I would call the collaborative services or the shared services That we are Proposing in this budget Here's what we told you a year ago Here's where we are now in comparison to what we told you last year. We established a three-year budget plan In fiscal year in fiscal 19. We said we would end the year with a balanced budget through reductions Actually, we said we hope to end with a surplus That surplus will be about 600,000 for FY 19 in FY 20 last year We said we're gonna take that surplus and use it to offset an operating deficit and and have a balanced budget using the Have an operating deficit and use that surplus to offset that operating deficit Even though we've seen continued reductions in state funding and We anticipate that we'll have an operating deficit in FY 20 of about 186,000 that we covered by cash in on hand as you noticed since FY 18 We have been building cash in anticipation of FY 20 and FY 21 We had said last year that we anticipate balancing this budget through providing value-added products to the state government and Vermont providers and we are in that process right now of looking at ways to develop new revenue streams for FY 21 just wanted to sort of set the stage in terms of where we were where we are and where we're going Before I hand it over to Bob and I'll hand it over to Bob Thank you, Mike I'd like to go through some charts that are relevant to our FY 20 budget request But before I start I'd really like to thank Agatha Kessler and Sarah Kinsler from the Green Mountain care board For their help and guidance in getting us to this point Before we move on to this year's budget like to recap FY 19 FY 19 ends June 30th Our expectations are that our revenue will be on budget, but our expenses will be 10% under budget This is driven by lower personnel cost due to some vacancies and administration and the technology teams We had originally budgeted for FY 19 23.6 full-time equivalents Yet this year we have run around 21.8 full-time equivalents on average for the year also our Technology spend is lower as we have paused or delayed the implementation of several technology projects for our review and The potential incorporation into the collaborative services projects, which Mike just spoke about Finally Evidence of our well Being is that our cash on hand For FY 19 is projected to be 2.2 million dollars at the end of the year or 150 days Which is considerably more than in our previous years Moving on Our budget assumptions have been shaped by many factors The budget was developed from a review and Assessment of vitals cost at its lowest possible level by person and by vendor Comparing what we've spent for FY 19 and prior years with what we anticipate those expenses will be in FY 20 the following are Budget assumptions which vital sees as the most significant first and foremost is that we need to complete our current contract requirements The next would be the award of follow-on contracts from diva and OCV and this will only happen if we're successful in meeting our contractual requirements as Mike mentioned we need to maintain our critical talent and Finally we need to continue to identify and pursue cost reductions and opportunities Moving on to revenue In FY 19 we transitioned from contracts awarded on a state fiscal year basis To being awarded on January 1st So therefore follow-on contracts will be a full year in length, but spanning a half of FY 20 and one half of FY 21 So therefore one half of the year will be a firm Number based on the left-to-go portion of that awarded value of the contract Well, the other half will be an estimate and as I will describe this in a future slide management believes that Management is confident that we will be able to to make these projections Finally, we've shown FY 21 to illustrate our anticipation That the revenue for the state in FY 21 will be stable this chart Shows the decline in state funding since FY 21 These values are contract values Since FY 17 there's been an overall reduction in vitals funding of about $1.3 million or 22% and As vital state funding has declined we have taken cost out of the business to remain sustainable I Just I just want to point out an Observation here as I was thinking about this slide I don't believe anyone in health care that I've seen so far has essentially lowered the revenue and their cost and Been six as successful as vital has been in lowering that almost 22% This is a phenomenal job that Quite frankly these people did in making sure and enhanced operations at the same time I'm pretty proud of this the staff at vital for what they did Thank You Mike Focusing on FY 20 revenue the CY 19 Diva contract is shown in green and It is based on on the left-to-go portion of the awarded contract. So this is our CY 19 contract from July through December 2019 The other half of this is a projection for CY 20 for January 2020 through June 2020 again vital believes That it will be successful in a final contract with the vote that is at least equal to this estimate One takeaway from this chart is that over half of our revenue is based on firm awarded contracts? Mike This is back to me because I am excited about this project to me This is an important sort of blueprint for a project because fundamentally it seeks ways In health care to collaborate and lower cost and avoid Duplication this is an effort that attempts to do just that If successful in J let me just give you a little bit of background on this in January Through the initiative of diva and with the support of vital and others We decided that instead of all of us Whether it's one care whether it's the blueprint all of us buying essentially the same software three times Let's figure out a way of collaborating to only buy it once and let's share Some of this software some of this software is pretty expensive As you as you can see in the budget process. I think we're near up $700,000 in total expenses on this so we looked at ways in order to collaborate in order to buy this once and in many cases Vital is taking the lead these four Essential items are one having a common master patient index Two is having a common terminology services so that we all are on the same page and The three is having a hub where we can bring in more information Into the V high and then lastly and this is this is quite important is an interface hub That the utilities of this interface hub is used by most major sort of health care Operations and it gives us the ability to deliver information To guarantee the delivery of information where we want it to go we can point it to just about where we want to go I am very excited about this project I think it shows a map of what we can do in Vermont if we sort of all get in the same room and and put our heads together and you know, I Would like matter of fact, I'm kind of insisting as they will know I would like to see this in place up and running before I leave a vital and we're pushing towards that right now Thanks, Mike moving on to expenses Labor costs for vital are our largest expense item and this year Our budget assumes 22.6 full-time equivalents Again for comparison F1 the FY 19 budget was 23.6 and our current forecast is 21.8 Our expenses for material and services Represent an overall increase and this is driven by the addition of the collaborative services Projects if you take these projects out and compare them to the FY 19 forecast It's about the same so Meaning that our budget for material and services for FY 20 is essentially flat Focusing more on expenses again labor is our largest expense at 2.9 million or 47 percent of our total spend The next largest component is the high hosting in previous years. I've identified this as modicity However back in July of 2018 they were acquired by health catalyst They represent 17% of our expenses technology is next and It comprises 13% of our expenses and contains data security network services Along with software licenses and services We have also included in this budget additional projects to enhance security of the VHIE Finally I have a catch-all basin here called all other this contains occupancy Consulting insurance supplies, etc It should be noted that in FY 19 vital was successful in reducing our footprint at our office from 11,000 square feet to 7,000 square feet and reducing our rent To the projections that we used within the FY 19 budget Finally, we should note that as we add additional functionality to the VHIE whether security related or operational Our cost vitals cost will go up over time since FY 17 vitals Organization has been flattened to streamline reporting promote coordination between employees and Reduce cost for example directors now report directly to the CEO instead of other executive positions Given the size of vital and the additional level of management what excuse me given the size of vital and an Additional level of management is not needed. We have also changed some Personnel responsibility to focus more on business processes and organizational efficiencies So while vital is a lean organization One deep in some skills. We are still capable of meeting our contractual requirements. I just want to add here If you look at FY 17 There were two layers of management That are not in the current FY 20 and perhaps the last half of FY 19 sort of organizational chart We basically took out the C-suite Positions out of the organization and we also have taken out the vice president Sort of roles in that organization as well So you see two levels that are virtually gone I think it's important with the size of our organization. We need to be quick. We need to be nimble We need to be responsive to our clients and to the market that's out there And I think this allows that to happen So in terms of headcount this year We have not included it as Mike has pointed out the other COO Position which would have been in our FY 19 budget In addition while we do have Some open positions to bring us up to our forecasted full-time equivalent projection for FY 19 This budget does not include any new physicians In more detail our salaries and wages assume a 3% inflation in addition. There is no bonus program And we have also assumed that We will have the same benefits providers as we currently have We have incorporated for inflation for those benefits a 6% Inflation now we have seen that the there is a potential for about a 9.4% increase to health insurance, but that only adds about four to five thousand dollars worth of cost to our budget All other benefits we have assumed a 3% increase moving on to What was formally known as modicity which was acquired by health catalyst We have actually seen a more positive approach by health catalyst since the acquisition To with our relationship They have gone to great lengths to help us in a number of Resolving a number of issues We expect to Conclude negotiations with them on a six-month extension and our estimate for Their cost is unchanged from this year their charges for the most part except for the interface connectivity charges, which are more of a Project-oriented charge are very Stable, they are monthly periodic charges Finally moving on to the balance sheet Vital has a very simple balance sheet the largest portion of our assets is Cash and accounts receivable With cash we project that we will continue to build it through the end of FY 19 Then we will consume a small portion of that cash and FY 20 to cover our operating Deficit of 186,000 by the end of FY 20 we project that will have about a hundred and seventeen days of cash on hand Our projection for the balance sheet also includes Two months worth of accounts receivable With our customer The state of vermont and this is due simply to the cash conversion process which takes about 50 to 55 days The last piece of our asset Base is our property plan and equipment and this While minimal represents leasehold improvements and computer equipment at our chase mill office by the end of FY 20 Vital's balance sheet will remain strong Concluding vital has minimal liabilities. We have accounts payable represented by the blue band above we have in some years we have had a Liability to the state Involving the resolution of the FY 17 grant final billing which was extinguished last year and Finally we have accrued expenses which are in the orange band if you take those and you Calculate a quick or an asset test ratio You come up for FY 20 with about eight times which is a very healthy measure of How liquid and how strong financially vital has been come over the years So concluding my presentations I'll take any questions if there are If it's okay with the board, I'd like to because the technology section falls Mr. Chair the check technology Achievements and plans falls directly into the budget aspect. Would you mind if we just kept going or do you want? Okay? Thank you. I mean I'm going to talk about some of our technology achievements and plans and the First thing to point out is that our focus remains You know as I've talked about before that the technology plans support the plans for the V high generally And our focus is on the most important areas that we're focusing on for improvement of the V high Around data quality data availability and ease of use Patient matching patient consent and data security and privacy The as we've talked about we have a new initiative since I spoke to you last year and since we set our technology Strategy last year and that's around the collaborative or shared services And even though it's a new initiative since last year It really is targeted directly at the priorities that we envisioned last year which is around improved patient matching improved terminology services and improved interfacing capabilities as Mike and Bob have spoken about and With the other participants in the effort we conducted due diligence around the potential Technology solutions for this and we vetted the technology Alternatives and we're now preparing to move forward as Mike has described and this Implementation will undoubtedly be a major priority and focus in the technology team in the coming year Next slide and as we talked about last year of reviewing our approach to improve The way we provide analysis data. We actually sort of expanded our focus on this as I've spoken about before Where we wanted to look at our entire architecture and technical platform and we've conducted a request for information to look at the what we're calling future platform we considered 35 companies in the market and Wound up at 14 companies that we sent the RFI to and had responses from 10 of those We temporarily slowed that to focus on the shared services initiative But we are picking back up on that now and conducting the analysis of our RFI responses to determine the feasibility of changing Platforms and in this first phase. We're really trying to look at the feasibility. What would it cost? What would the opportunity cost be? Because as we focus on replacing the platform and if the outcome is feasible and certainly we'll be discussing that with With the folks at diva and other stakeholders We'll conduct an RFP process that will have Stakeholder engagement and making a decision about that We're going to continue to advance our infrastructure approach and as I've spoken about before I see this as minimizing the overhead costs In first thing is that you to create a project plan to establish hdm The the data warehouse side of our architecture Disaster recovery capability for that and we collaborated with the folks at diva and the agency of digital services on the plan And we were beginning the first phase of that which is known as business impact analysis and what that does Inventory is all the the business processes that we need to support to operate the v high And the system and it ties out the systems that support them and basically establishes the criticality of those in the disaster recovery requirements and Once we go beyond that phase we start to make some Investments in the technology to support the disaster recovery So we're looking to have an outcome on the future platform to see if we're going to continue with this platform before we make that investment We're also looking to streamline the infrastructure and we've Had some good progress there We decommissioned our infrastructure that was at rack space in Chicago and there was some pretty significant operational savings from that we established a support resource partnership so that we can better manage the infrastructure and also up to position us to be able to better advance the infrastructure So we have a flexible resource that we can call upon and more depth on the bench so to speak And then with the shared services initiative will start to move away from the owned Infrastructure as I've spoken about before and we'll be moving rhapsody out of our own infrastructure In the area of data quality there's been some I think very significant achievements as the board knows We established a new connectivity criteria, and I know the board approved that criteria We're working with health care organizations now to evaluate their status against the criteria and to establish work plans for advancement through the criteria tiers We also completed a project around terminology services to Standardize the top eight lab tests that we receive in the data across 30 health care Organizations as the data is as the data is received and with that that experience will serve as well as we move into the shared Services initiative and adopt a new Terminology services technology and advance our capability further there And we've drafted a data governance model for the shared services effort And there'll be a lot of data governance questions that will come up as that proceeds And the air patient matching as we've spoken about that's another element of the shared services effort And we conducted an RFI and involve the the participants in a request for proposal For the MPI technology and we selected a vendor pending successful contracting. They're known as varado We reduce duplicates in the current database And we will implement a new master patient index as part of the shared services initiative In the area of data availability and ease of use I think it's been some exciting developments in this area We have now integrated with the UVM Medical Center electronic health record and Providers can now query the V hide directly from within their electronic health record Which lowers the barrier to them accessing the data and being able to use that and we added that We've been doing that with the veterans administration. And so now this is our second site using that technology We implemented two single sign-on sites for vital access So that so if they if they're not integrated directly into their electronic health record We can make it easier for them to get to the portal Uh that that we provide the data in and we'll continue to expand the sites that that use these technologies In the area of patient consent We now have three consent interfaces live and we expect to hit the year end calendar calendar year 19 target of 42 percent consent By june 30th, so hit that that mark early And we're currently engaged with all vermont hospitals to expand those interfaces where the where the organization has the technical capability to implement that In the area of security, we we're constantly focused on this and I think it's probably the most important thing that we focus on in the technology program We continued our robust program of regular audit by our industry expert consultants And we continue to improve our results year over year We established a formal governance group with diva and ads that we're calling the v high security governance group And that group meets monthly and does a comprehensive review of our status in regard to security and our plans and in our progress against those plans We established a cyber security framework. We used the national institute of standards and technology uh cyber security framework, which provides a better structure to operate the program And we're currently working on a master system security plan which establishes security standards for every individual system within vital and how we operate those And we're we're about to release a request for proposal for a security monitoring system Which is known as a sim a security information and event management system And so now we're passed to andrea Thank you Wanted to provide some updates for you And many of these frank touched on already But in the area of meaningful use and security risk assessment Consultations vital offers a service to health care providers across the state of vermont and there is The intent is to improve data quality to help them meet measures that are set by the government to Attest for meaningful use or effective use of their electronic health records There's it's pretty significant focus on data quality in this area It's a tremendous a tremendous time commitment. So there are high numbers of hours and low numbers of organizations because it's a tremendous lift But we're really proud of this effort. We um have In the area of data quality in particular It is working with organizations to to establish Are they capturing accurate data from their patients? Are they capturing it in the appropriate area of their electronic health record? And how do they navigate the system to then attest and achieve meaningful use? In march There were our goal by the way is 80 hours per month for the calendar year 2019 and in march We had 103 hour 0.5 hours so pretty significant The percent of vermont patients providing consent. This is an area frank also touched on The red line is the target, which is 42 for calendar year 2019. We are currently For the patients that have been asked 40 0.86 Percent of them have provided consent We are on target to hit that 42 percent Rate in june by end of june The connectivity the work plans are a component of the connectivity criteria, which frank touched on it earlier These are in progress our target for the year is 89 and the Again, it's the goal is to help organizations achieve the next tier So it's are they capturing accurate information? Are they missing data elements? And if so, how can we Make sure they're in the messages and then are the transmitted to the v high If a healthcare organization is contributing electronically to the v high They are considered meeting tier one at this time and we're still evaluating tier two and eventually tier three So point of care utilization put another way This is our providers do providers need information And are they accessing the v high to help make their healthcare decisions for their patients and We continue to try to make this easier for healthcare organizations to implement And we feel like we are making significant progress in this area We have three ways to access to v high, which frank also mentioned In march there were 3086 Vital access queries That's the web-based portal across community access Which is currently veterans affairs administration and newly implemented university vermont medical center for 236 queries in march And single sign-on we have implemented at northeast of vermont regional hospital And the vermont chronic care initiative and those were 193 queries Another area where we provide another value-added service For for healthcare providers to receive the information they need is called provider results delivery if I'd like to give you an example in case because sometimes it's a bit Confusing to people but if I use myself and as an example I have I love cheese So at some point in time I may Be in a position where I need to go find out if that cheese is affecting my cholesterol level So I may go to central vermont medical center for example and have a lab test done That lab test Would then be delivered and this is this is a real example Of the communication we have with these organizations The lab result would be delivered seamlessly Into my primary care providers electronic health record at the health center in playing field And they may not know it So in the month of march over 135,000 messages and it's not just lab results It's laboratory results radiology reports Transcribe reports are delivered into provider electronic health records. And in fact there are 530 providers receiving those results That's just for one month I do want to emphasize this this is something that I was astonished with about when I first came to vital That we weren't talking about that you know over a course of a year we deliver about 1.4 million Lab results radiology reports and transcribe notes reports. This is important It's important to the day-to-day operations Of providers out there to know what labs getting the labs to the right place at the right time And often as Andrea had said The provider doesn't know it just happens automatically within their EHR or their database and And they're oblivious to where this is coming, but it runs through vital which which I asked Andrea to sort of pump it a little bit. She did Because it is something that I think we need to be a little bit proud of of what we do and how we do it And when you're not noticed, I think that's a good thing It's only when you're noticed that That sometimes you run into problems on on these sort of things. Mr. Chair. That's our presentation We'll be happy to entertain any sort of questions that you have on vital and in our future Thank you Mike questions from the board Jess Thank you very much for the presentation A couple quick ones on the v high hosting with medici the contract with health catalyst Um I was wondering when the contract expires and why only a six month extension The the contract expires june 30th We've asked for a six month extension because I want to see what the results are on the future platform To see what's what is happening and maybe possibly another six month extension But I didn't want to bring it out over multiple years until I could see what was happening with the future Platform analysis. Okay. That makes sense. Thank you. The second was around the patient consent and the I guess this is slide 29 The current engagement with the vermont hospitals to expand interfaces where possible I'm wondering the where possible of the vermont hospitals that you have Interacted with where is it possible? Where is it not possible? Why is it not possible? Sure Well as as we indicated live electronic patient consent is with the university of vermont medical center southwest of vermont medical center and northeastern vermont regional hospital electronic Patient consent project in processes with northwest medical center, and I think that's going to come online pretty pretty darn soon here um electronic patient consent projects in progress after EHR upgrades because there's a lot of well, you know this there's a lot of EHR upgrades going on out there right now North country hospital uvm health network central vermont medical center uvm health network porter those are going to happen in the fall I think is what what my anticipation is on us and still investigating is coplay hospital and giford medical center electronic patient consent projects on hold Springfield hospital and ruttland regional because they've got some competing priorities down there and EHRs that are not capable of electronic Patient consent are brattle borough mount of scutney and grace cottage at this time Interesting very helpful and interesting. Thank you Can you just tell me what those competing priorities are? I'm not sure I know I don't know what the specifics are Um, but I tried a couple of times and they were very very friendly But they just said we we are not able to do this possibly in the fall is what they shared but That was not concrete Okay, and then my last question actually is on this slide Uh, the number of providers receiving results in march 2019 530 i'm wondering if you could unpack that a little bit of those unique providers And if we thought about the geographic distribution what percentage of them for example are uvm medical center You know as a hospital employee. That's a really good question. I think that that's a good question And they are to answer your first question. They are unique providers. Okay and typically they are not hospital Because typically the hospitals have their own laboratories And the the benefit really are the Offices the off-site offices Okay, so the large majority these are independent providers not affiliated with hospitals Well, sometimes they are affiliated, but they're not in the hospital. That makes sense And Okay, yep. Thank you Other questions for tom Um, one is just a a reminder i'm looking at the A line item education and outreach which is phasing out As a part of your expense report and i'm just asking you to remind me Who was being educated and outreach to That was mostly and correct me if i'm wrong website development And we brought that in-house in terms of website development. Okay And going to the chart on page 32 Um, this your your target for consent is 42 percent for 2019 Um, do you have targets for 20 and 21 and Or what assumptions have you made in this budget presentation having to do with Any changes in the consent policy? What we have done in this budget is assume at the time there's I'm confident there's probably going to be a change in consent policy But what what is um, well, i'm not I'm hopeful that there'll be change in consent policy What we have done and assumed in this budget is a current consent policy as it moves to And opt out. There's obviously in legislation right now a fairly consider Considerable implementation phase in terms of how you do that Um, that was not factored in this budget. We would probably divas taking the lead But we obviously are in partners with diva on that. We'll have to sort of Flesh that out of how that works, but it's not in this budget right now So there might be some going down the road if The consent policy has changed them upside opportunities In terms of leveraging Past investments Yes, and and by the way From a technological point of view, this is not a heavy lift for us From a from a Implementation view view and the ability to make sure that we We invite people and we listen to concerns as we're implementing and come up with an implementation policy that takes those concerns into Into place that's going to take a little time and one more looking at the The 40 42 percent calculation What what is the denominator of that ratio? I think it's five in terms of Vermont patients. What what is what is the number? I think it's five seven. It's a 574 thousand And change are the number of patients that We have data on in the v high So that's A little less than the total population in the state obviously But I see that's the denominator we used because it was more accurate than is 174 thousand Um that counts and the denominator would be the the the population of the state Just there's five we We use 574 on the bottom. I think we used 200 and something on on the top I'll get those numbers for you We you know, even if you use the Vermont population of 610 I mean, it's it's minimal the change in those in those two numbers and that counts And opt out so it's everyone who's been asked so it's a little more than 200,000 I just have one question in terms of your fiscal year 20 budget assumptions Do you have any worries about any of these assumptions in terms of the likelihood that they'll bear fruit? Um, we're hoping That all of them bear fruit We are you know, we're under the assumptions We made the budget on on the assumption of what we put up on the screen here We're hoping all of them bear fruit with any budget you sort of adjust through through the year if something Happens or changes. I think You know normally we come back about half year because of our our revenue cycle And and discuss any changes with the board. I expect perhaps we'll do that again As we move forward You know, mr. Chair, that's a great question I had more fears last year than I do this year To be honest with you. I I see and I've said this in testimony in the legislature Vital is an important part of health care reform. I'm convinced of that in this state And I think the more that we can collaborate and bring vital To that point. I think it is It is essential for a well-run health care Um sort of policy to have an established vital and I wouldn't say that if I didn't believe it You know, I I have no vested interest in in this Other than you know, I get a salary and and but I'll be leaving The the question, you know that I have is can we pull this all together and and make sure That we're all pulling in one direction. I think vital showed that it can be done You can reduce costs you can reduce revenue and you can be successful in in doing this and I think The thing that I think That I'm working on now with this team is how do you bring in more revenue? Now that we've sort of stabilized operations And reestablished our credibility and now have the tools to really move forward. How do we bring in? our revenue I'm Confident we'll bring in revenue. It's just will it meet the needs of our future direction and I think it will If not, we're going to open it up to public comment Would someone like to offer a comment or a question Ken I will say that I was a little disappointed In the presentation because having worked with mike smith and appreciating the team I thought this report would have been Produced probably within a month or so after he took over And it seems it has taken a little longer and I just assumed that has something to do with age slowing down a little I know that in some meetings several years ago. I really thought vital Frankly was use the word sort of a disgrace of a project With very unclear direction help comes leadership. So I just want to say it's appreciated to have a much more Robust presentation That presents The potential of what vital convenience healthcare reform that Other public comment or questions Yes, is it possible to elaborate more on If I understood correctly patient consent using electronic format So how understandable Will the format be and how will it be presented to the patient? This is on future, right? We're talking about if the opt-out is we're working through those Details now the legislation calls for us to come up with an implementation plan It calls for the board to sort of approve the implementation plan to look at it But we are looking at ways in order to get that information out As we speak Get that information out and make it easier for the patient To to either opt in or opt out It's it's a little the the process right now is a little haphazard and trying to bring that in but I I guess to answer your question. That's to be determined as we move forward The financials that will pay for that because I noticed like you have education and so forth the way you got it broke out what would the clarification be on Is there a specific line item for that in terms of the financials I think that would probably be a more of a question for diva than us But those are sort of discussions that we will have with diva as we move forward I have not counted my Was the chickens before they hatch because we still have legislation that's going back and forth between the house and the senate It passed the senate yesterday. It's in the house with the amendments coming back to the senate Thank you deal because those will be questions that the board will obviously be asking absolutely certainly will want to know what the Reach out is to vermonis And hall vermonis can be assured that they actually get a chance to weigh in one way or the other We've heard from states like main where there's actually been direct mail pieces Two residents there and things like that. So I guess we're all we're all just going to have to stay tuned Yeah, and and mr. Chair, we believe that the more outreach the better on this because We want to make sure that patients make the right decision and also outreach to Various organizations to make sure that their input is heard on how we output How we do the output Okay, any other public comment or questions? Seeing none, thank you very much. Thank you and thank you for your time All right So at this time we'll invite jenny and emily down Good afternoon. Good afternoon. I'm emily richards the director of the health information exchange program at diva And i'm jenny samuelson the deputy commissioner at the department of romey health access So here's the overview of what we're hoping to discuss today um New diva staff introductions for jenny Um Bit about the consent policy and how the health information exchange steering committee had been thinking about consent policy implementation We wanted to give you an update on the 2019 hie steering committee Uh, a very quick briefer on the vital diva contract and general hie program update So So, um, I know many of you, but i'm jenny samuelson I have recently taken the role of deputy commissioner at the department of ramon health access prior to my work In uh, in this role I was working in the commissioner's office at diva and then prior to that since 2008 with the blueprint for health I've got a history of tracking the help the advancements of the health information exchange And other health care reform activities through my work at diva prior to Working in the blueprint. I worked in public health. Um, and that's where my and long-term care, which is where my background originated You didn't talk about your bowling skills And I do enjoy bowling every once in a while You're good at it And I hope jenny doesn't mind me saying but I mean to me this seems like a perfect transition for the hie program My goal cost obviously who we all hold near and dear did an incredible job of building up individual units at diva Including the hie unit, you know, we saw a lot of progression under his leadership And now jenny is working to unify All of us under sort of the auspices of payment reform and care Using hie as a tool. So I just think that this is a really great evolution Okay, um, so like I said, we we hope to talk about the health information exchange consent policy a bit As you all know, it's still in the legislature for discussion. Um, so this is a bit of a placeholder But you know, jenny and I have been sent a health and welfare and house health care Over the last few weeks and we've had a lot of robust conversations with health information exchange steering committee about how a consent policy would Be appropriately implemented or We'd achieve shared goals and what we've noticed through those conversations is that Both sort of advocates and counter voices and those invested in it were kind of sharing three goals Around implementation of the consent policy first inform us being that we all agree that informed consent is really essential to this informed consent meaning that patients really understand how their data is exchanged why And what their rights are in terms of data exchange The second being that however a policy is implemented that it'd be a robust and transparent process both to stakeholders And to the green mountain care board the general assembly And finally that um, there's a real stakeholder engagement process So again opposition voices and advocates alike have a place to say we want to represent a diversity of stakeholder needs or patient needs Um, and we want to make sure that we're achieving the goal of informed consent And we're really hearing those voices and building them in so what we don't know What is going to happen at the general assembly with the consent policy? We did want to just sort of share those interactions with you And make sure that you knew how the hie steering committee was thinking about supporting this process so back Back in our history in january when we were talking to you about consent and um, steven odafe presented divas recommendation In the consent policy report We've gone to the hie steering committee who's newly formed for 2019 and discussed how to implement And we really thought through kind of a Five essential pieces of the implementation process Again multiple places for stakeholder feedback multiple places for accountability and really holding Partnering with stakeholders to help us identify the best ways to get patients involved and helping us to implement those practices So we're starting here with diva proposes a draft consent policy And that um, I think as steven spoke about was aimed at not changing the current consent policy In a Not changing it too much But really emphasizing what the roles of the health information exchange operator are providers and the rights of patients Then asking diva to facilitate stakeholder work groups to determine how to best implement policy And this those stakeholder work groups are intended to result in a recommendation So we'd pull together groups like the health care advocate aclu disabilities advocates and others And really get them thinking about the diversity of ways that people here and Can absorb information and really be planful about informed consent implementation Then the steering committee planned to take that recommendation Um and sort of map out how to successfully implement it Some of these things have a technical component some of these things have a development timeline So thinking about like how can we feasibly roll out all of the recommendations that the stakeholders have come up with We would come back to the green mountain care board To review the consent policy and the implementation strategy at that time We thought it would be best as part of the hie plan because we were coming to you anyway with that And then sort of get to work um and implementing hopefully what you all approved Simultaneously the idea was that diva and consultation with hie steering committee Would be providing regular updates on how planning and implementation work So I think those sort of concepts are reflected in what the general assembly is discussing now and if that Doesn't result in what we think it will result in we still feel Diva and the steering committee still feel that these are sort of the tenets to successfully implementing a change in policy um So guiding principles for implementation I think it's important to understand sort of the essence of what the steering committee talked about when they Talked about achieving those three goals particularly in informing consent in a railway So when they thought about what would guide the implementation process they thought about these principles First to build on the consent policy management successes of other system systems You know today in vermont there are some health care systems that are health care organizations that are doing this In a way that I think patients would feel like is successful So not repute not uh duplicating what they're doing but rather building on what they're doing And we have a lot of examples of states that have the opposite policy of us Or a dynamic consent policy as we might consider it into learning from how they've implemented those processes prioritizing patient education and access to information for all of the reasons that I just covered Working to reduce or limit burden associated with consent management and envelope changes to processes and a broader consent management practices And we heard this from legislators. We heard this from the steering committee I mean the privacy disclosure is already required under HIPAA And we are already asking our health care organizations to talk to patients about consent So we don't want to add an additional process. We want to consider really thoughtfully what exists today What are their current obligations and build the process into what exists in the provider community? Respecting existing state and federal laws regarding sharing of specific types of health data And this is a nod towards there are some clinically sensitive data types that will not be covered by this policy So making sure that patients really understand what is and is not exchangeable and how Um honoring consent preferences that have already been expressed by vermont patients This was really big to the steering committee because we don't want to go back out and ask people We want to make sure that if somebody has expressed a consent preference already or 40 percent of vermontures have That they don't need to be re-asked, but the opportunity to change their preference is available and finally Assessing feasibility of different consent management practices and planning implementation strategies accordingly Steering committee talked a lot about a self-service module meaning not a provider driven consent process whereby you have to see a clinician and they have to record your Consent preference working towards a way whereas us as patients whether we're seeking care or not Can manage our own consent preference, but that's not going to happen overnight. So creating a feasible plan together So i'm going to switch gears and talk about the steering committee and Hopefully my one and only typo in front of the green mountain care board, but that first name should be jenny samuelson So, uh the 2019 steering committee kicked off In february or so and just to sort of set the stage as a reminder Coming off of the 2017 evaluation which health tech executed They pointed out a lot of um things that vermont could be doing better and one of them was governance So we pretty immediately set up a steering committee First and foremost to help us develop a statewide strategic plan That committee was great. They hit the ground running. They developed the plan presented it to you which was approved in november So now they are building on that plan which was really foundational and they've jumped into a few goals this year So you see that we've we've kept the uh group relatively small and in the hie plan we detail why This group is asked to do a lot of work And there are many existing groups of stakeholders that can hopefully represent specific stakeholder interests And they have committed to reaching out to those stakeholders to involve them in the process and planning But not burdening them by asking them to be on this group So the folks in green are new But hopefully those everybody here looks relatively familiar to you So just to talk a little bit about their goals and these are um Detailed in the hie plan from that you all approved the existing plan Uh, we've we had a tactical plan if you remember. So the hie plan uh discusses, you know Health information exchange broadly challenges Essential pieces keep players and then we've got an annualized plan that says okay So what are we doing this year to address those? issues that we've identified And so for the steering committee, this is what they've uh committed to So first to assess potential changes in the state's consent policy, which we just discussed Next to conduct an assessment of the state's data governance efforts and then just excuse me and define the steering committee's role in relation to existing work Just for like the non a non technical explanation of data governance is just sort of policies and standards and operational practices That would allow you to exchange actual data elements And so the steering committee is at a really strategic level planning level But we know that data governance is needed to successfully exchange clinical data across the health care system So trying to figure out where those two concepts kind of marry and how the steering committee can help support policies and standards, etc that will Further the achievement of the goals that they've outlined in the hie plan So that's underway They've also committed to evaluating health information exchange proposals current work and the hie plan implementation So year over year, they'll just be looking at what they committed to and and how it's been going This year I we kicked off with a much more in-depth look at which each organization Represented on the steering committee is doing to further hie goals where their challenges are where there are opportunities It's been a really incredible opportunity To start a conversation about what we want to achieve in years to come where there's duplication where there are opportunities It's been great We actually I think we wrapped up the last one today and the green mountain care board presented at our last meeting which was great on vcures The next one here a draft a technical roadmap that reflects a three to five year investment and growth strategy Related to key hie strategic objectives, and I'll spend a little bit more time on this because this is their big big deliverable for the year And then finally once they've done that they're going to look at financing and sustainability for the year to come Last year they reflected on sort of key considerations and challenges as it related to financing and sustainability and thought and reflected on the need to Shift the public private investment ratio in hie and so this year we hope to add some granularity to that Hopefully a few tactics related to execution of the technical roadmap as well And no no later than november 1st We'll be back not me, but Someone will be back To update the hie plan or to provide you with an updated hie plan that will include all of those things that we just discussed And I think one of the key points here Both through the the presentation you saw from vital earlier and through the progress of the steering committee Is that we committed in the last hie plan to continue to make the progress that you've seen And over the the previous year and I believe that both this and the vital presentation Really began to demonstrate that we have made progress in achieving some of those goals towards that tactical plan So just a bit on the technical roadmap So this year's hie plan we're envisioning it as an update rather than a full-scale overhaul So in the current hie plan what you see in the technical section Is a discussion of the technical components of hie An it modular architecture that separates those components into foundational and or exchange services and end user services Talks about roles and challenges for achieving each technical component So we're going to build on that section this year An action plan that we'll look at the next three to five years and what we need to think about in terms of data exchange technology And all of sort of the component parts that surround those In order to further the hie goals, which are stated in the plan itself So to help us with this We've hired a collaborative of national experts lantana consulting in vela toora And their approach is to develop an actionable actionable roadmap That's kind of helping us balance immediate needs. How do we solve for the immediate problems and consider what's coming up in the future? And we'll talk a little bit about how federal government and others are driving innovation very quickly They also want to make sure that we're thinking about Safeguarding the investments that we've made not locking ourselves into vendor relationships really creating some agility And advancing what we've built to date rather than creating new things where services are So lantana is a vermont based company a woman-owned company company may have Met the president and ceo lyora el schuler She helped us with some of the technical components of last year's health information exchange plan And she's been in this world for 10 15 years first Helping center for medicaid or medicare and medicaid services Established standards for meaningful use or that the electronic health record incentive program And she's evolved her business in many ways She's asked to be a national leader on setting national data exchange standards through hl7 And we're really I just think lucky to have her we had great success working with her last year And she's brought in vela toora vela toora is important to us because you may remember Michael and I came back last year and we said we based all of this health information exchange planning on use cases Or what it means to individual stakeholders, right? But vela toora is really like where that use case concept was kind of birthed as it relates to health information exchange They have something called the michigan health information network, which is kind of This ancillary governance body that's coming up policies and standards that influence the hie operator But not or not the hie operated themselves And they're an offshoot of the learnings at the michigan health information network So we're going to build on their ideas of what they call the use case factory They test interrupt our ability possibilities In a technological framework And they just have had a lot of success when it comes to bringing different groups together So I think those two groups together will really will benefit the state of ramon And we're kind of running with this model of you know, we're a small state We don't have a ton of national experts So bringing Be using the steering committee to think really Thoughtfully about what our strategy is for the year to come and then bringing in expertise to help us achieve Our goals on an annual basis So i'm just gonna I'm gonna shift gears to the diva vital contract, but I want to make this one quick because Vital did such a great job of talking about all of their component parts But there's a couple of things that I wanted to leave you with here First like we're noticing that vital is meeting or superseding all of their goals for this year Which is great and all of those goals are in alignment with the health information exchange plan Which this governance body the steering committee set forth So that alignment is really incredible. I think and so this thing that you're seeing On the top right of the screen. That's the it modular architecture. Sorry. That's such a boring phrase But that's the thing that we put in the hie plan to sort of Guide how we're thinking about who invests in what in health information exchange And the fact that you need to build the foundation of the house before you're building the roof And so we've separated the component parts of vital's contract to align with that it modular infrastructure And they've set goal. We've all set goals Towards furthering each of those component parts, which I think is great And I loved the question about what are their goals for next year? And we are actually if you can believe it already thinking about their contract for next year The way the federal funding process works is we need to go to the feds in july and say this is what we're thinking for Six months for now from now. Can you help us by providing some federal participation? And so we've been partnering with vital to both build on this work and to take advantage of some more expansive opportunities They're thinking a lot about what has been successful in other states. For example connections with The hie and ems services a lot of California for instance has had great success in rolling that out So how can we take advantage and build on what they've done and cms really likes that project? So that's an area where we can get federal support to sort of build an avenue of exchange so Over the next few months we'll be setting those goals and going out for the federal funding request The final contract will be drafted in the november timeframe just because we have to send it back to cms to review In our plan is to execute on january 1st So shifting gears once more An hie program update. I think for the last couple of times we've been here. I just wanted to make sure that Sort of some things that are happening at the national level are on your radar and kind of the big picture things that are impacting the program are Just you know in your realm of thinking as you consider what the steering committee is doing and our relationship with vital So first and I this is duplicative. I've mentioned this before but I think it's important um Vermont and other states across the nation have taken advantage of federal funding under the high tech act first to digitize health records So this is where the boom in electronic health records happen to their meaningful use under Medicare and Medicaid We still operate the Medicaid meaningful use program and will through 2021 It's actually a very successful per capita program here in roman. I think we're ranked number three So a lot of providers have taken advantage of it So cms first thought great We need to digitize its health records and then they thought there's a funding opportunity here Let's drive towards interoperability or actually making these systems talk to one another and data exchangeable across the healthcare system So they've continually expanded funding opportunities under that act over the last few years It's important to note that this funding opportunity expires in late 2021 We've really maximized a lot of great opportunities through the high tech act And what cms has said is we've noticed that nationwide So we're going to hopefully make this this opportunity continually available under the Medicaid management information system And that's just the sort of how the technology we use to operate Medicaid And folks do nationwide. So we're in a transitional period. We're still learning a lot about exactly what those mean that means But that could have a potential impact on the types of projects we can fund particularly as they Go further and further away from actually Medicaid direct care Next up here is that the office of the national coordinator and cms have proposed a couple of rules They're complicated and there is a lot to them. So I'm just really oversimplifying this here But generally speaking they're aimed at driving interoperability and simplifying patient access to records So they're using a lot of carrots and sticks to make that happen It's still in rulemaking. So they I think the The public comment period is open for another month or so But this will very likely have a pretty big impact on how folks develop technology in the hie sphere And then how payers and patients can interact with data As part of this and we've talked about this before The 21st century curators act which came out a couple of years ago Imposed upon the office of the national coordinator to set up something called the trusted exchange framework and common agreement So they're now just creating rules around how they would implement this and this like very simple graphic on the right hand side Kind of explains what they're trying to achieve. So they're saying we need one national hub hie hub We'll have qualified health information networks underneath that so that could be regional hubs That could be local hubs depending on whoever qualifies and then we'll have participants who could be EHRs they could be local hie's they could be payers All feeding up into those qualified health information that qualified those qualified health information networks So the idea is to support achievement of national interoperability. So us as patients We can see a provider here in vermont. We can go to wisconsin. We can go to california and our data is going to follow us because most of the rules of the feds have pushed so far have been really state driven and have have Um resulted in state derived approaches and so what they're trying to do is create this national landscape So a lot to be seen there Um, you know a lot could happen Someone one of our national experts to set said today five years in health information exchange is like a lifetime so You know we could come back a year from now and the landscape could be very different So I wanted to have that on your radar And then partnerships are expanding. Do you want to touch on that point as I've been talking a lot? Yeah so, um In vermont one of the things that we that we began to look at is is that the the landscape That we had here There were there were multiple times that we were being asked to invest in the same sort of technology And specifically we asked a few of our partners the blueprint vital And the aco to look at whether there was an approach where we could begin to partner across those programs to make the investments one time So coming out of that work vermont is now That that group of partners identified main as a as an opportunity for us to create a shared services model because a mean has established and set up technology around their translation services around the connectivity and interfaces And so we are we are planning on part the that group of partners is planning on partnering With the state of main to create a shared services model under that shared services model We're kind of We're exploring The opportunity for us to shift some of the elements further up into Providing the the data matching and the data management earlier Which may allow us to Begin a conversation about what types of data we can exchange We have also started the conversation across the new england states and exploring strategies across the states For maximizing data collection through the prescription monitoring program and systems And the sensible connect collection of that data Into the hie's And the health record systems I'm just to add to that. I think that's great and you know cms For the last couple of years has really been pushing states to reuse investments And to think about regional approaches. So this is really an alignment with where nationally folks hope that we go And it allows us to take advantage of a lot of the great work that's happened region wide You know, I think main's excited to work with vermont because braille has done things that they haven't and we're really excited to take advantage of Their hie particularly as they have an entirely different financing and sustainability model than we do here So it's an interesting way to think about how we feel So that is it. We have 30 minutes. We'll put it in go over Are there any questions? Did great Questions That's all thorough you were Can I make an announcement? Can I help you make it a little later? Okay, I just it's about public comment and then I go. Okay. So I just want to make sure folks know that Open or public comment is a Starting today on the vital budget. It is posted on our website under public comment and under what's new And again, it's opening today It will run until monday june 3rd at 12 p.m. And the materials are linked to that public comment Thank you Public comments on the presentation Any comments or questions stale So I'm looking at the hie steering committee and I can't help but notice I'm trying to be careful how I word this because There's definitely two sides To this theme I'm looking at the expertise is addressing this issue Now it is an issue that needs a lot of expertise to design A system that's going to work I can't go to the regular consumer to get that I need something like a think tank It's really complicated what some of these issues are even in terms of consent At the same time Look at who is giving the input and It's experts And this is one of the things that bothers me a lot is It's not james tree It's not the average person that is actually going to be asked for To give consent And I don't know how you work that disparity I even experience it when I walk in I have been around health care so much I can get a better interaction in a doctor's office Then I know some people can because I know the system They might say you asked a good question and I'm thinking to myself That was because I know the system. I didn't do what I do I probably couldn't have asked that question so I'm just I just as a consumer think we need to be really careful with this going forward We need everything they've done and you did excellent work I'm not criticizing You've done excellent work but I am testing the waters of it And that's what I think we need to do somewhere down the road here There is going to still be that test of Those that are being Octagon or octa going to have to be an understanding of The person that has been affected which brings up the curiosity question of Under ought out For the only time that they consider the importance of their consent Is when they have a problem At which point it's a complaint to opt out Those are some of the things you get into that I just can't help but wonder about And maybe it sounds like I'm overthinking it, but I'm not sure that I am Is Linda Liu meant to be the consumer member? And I don't know her at all, but Would you call her the average consumer or she's a very knowledgeable consumer she did work at Blue Cross and she is an RN So she has a great background You know The h.r.d. steering committee is a big commitment Um, and so it was not easy to find a consumer wrap. I think healthcare advocate tried to help me for a while Um We were lucky to have Linda because she is really knowledgeable and able to jump into this area That's often very technical, but I think today is a really good question About how do you involve the consumer voice in the consent policy implementation? That's why the steering committee really wants to rely on that stakeholder engagement series So we are thinking about the diversity of consumer needs and how people internalize information This is not the easiest subject. I mean, you know, just even using the term opt in opt out can be really confusing to people So thinking about how we're using language and mechanisms and placement in a way that's going to be most meaningful to people I think one of the other things that we talked about with the legislature Recognizing that folks receive information in different in different ways and from and from different people in a variety Abilities to ingest that we really in this process not only want to engage stakeholders in The process of informing how we're going to implement If there is a change of a consent policy, but also assist us in providing the information And beginning to look at where we do consent as not potentially only in a provider's office Where you're talking about a traditional healthcare provider, but can we begin to look at? our designated agencies and other Places where people can receive the information in a way that may be more culturally appropriate for them And and also to potentially receive it in multiple different locations. I think we have a lot of conversations about duplication I think that the opt-in opt-out conversation is a potentially complicated Question for many individuals and their circumstances change So we want to give the opportunity for them to hear the information more than once Other public comments or questions So my name is Eric Schulte, I'm the health care advocate. Um, I'm heartened obviously heartened that the discussion has moved away from V high operational goals and a 42 percent to thinking about The meaningful consent of patients that I have continued. I don't think the Debate is truly about opt-in and opt-out. I think if you look at most of the literature on this, um, That is a general opinion and the real issue is how can we do this in a way that Vermonters understand what they're doing or not the goal is not just to increase participation at the expense of consumers I think the devil is going to be in the details in this stakeholder engagement um I think there's room for substantial improvement in how this plays out. I think these are concerns about engagement that legislators have expressed I would also like to build off of what dale is saying that there is no universe single person who represents consumers and I think the board has done a In a different arena has done a wonderful job of realizing that you have to go to where people are And I think in this stakeholder, it's not going to be it in stakeholder engagement process. It's not going to be enough to have one representative but that I hope that Diva will make the investment to go out and meet vermont who's where they are so that they can hear their input and You know that might be leveraging community partnerships. I know at least in the property world The vla has vermont legal aid has substantial amount of community Relationships with organizations, and I think we would be more than happy to work with the above to Set up focus groups or town halls in the communities where vermont lives Thank you. Thank you. Other questions or comments from the public Susan I was hard to see The group of people that will be consulted was white and to include more than just the officer the health care advocate Well, I think they do a tremendous job They're just one body and the aclu and I think I even saw disability advocates in the list So that was a nice thing I think one of the takeaway lessons from the sim grant was that true stakeholder engagement Takes a lot of time. It's necessary to build the buy-in for anything to succeed But it takes time and maybe more significantly It takes money and resources and people who know how to make things accessible So while I'm really encouraged to see the words appearing I hope people do it well and that's going to take money It's going to take people who know how to talk to people with disabilities and know how to have an accessible meeting Giving people 50 page handouts. This is what's happening right now in the world of developmental disability payment reform Handouts are given the day of the meeting even a couple days before the meeting, but they're not accessible So it'll be great if the people are in the room, but please make it A process is that people can actually engage in people with low literacy low health literacy Different ways of communicating different languages. We're all healthcare consumers We're all going to have our information sucked into the great big be kind We should all be able to understand what's going on. Thank you, Susan other public comments or questions Seeing none. I wish to thank you both Is there any old business to come before the board seeing none is there any new business to come before the board? Seeing none. Is there a motion to adjourn? All those in favor signify by saying aye. Aye. Any opposed? Thank you, everyone. Have a great rest of your day