Healthcare Wait Time Study that was convened by the Agency of Human Services, the Department for Financial Regulations, and the Green Mountain Care Board. Up front, I want to acknowledge that this study occurred during the pandemic and would like to start by thanking our healthcare providers, staff, and Vermont hospitals for their work to fight COVID. Healthcare providers have worked tirelessly to care for the sick, including those with COVID-19, to establish the Statewide Network of Testing Centers, provide mass vaccination, and so much more over the last two years. They step forward and continue to step forward, and as a result, Vermont has one of the lowest COVID-19 death rates in the country. Let's thank them and keep that in context as we review the results from their wait time study. Looking back, anecdotal reports of long wait times for healthcare services have been circulating for some time, seven days chronicled the issue in September of 2021. Then Secretary for the Agency of Human Services, Mike Smith, convened a study that was intended to quantify the issue, identify key challenges, and to address them. Working together to make sure Vermonters have timely access to appropriate care is the primary goal moving forward for these findings. With the study, we recognize that while wait times preceded the pandemic, the COVID-19 response fundamentally changed the landscape and contributed to the issue. Based on what we're seeing in the landscape with people showing up in much more acute need for care, we recognize that one of the non-COVID-related risks of the pandemic is the delay in preventive care and treatment. As such, addressing wait time delays in care is essential for moving forward for recovery and revitalization. In order to be thorough within the timeframes allotted for this study, there was a use of multiple methodologies and different time periods, and it includes data which is intended to simulate the experience of Vermonters. The findings across each of these methods includes those before, including those before and during the pandemic point to long wait times in Vermont, particularly in certain specialty areas. These wait times occur regardless of a person's health insurance status. This is a first look at a complex problem at an unprecedented time in our history. The study was initiated in September of 2021, portions of the data collection occurred during the downslope of the Delta Pant Wave and ended with the start of the Omicron variant in December of 2021. Thus, two-thirds of the data in the study was collected during the pandemic and represents a system under pressure and at a time when the state and providers needed to prioritize resources, which has contributed to the ability to provide non-urgent care. Further, new safety protocols and workforce shortages have impacted services statewide. Even with a number of people needing care for COVID-19 decreases, the system will be impacted by workforce shortages and potential new demands for deferred care. In other words, this study is a snapshot of where we're at and represents a real issue made worse by the pandemic and is going to take time to resolve. I'm confident that the study results and future transparency will be a useful guide to the progress through recovery and revitalization. Again, this is a complex issue. In order to make progress, we will need to work collaboratively with the healthcare system and patients to identify opportunities for improvement, which are multifaceted, ranging from processes in hospitals to communication among diverse providers to IT systems to payment methodology and Vermont's regulatory environment. Improvements in wait times will necessitate actions from the state and healthcare organizations, which are reflected in the recommendations. I am excited to see that the hospitals already acknowledge and are working on the issue, for example, the UVM Health Network published and is making progress on an access plan. While the pandemic has made a pre-existing access challenge even bigger, it has also demonstrated that innovation and partnership are possible to solve complex issues. I have spoken with healthcare leaders and we agree to work together to make progress collectively. I am confident we can address this issue together. So let's start by digging into the findings. For that, I'm going to turn it over to the Director of Healthcare Reform, Ina Bacchus. Thank you, Secretary Samuelson, and good morning. I want to reiterate Secretary Samuelson's remarks that this study was indeed conducted during a time of unprecedented disruption and strain on the healthcare system in the state of Vermont and that these findings are even more important as we move as a state collectively towards revitalization and recovery after the pandemic. This study was undertaken in collaboration between teams at the Agency of Human Services, the Green Mountain Care Board, and the Department of Financial Regulation. And I am very thankful for the team-mates' contributions to this work. It is a large body of work and we provided for individual contributions from each of the teams and collectively brought the work together in this final report. I also want to thank the people who contributed to the multiple avenues of analysis that we took. We heard directly from Vermonters in this project. We heard from providers and we heard from those who are working in provider offices and hospitals who worked cooperatively with us as we undertook this study and review. I also want to thank the consultants that worked alongside our team from Oliver Wyman, Oliver Wyman Health, and Oliver Wyman Life Sciences. I will start by summarizing the key findings and recommendations of this report so that we can work our way through the multiple areas of analysis that we undertook and you can see themes and learnings from each of those areas and you can see how they influence the recommendations that we have to make here today. And we'll circle back to the recommendations again at the end of the report. I also want to just take a moment to talk through how I'll work through the findings and the report on the whole. I'll summarize key findings and recommendations and talk about the study rationale and the structure for the work and then I'm going to turn it over to Commissioner Pichek to talk about how we quantified the problem and then we'll talk about possible causes. So first, in terms of key findings, a summary of key findings, wait times do appear long in Vermont for certain specialties across multiple methods of analysis and time periods as Secretary Samuelson already stated. For approximately half of specialties, wait times are over two months. I want to emphasize that we don't have available data now to be able to understand whether or not clinically appropriate care was provided and how persons in need of clinically appropriate care may have been triaged. Meaning we know that we can measure long wait times but we don't know yet how to measure who may have received care within two weeks versus who may have received care at the end of the wait time indicated. We also know and as Secretary Samuelson said, wait times were long prior to the COVID-19 pandemic and we'll share with you and elaborate on how we determined these findings. Wait times vary significantly by and within specialties with dermatology, neurology, psychiatry and endocrinology services having the longest wait times depending on analysis. We will go into depth with you about our methodologies for these analyses but I want to emphasize that we took a statewide look at this issue. We looked at services provided across the state of Vermont and we looked at services available for Vermonters that are being provided by providers in other states. We included in our look services provided by hospitals as well as services provided by private clinicians and private practice. Also in our key findings, metrics to assess wait times such as the first and third next available appointments, we found do not always reflect actual patient experience of accessing care. And that's another key theme in the work that we undertook. This study was guided by the principle that we were trying to understand the waits for health care services through the eyes of patients in Vermont. Finally, as Secretary Samuelson also already shared, our findings showed that wait times are similar regardless of insurance coverage type and that wait times were not longer for patients with Medicaid insurance in general. However, for a few practitioners in private practice, specifically a few specialty types, they are accepting Medicaid insurance all together at lower rates. Based on those key findings, I do want to review our recommendations and summarize our recommendations for new initiatives as well as ongoing work that we are engaging in collaboratively and in partnership with the health care system. The first new recommendation is to continue tracking and reporting wait times for health services in Vermont. The Department of Financial Regulation would be charged with monitoring and tracking wait times ongoing and making this information available to the public. As we'll continue to explore with you this morning, we learned a lot in terms of how to assess wait times from different angles and we know that there is more to learn about the best ways for us to monitor wait times ongoing and we want to do that in partnership with health care providers. The next recommendation is for hospitals either to establish a board level committee or designate a board member to be responsible for participating in monitoring wait times at their facilities and in continuous improvement to promote patient access to care. We also recommend that hospitals and independent practices coordinate and collaborate to share information and successful strategies designed to improve wait time. Further recommendations for continued action include the Agency of Human Services, the Green Mountain Care Board, and the Department of Financial Regulation continuing to study this issue. We have learned a lot in the few months that we've been studying this issue and we've certainly learned that we have not uncovered all of the all stones. We know that we want to look at and understand access to primary care in the state of Vermont, that we need to do a comprehensive assessment of access to mental health and substance use treatment services in the state of Vermont, and we've also determined that further review and improvements to the regulatory framework may be necessary to promote patient access in Vermont. We also determined that because of the specific data that we saw relative to some practices that are not accepting Medicaid patients at the same rate that they are accepting commercially insured patients, that we need to investigate and understand the barriers for those private practice practitioners in particular in accepting Medicaid patients. We also recommend continued focus and prioritization of the recommendations in the comprehensive workforce development strategic plan. We heard from providers about issues, numerous issues related to the healthcare workforce, and how these issues are a part of a multi-factor problem with respect to wait times, and we certainly know and can identify areas in the workforce development strategic plan that could help to address this issue. Specific examples are exploring whether a physician assistance program can be created in the state of Vermont to provide a stronger pipeline for physician assistance to be working in practice, as well as employing supply and demand modeling on going to determine whether we have adequate supply of providers to meet demand for services and expanding telehealth coverage and making tele-billing requirements clear, as well as working with the Office of Professional Regulation to ensure that there are speedy paths to licensure for practitioners in the state. We also see that there is room for continued quality improvement, specifically quality improvement in terms of how care is distributed between primary care and specialty providers and how these care providers integrate care in services in four Vermonters in the most appropriate way. And finally, we recommend that we need to continue our focus in shifting to a value-based payment model in Vermont, a payment model that rewards health outcomes, the most appropriate distribution of care, and that moves away from the fee for service incentives for reimbursement that we know can drive utilization of care that may not be necessary and that may impede supply for those in need of care. I'm going to frame up for you how we engaged in this study and how we arrayed this study and again how we looked to design a process that really was oriented towards seeing the system through the eyes of Vermonters experiencing access to care. As we heard already this morning, we certainly know and have heard about anecdotal reports, about long waits prior to the pandemic, and emerging reports were highlighted in the media in September that brought to light challenges and severe consequences for some Vermonters facing wait times. So through this study again, we wanted to hear directly from Vermonters, both in public forums and written testimony to invite anyone to share information beyond what had already been reported in the media. And I want to read just a couple of the quotes here, which do provide for some of what we heard. It is not okay for someone with a potential diagnosis of leukemia to wait four months just to get in the door. Some leukemias will be terminal in a shorter time than this. Others shared and expressed, I can't imagine how many other parents are struggling to find care for their children. And it was said, I'm a doctor and I told the scheduler on the phone, it was likely cancerous. They gave me the earliest available appointment of five month wait. We know that there are impacts of delayed care when care is clinically appropriate. There is evidence that long wait times for clinically appropriate care can lead to worse health outcomes, especially among older and more vulnerable patients. And this is a key and important finding because as we experienced throughout our study and observed that there are multiple barriers and it's a complicated process to obtain appointments in the healthcare system. And we know that people who do not have the time or may not have knowledge of the healthcare system would then experience access to care issues at a disproportionate rate. The risk of patient mortality is increased when wait times were longer than 31 days for older and more vulnerable patients. There is an emotional impact. People experience frustration, anxiety and suffering when they or a loved one is unable to access the care that we need. And this was a theme that was echoed as we heard directly from Vermonters and others. We know too that there is a financial impact when care is delayed and that delayed care can have a significant impact on hospitalization costs since some individuals will have gotten sicker when they do not receive timely care and that those sicker individuals require more interventions at greater expense. There is an equity impact as I already mentioned, barriers to care disproportionately affect those who may not have time, resources or knowledge to navigate a complicated medical system. So again, our study goals were certainly to understand wait times through the eyes of Vermonters and also to try to quantify and corroborate the anecdotal reports about long wait times. We invited Vermonters to share their stories. We brought providers and experts together to speak directly with us about wait times in the system. We gathered data from multiple points of view to validate patient and provider reports and measure wait times statewide. We also considered reasons why medical wait times were so long in Vermont, including the role of the COVID-19 pandemic as we've shared already today. We finally developed recommendations to help address medical wait times and improve patient experience. I'm going to turn it over now to Commissioner Pichek who's going to talk with you about the different approaches that we undertook to quantify this problem. Thank you very much, Ena, and good morning, everybody. Thank you for being here. Echo Ena's thanks to the Green Mountain Care Board to AHS for their work in this evaluation. I want to thank the DFR team for their work as well. Many hours were put in, a lot of analysis, a lot of detail, and happy to share the findings today. So I think when we're trying to quantify wait times, one of the first things that we have to look at is what are the metrics that we're going to measure them by? And when you look across the country, when you look across Vermont, there are no uniform standards to measure and quantify wait times. So that is a challenge, no doubt. Also, when we look across Vermont and across the country, there's very little data collected. There's very little evidence that medical communities are trying to quantify this data themselves. So we really had to start from scratch in terms of what are the best approaches, what are the best ways to try to quantify this data. So for us, that meant really trying to have multiple streams where we heard from Vermonters, we heard from provider communities, we looked at different data sets to try to answer this question of are medical wait times longer in Vermont, and if so, why is that? So the first place we started in trying to understand that is with Vermonters. As we said, we wanted to hear from Vermonters, we wanted to have this evaluation seen through the eyes of Vermonters. So we held public listening sessions. We had over 20 or 70 participants in those listening sessions. We heard stories that were certainly challenging and heartbreaking. They corroborated the stories that were reported in the media primarily by seven days late in the summer. And it told us that we needed to look further, that we had heard directly from Vermonters. We'd received about 70 additional written testimonies about challenges accessing care in Vermont. And those stories combined really told us, let's go to the next phase, to the next level, and try to get more information. We did that by speaking with providers, the community that obviously provides the care that sees hundreds of patients every year that can tell us their experience, what they're seeing, and how we should consider evaluating this. We heard from over 90 providers, both in focus groups and survey results, that were very valuable. They talked about challenges relating to workforce, to retention of workforce, to recruitment of workforce. They talked about increase in administrative burdens and administrative tasks that they've been dealing with for years, but also obviously throughout the pandemic as well. And they also talked about communications and technical challenges that they're experiencing that add to wait times and challenges referring primary care patients to specialists. There was also a discussion about whether all referrals from primary care to specialists are appropriate and whether care that's being received at the specialist is also appropriate, whether that could be referred back to primary care. So all of those again were corroborating what we heard directly from Vermonters that the provider community found concerns about wait times. They had some suggestions about why that was occurring and it made us want to go further and try to quantify this data more holistically. So we tried to do that through three different primary methods and I think the importance here is to understand both what this data tells us and what the limitations are as well. I think what it tells us is that when taken together for certain specialties, medical wait times are long in Vermont and where we do have benchmarks, Vermont performs worse than peer states. So I think that's important, but at the same time it's important to recognize the limitations and I'll go into that for each of these. On the claims data analysis, this was done with vCures data looking pre-pandemic. So from 2017, 2018, 2019 that was done by Oliver Wyman, an independent analysis and it looked at the wait time between the provider visit, the primary care visit, and the specialty visit. The secret shopper program was primarily conducted by the state of Vermont led by DFR where we called over 800 specialties acting as if we were a Vermont consumer, again trying to get that perspective of a Vermonter seeking care. We had certain special, certain reasons for seeking care among 21 specialties and then we recorded the wait times that were provided to us through that program. Again, for that program, as Secretary Samuelson said, conducted during the pandemic, conducted primarily in December of last year, but into January as well. And it is a snapshot, it's that snapshot of time, so it's not indicative necessarily of wait times overall or over the entire year period or over multiple year period, so I want to make sure that's evident as well. And then we did a review of a primary care chart. So we looked at about 2,300 primary care charts, again looking at referrals from primary care to specialties, seeing how long those referrals took, and we're able to get that from about 2,300 patients for the year 2021. So again, that conducted during the pandemic. Looking a little bit more specifically at these three analyses, starting with the claims data analysis. You can see here that the first thing we needed to do was try to identify some peer groups within the region that we could compare Vermont to. So you see there the primarily New England and the Northeast States, where Vermont matches well in terms of providing care at a managed or well managed level. From there, all of a Wyman looked to find the right demographic mix, the right mix of chronic conditions to try to get as much of an apples to apples comparison as they could. Again, they looked at wait times between when a patient saw their primary care physician for a specialty diagnosis and then when they saw the specialist for that same diagnosis. If we look at the results in the next page, you'll see that wait times, as I said, when we compare ourselves to pure states, do not measure as favorably as we would like. When you look at how many of those visits were able to be seen within 14 days in Vermont, that was 22%. In pure states, that was 27%. When you look at the 28-day time period, 34% for Vermont, 43% for pure states. And then on the outside scope of this, on the 60 days that somebody was able to see their specialist, 50% in Vermont, 63% among pure states. And we'll mention also that overall wait times from this analysis showed that from the primary care visit to the specialist averaged about 100 days for 2017, 2018, and 2019. Now again, one of the limitations on this data is that this is a subset of patients. These are patients with chronic conditions, things like heart disease, diabetes, asthma. So it is a subset of Vermont patient care, but they are likely individuals that are in the system seeing primary care doctors and seeing specialists on a somewhat routine basis. Looking at the next analysis, which is the secret shopper program, we mentioned that we made over 1,000 calls. We called over 400 unique specialty practices. These specialty practices represent over 90% of the physicians in Vermont that provide these specialty services. The map there on the right, you can see the geographic distribution of these phone calls, the larger the circle, the more calls that were made into that particular community, basically representing the size and population of those communities. You see that we also included contiguous counties and care that might be provided in New Hampshire, both at Dartmouth in northern New Hampshire as well as western Massachusetts and parts of New York as well. So for each of these unique specialty clinics, the state of Vermont called as a blue cross, blue shield insured. And we also called as a Medicaid insured to try to assess whether there are differences in the types of insurance that individuals have. We called 21 different specialties. And again, we tried to replicate as closely as possible the experience of a Vermonter trying to access care here in our state. Looking at the next slide, you'll see that there really was not a significant difference between those that were calling with commercial insurance versus those that were calling with Medicaid. In fact, those with Medicaid had slightly shorter wait times on average compared to those with commercial insurance. And generally, there were both equally long when you compare them in terms of the wait time. So in some ways, a favorable result that Medicaid was not being seen in a slower time period. And this is data that was also confirmed by the Oliver Wyman analysis as well. Looking at the next slide, we look across specialties. So this is across specialties, both commercial and Medicaid. And you'll see here that there is a wide disparity between these specialties. This is the median wait time for the calls that we placed and the appointments that we were able to provide. You can see some are quite relatively short on the left hand side of the slide while others comparatively are relatively long. But we do want to say that, you know, of course, not the acuity, the reason for the call may differ between these different specialists. So we tried to have non-urgent reasons to seek care. But that being said, there are still reasons why one type of care might be perceived by the provider as more urgent than a different specialty. So that needs to be considered. But generally what this tells us is that there is this disparity between specialists in terms of wait times and something that needs further exploration. Looking at the next slide, we'll also see that within the specialties themselves there was also quite a discrepancy in terms of appointments. So those green dots represent the first available appointment by specialty. Those orange dots represent the average wait time. And then the red dot represents the longest wait time that we received in terms of one of the secret shopper calls. So for example, with dermatology, on the one hand, certain providers said they could see an individual within 11 days. Different providers said that that would be 410 days. So again, I think this speaks to the reason why it's important to provide transparency to the consumer. That if somebody happens to call that clinic, they can't see them until over a year, that they understand and realize that there might be a care that is more easily accessible to them. Maybe in a different geographic region, maybe not. But a critical element of transparency that we think needs to be provided to Vermonters at large. And that of course would help smooth out some of the supply and demand issues that we might be experiencing in our state geographically as well. The next slide looks at the same data that we just referenced, the secret shopper data. It's looking specifically at the Burlington Metro area. The reason we are looking at the Burlington Metro area is because the only national survey that tries to replicate wait times through a secret shopper program does so for medium metro areas. So we are able to compare as much apples to apples here in terms of at least the size and type of location in city. Now again, an important caveat. The Merritt Hawkins survey was conducted in 2017 prior to COVID-19. Ours obviously as we mentioned was conducted in December of 2021, leading into January of 2022. But when you look at the results, you'll see that on average Vermont is experiencing longer wait times for these four specialists that we're able to compare against. The Merritt Hawkins analysis only reviews these four specialties. That's why we have them up here. We did use the same exact reason for seeking medical care as they did in their survey to try to replicate it as closely as possible. So again, I think this is another instance where it tells us that this is an issue that needs further examination. And then finally on the secret shopper data, we also looked by hospital. So we put all the specialties that we called by hospital together and looked at what the average and median wait times were across the spectrum and then how they performed for each of the entities themselves. So again, here an important caveat that there are certain specialties as we all just saw that have longer wait times than others. Some of these hospitals have more of those specialties than others. So that's again, something important to consider. But when you see that difference, especially when you're trying to look at hospitals that are relatively similar to each other, again, it's another reason that we believe further exploration is required here to truly understand whether these differences are meaningful or whether they are simply the byproduct of the populations that these entities are serving. On the last slide, this is the blueprint analysis that we mentioned. So we looked at 2,300 blueprint charts. We again tried to assess the time between primary care visit and a follow-up specialty visit. Similar to the secret shopper program, you can see that there's a wide disparity here between the special list in terms of wait times. Some of them corroborate the secret shopper program data like rheumatology. Some of them diverge, such as a dermatology. But again, it speaks to the fact that for us, there's more information that needs to be gathered about whether these differences in specialties are clinically appropriate, whether people within these specialties, even if it's 87 days, are seeing care as quickly as they need to see care or whether that is not happening, and it's leading to worse health outcomes. We just don't have that data. It's not being tracked by the state of Vermont. It's not being tracked uniformly by the healthcare system. So something that we believe is important. One point of note, again, for the secret shopper program and also for this blueprint program as well, we're looking at the specialty, right? So the time from the primary care visit to the specialist. If you don't have a primary care doctor, there's also a wait time that will be associated with that to try to get established with a new primary care doctor. If you have a primary care doctor, there may be a period of time that it takes for you to get an appointment with that primary care doctor. So that is not represented in the wait time analysis for secret shopper or for blueprint. Also for secret shopper, if you need any imaging or lab work that might be required before you can make your appointment with the specialist, that could be something that adds to the wait time as well. So I think in conclusion, when you put this all together, each of these different methodologies, you know, they have their strengths, they have their weaknesses, but it is what we were able to do with the authority that we have. And again, I think that speaks to why we believe one of the recommendations should be expanded ability to develop metrics collaboratively with the healthcare system so that we can track these metrics on an ongoing basis so that we can measure whether we're improving and so whether Vermonters have more transparency into this as well. And I think that will be very critical for us because the analysis also showed that Vermonters are getting older. I think that's no surprise to any of us and that our primary care doctors and our specialists are getting older as well. So over the next five years, for some of these specialties that already have long wait times, we do anticipate that the demand for those services will go up and that the provider community may actually go down due to retirements and people working less as they get older. So all the more reason for us to come together and try to solve this problem now. So with that, I'll now turn it back over to Ina to again summarize why some of this might be happening and to reiterate our conclusions. Vermon is unique among states in taking a look at the issue of access to healthcare across the entire state and across multiple types of providers, as I mentioned, both hospital employed as well as private practice providers. This is certainly new ground and new territory that we are treading with this analysis and with that we can see that this issue is a multi-factor issue and we can also recognize that we have more to learn about the contributors to the problem and we want to do that again in collaboration and in partnership with the healthcare providers and people who are working in Vermont's health system. Even though we are looking at this problem and seeing it newly with the with the quantifying information that Commissioner Pichek has just shared, we do we do posit that there are some potential factors that are influencing wait times for care in Vermont. These factors include the workforce availability and composition. Demand may exceed supply for certain specialties. Demand may exceed supply of hours worked may exceed supply in certain areas of physicians. Hours worked by physicians are stable but the workforce is aging and we do know that as the workforce ages clinical time does decrease. We also know that there are certainly teams of specialty providers that work together to deliver care and to move people through practices and advanced practitioners have a key role in these teams. Our analysis did not look at the supply of advanced practice practitioners in the state. We know that they are critical components of care teams along with nurses, along with front office staff, along with a host of people working in the healthcare system and we acknowledge the workforce shortages that have certainly been created by COVID-19 or exacerbated by COVID-19. The distribution of care may also be a contributing factor to wait times for certain services for Vermonters. Care that could be delivered in primary care care that should be housed in primary care is delivered at times in specialty offices when in fact it could be well managed in a primary care setting. We heard from specialists and primary care providers both on these issues related to the distribution of care and we also heard that for some patients they are being managed long term in specialty care settings when in fact their conditions are stable and they could be well managed by primary care providers instead of specialty providers. Again COVID-19 is likely exacerbating the issue of long wait times these long wait times as you saw demonstrated with the claims data analysis in particular we do see evidence and that long waits appear to be true prior to the pandemic but the workforce and staffing shortages caused by the pandemic are certainly factors that we've considered that are influencing this problem today. There's a complicated referral process and Commissioner Pichek just talked about some of that complicated process. There's numerous steps and requirements and in receiving numerous steps once you've received a referral to then obtain that specialty appointment visit and often lab work and other documentation is required by providers prior to the appointment actually being scheduled and there's a lot of communication between provider offices that needs to occur in order to efficiently schedule these types of services and so that presents multiple points of potential failure that can slow that process down because it is a complicated exchange of information between multiple actors the patient the primary care provider the primary care provider and the specialist the patient and the specialist and back looping around again. Technology is also something that we've posited could be a factor in influencing wait times. There has been slow rate of adoption of telemedicine in some areas e-consults and office hours and for each EHR in electronic health record interoperability across different sites of care and as I just mentioned providers in different settings need to be coordinating and working together to engage in the complicated scheduling process and so if their systems for communication don't work well together that can be a hindrance as well. So I'll repeat again the recommendations for new initiatives that we have that we have identified during this study tracking and reporting of this information ongoing with work certainly to best articulate and enshrine the way to measure wait time for appointments in the future. Hospitals designating particular committees or board members that would be responsible for participating in monitoring wait times and to promote continuous improvement in patient access to care and services and coordination among hospitals and independent providers should be also pursued specifically related to those areas of potential failure in the scheduling process and in the information that I just shared and we've recommended further study by the agency of human services the green mountain care board and the department of financial regulation to look at access and timeliness of appointment of appointments in primary care this certainly could be another factor that is contributing to wait times for specialty care appointments access to mental health and substance use treatment doing a holistic assessment of Vermont system and service availability and reviewing improvements to the regulatory framework such as the green mountain care board has already initiated a review of whether the thresholds for certificate of need are appropriate the certificate of need process is is a key process in the availability and access of facilities that provide for access to patient care in the state of Vermont and further the green mountain care board looking at its regulatory processes and how its regulation of hospitals in particular is a component of the landscape in which hospitals are working in the state of Vermont we want to also as I said before and as you learned from the data we shared regarding Medicaid access to specialty care and appointments we want to look at and understand the barriers for those those practices that are private and that are not accepting Medicaid patients at the same rate that hospital practices accept Medicaid patients for certain specialty services again we want to emphasize that there are many recommendations that are already in play in the health care workforce development strategic plan and that these recommendations speak to numerous areas that we heard about from providers as we undertook this review and this study the physician assistant program is one if if we posit that advanced practice professionals are key components of the specialty care team then it would be important for Vermont to explore whether we have a healthy pipeline for physician assistants advanced practice professionals working in the state we also in this work we employed supply and demand modeling of a sort and we did look at whether supply and demand for specialty care were impacting the availability of appointments in the state and we think that this sort of analysis should be employed ongoing we also recommended in the workforce development strategic plan specific strategies to increase telehealth coverage which would improve the availability of services for some Vermonters and certainly making tele billing requirements as clear as possible to promote the utilization of those types of services we also recommended that the blueprint for health which is a program that supports primary care practices patient centered medical homes community health teams and the care continuum working together that the blueprint for health program looks specifically at quality improvement activities to promote referral best practices and care distribution between primary and specialty care so that we can promote the best utilization of the resources in our state for the most appropriate type of care in each setting and finally we do we do recommend and certainly want to continue our focus as a state of Vermont to shift away from a fee for service reimbursement to a system that focuses on population health and outcomes and that focuses on the most appropriate care being delivered at the most appropriate setting and when patients need that care some online questions routines it seems like there may be some sort of investment that's needed on the front end especially with the data sharing involved hospitals and kind of collecting this information going forward I don't know who this question was before but how how much do you see some of these investments costing and how that discussion would play out in the legislature and involve some of the hospitals so I think as we've mentioned during the study this is really preliminary data we are in the process of you know we've analyzed the findings we see what we found but we need time to work with our health care system to identify really what the solutions are it's hard to quantify what those investments would be needed until we have an opportunity to really do that collaboration with our health care partners and so on that we'll have to get back to you but again we are committed to working with our health care system to really did it get in now to the root causes of what the data has shown my other question is you know access to primary care is a cornerstone of shifting away from fee for service to full payments all pay or whatever it may be I guess to what degree does we do these hospital wait times and access or delayed access to care to what degree does that hammer against our partners and how would we I guess overcome that first of all as we indicated we didn't look at access to primary care and the reason we didn't look or start looking at access to primary care right off the bat was because again we did orient our study around the experiences that we heard from Vermonters in those first in those first public forums that we arranged and we did hear a quite a number I would say an outsized number of issues with specialty care access which is why we focused our analysis there you are correct that primary care is certainly a cornerstone for healthcare reform we know that here in the state of Vermont that we've been able to build on the successful foundation of the blueprint for health which does invest in primary care and make resources available to practices that otherwise you know may not exist in other states and that practices are supported in collaborating and integrating care across the continuum so I think we need to look and understand what access looks like for primary care and we that's one of our key recommendations for the future we know that the primary care system certainly does need to be strong and we want to understand we do want to understand the primary care system in light of these findings about access to specialty care so how do we handle this how do you balance the fact that yes it's very complicated but what do patients do right now at this moment they need to see something that's a great question and I'm going to I'm going to field it to commissioner Peechak because I know that he's got something to say here well the order just on the question of what do Vermonters do now right we had that one chart that showed that disparity between providers in terms of the specialty appointment times so I think it's important for individuals that might call and hear that there's a long wait time to not stop there to call other providers in that specialty maybe outside your geographic area as well if it's outside of the network if you have commercial insurance if you can't be seen in a certain period of time there are regulations that provide for the same type of cost reimbursement if you have to go out of network so I think the answer to that for now is that you shouldn't you know don't take the don't take a call with a long wait time as a roadblock shop around and try to find other appointments that might be more you know available in terms of your question and I think also sort of you know what do we do here what or what how do we you know try to dig into this more you know I think the recommendations the first two recommendations work well together we need to measure this better we need to measure this across the spectrum not just specialty for primary care mental health access as well we need to have hospitals and independent doctors we need to have all of that together to try to better understand and quantify the wait times but also quantify the question of if there's a hundred day wait time but everyone that needs to be seen in two weeks is being seen in two weeks and everyone that can wait six months is waiting the six months then maybe that 100 day wait time is appropriate nobody is receiving you know care that is that is not at the right time but we don't know the answer to that question and that's why we need to find a further that's why we need ability to get further metrics and that's why we're also asking the hospitals to engage in that process themselves to evaluate and collaborate with independent physicians to try to get at those root root to those root questions really a lot of questions uh that was the only one from consumers like you know all people spend time yeah no doubt and that is that is you know a big challenge that we heard during this whole investigation when we talk to consumers when you have inequitable systems or you have systems that are hard to access those inequities are going to fall and burden those that are most are least able to navigate them right so that is no doubt not a not a position you want to be in it's just the position that we're in at the moment as we work to try to improve this complicated structure so we certainly recognize it's not where you want to be but all we can do is evaluate where we are at this time it's a good time to evaluate due to coming out of the pandemic due to all of the challenges that we face prior to the pandemic in terms of our health care system to try to plot that path forward so in a year or two years you won't have to ask me that question even six months we'll do it as quick as we get but yeah exactly right yeah i have two questions one was you said that uh wait times if you've been exacerbated by the pandemic do you have a wait time metric uh that was established prior to the pandemic against which you're able to compare the results of this so the Oliver Wyman analysis was looking at v-care's data for 2017 2018 2019 2020 so it did cover one year of the pandemic there was also the data was in a raw form so for both of those reasons they excluded the 2020 data so we did have 17 to 19 for this v-care's uh you know subset so that subset like i said included people with chronic conditions so diabetes asthma heart conditions and it measured how long does it take those individuals to get from their primary care to the follow-up specialty appointment for the reason that the primary care made the referral and for each of those years the average rate wait time was about a hundred days so you know the secret shopper as we said wouldn't include if you needed to do imaging or labs or things of that nature so that might account for why secret shopper was more like 40 or 60 days if you look at the average or the or the median and why that was a hundred days but but that is the that is the benchmark that's the data that we have pre-pandemic is that Oliver Wyman v-care's data um and then my other question is probably to the secretary you know um the commissioner talked about this inverse relationship between uh the trend line for need need for health care and the health care professionals they're going to be available to administer that care um is it possible that our expectations for when we're going to get care that we need from the health care system are just no longer realistic and that we need to confront um this new reality in which we're not we're just not going to be able to get the care we want so I think that's a very astute question um and this morning we were discussing that internally one of the things for us to consider is is that over the last five years um the consumer demand for many products not just health care services has led us to the point where people expect things to happen instantaneously again to reflect what commissioner p check mentioned the study doesn't actually demonstrate whether people got appropriate care within the appropriate time frames that were necessary based on their acuity and I think that that those two things are potentially colliding here in terms of our overall expectations that have meet that are urgent and now kind of expectations with the actual needs for people further in order to maintain and improve their health so it's a very astute question we don't have the full answer but I do think that what we are seeing is a generational shift in a consumer demand shift for immediacy while while having um an expectation in the health care system to serve people as they as they actually need care so you've laid out all the things you're asking the health care system to do you haven't asked the consumers as well I think right now my ask to consumers um particularly as we come out of the pandemic is to be kind and compassionate um to to be understanding but also to work with their primary care providers if they feel like they have an urgent need um and that and they feel like that needs not being met um that their primary care provider can help them navigate um the system um to to so that they can get again the appropriate care in the appropriate amount of time Dan from a free press Dan can you hear me okay thanks Dan um next person we're going to go to is Colin Flanders uh Colin I'm gonna unmute you can you hear me yep I can hear you go ahead so so I'm curious about whether the investment team has had any conversations internally about sort of how we can get to this point um as I'm taking specifically in terms of oversight like I see Dan here I know Dan has written about way times before um way times are a problem that people have known about for years and yet it's taken us this long to do something like this and just curious as what regulatory gaps have we found in and crew's job was this a track this um or was was sort of just nobody tasked with paying attention to yeah Colin it's a great question I think what you said about regulatory gaps is just is astute here because there there was a regulatory gap you know we have we do split our healthcare regulatory framework among the green mountain care board among ahs among dfr none of us tasked with this issue of wait times particularly when you're talking about system wide wait times so we do think we can rectify that with a recommendation that dfr uh has oversight around the metrics around measuring it around providing transparency not around you know what that means in terms of substantive changes for the healthcare system but if you're not measuring it you really just have no sense of whether things are getting better or getting worse or you have no sense of whether they're bad in the first place like uh like we talked about needing to go down and understand whether people are seeing uh you know the right the right doctor at the right time for the right treatment we just don't know the answer to that so I think um it's a critical step forward that what we're proposing here today and look forward to working collaboratively with all of the stakeholders to make progress on that okay so the answer is finished a little hard to hear over the teams but I did have one more question um as well um I think based on the answer to Pete's question it sounded like um we don't know yet sort of digging deep down into the data how many people who need to get care um what are getting in versus how many people who can afford to wait I understand that's some more data we need but I'm curious through the the work that you did through the focus groups through the surveys with patients themselves I guess can you say with certainty that there are people out there who are being forced to wait for things that should be taken care of where is that a problem we're dealing with um or or can you not say that yeah so I would say Colin it's definitely a serious concern of ours you know I'm not a doctor I can't make that clinical judgment but what I'll say is you know two things one in the public comments when we had the public forums you know we heard from individuals who said I am in pain both physical and emotional as I wait for my medical appointment I think about one third of respondents said that to us um so that is certainly impactful to us whether they're seeing whether they're being seen within a clinically appropriate time I can't make that judgment but they are certainly telling us that they're experiencing pain and deteriorating health conditions so that's a concern and we also heard through the provider feedback that they're not always able to do the necessary prioritization or triage when they get referrals in some instances we heard that primary care doctors might be overly using an urgent designation because they just want to try to get their patient into the specialist and that makes it challenging for the specialist to truly understand what is urgent and what's not urgent so it's not just that we are concerned that we don't have that data we're concerned that in many in some instances that analysis is not being done at all which means that people can be falling through the cracks so it is definitely a concern so you know like like we said we don't have the ability at the moment to understand who and who is not getting clinically appropriate treatment relative to the wait times so that was not part of this analysis but obviously that would be a concern you know you saw the data that suggested people are not getting care within clinically appropriate time periods there was a study by the VA that said you know that's established at about 31 days and particularly important for those maybe more chronically ill or those that are elderly so that's a again a real concern but we can't point to the data and say that there is a strong correlation that suggests that one's related to the other it'd be great if we get to that point in terms of one of the metrics that you try to track and measure but that's not a part of what we were concluding here in this study able to flesh that out like I know in Canada for example the way that they track their wait times they have set standards by which a certain amount of people they can be seen and that's how they they know like if you need a knee replacement you should it should only take this amount of time if it's taking longer that we notice a problem do you envision this taking to a place where we're going to be setting some clinically appropriate metrics or is that already you're not taking that so it's some it's a discussion that needs to be had there are examples that we heard where when you set certain thresholds you know there's an incentive to maybe do things that make it seem like you're hitting those thresholds when maybe you're not so there you know whether you know that's one of the limit you know you would you want to do it as simple and easy as possible but you don't want to create any perverse incentives on anybody's behalf and you want to make sure that you're actually you're accurately capturing the information so I don't want to prejudge if that is going to be something that's important or not I think it's going to have to be part of the conversation so we'll wait wait to have that conversation to make that determination and I would like to add thank you our our study was pointed on the time that individuals wait for an appointment our study did not take very other important things about the health care system into consideration and key considerations that we will be looking at in the future as well are outcomes for the population health outcomes for Vermont as a population I think we need to look at these wait times relative to our health outcomes for our population and similarly as we look forward to monitoring and providing the public information about wait times for services it's also important that we're providing information about the quality of those services and I think that's something else we would look to in the future as being an important pairing of information for people about what is a multi-factor issue so we've got this slate of recommendations I mean what's the next step here right I mean it goes to the hospitals on some legislature and regulators are involved I guess kind of what what do you see as the next steps and kind of as a timeline I didn't mention what do you see going forward again a great question I think it depends on each of the recommendations separately for the quality improvement related recommendations were we're beginning conversations with our health care partners that's something we're going to need to do in collaboration with them as mentioned before some of them already have identified this as a priority for example the UVM health network who has published and is working on an access study I think others will depend on the legislative timeline so for example the work that we have with DFR and ensuring that they can collect and have the authority to collect the data so we'll be taking each of these our next step is to take each of these layout a concrete plan for addressing them and again each of them will likely be on a different timeline based on both the priority of the recommendation and just the reality of the implement of the implementation with things like the legislative cycle we appreciate your time today


I have Victoria. This meeting will get started probably in seven or eight minutes. Okay. Hi, good day. Okay. Good to go. All right. Welcome everybody to the June 13th hyperledger technical oversight committee call. I'm sorry, July 13th. Did I say June July 13th. Okay. As you may be aware, two things that we have to abide by on the call. The first is the antitrust policy notice. So basically we need to make sure that we're not. Doing any activities that are against any of the antitrust. Laws across the world. And then the second one is our code of conduct. And then we need to make sure that we have a standard. We have a standard announcement. And then we have folks on the call and their ideas and their opinions. So as we look at the agenda today. We have this standard announcements. The dev weekly developer newsletter goes out each Friday. If you have something that you would like to include in that newsletter, please do leave a comment. For consideration on the link that's in the agenda. And then any other announcements that anybody has or would like to include in the report. We have. Four reports that are out there. Yeah, Peter. I just wanted to say that we've finished the, the draft for cacti last night and I'm submitting the pool. It was right now. And sorry for being slightly late. Oh, okay. No worries. Thank you for that, Peter. So we will be seeing the cacti report coming in lately or shortly. So quarterly reports. We do have an outstanding comments. That requires re-review. Peter. I think that, that one is on you for cello. You did have a. Maybe it has been reviewed already this morning. So it looks like we're good. Maybe we're all set there because I don't see any comments left over. So thank you for whoever did do that re-review. For the caliper one. Oh, this is the one Peter, you've got a comment. I think it has been fixed. At least it says it's been fixed. So if you could just check that and make sure that's the case. And then we can get this one merged in as well. And then we have the. And we have the sate, the report. So for this report, as you recall, right did submit the report for, on behalf of the sauteed community, there is a number of questions that have been put out there. That haven't necessarily been answered. And so we do need the sauteed community to answer those questions. look at the transcript for the recording for the last meeting. It appeared that the sawtooth community thinks that there's maybe just some typos that need to be fixed and there's no real questions that are out here. And so it doesn't look like they're necessarily recognizing the fact that there are some things that need to be answered. So we'll need to reach out to the sawtooth community and get them to answer those questions at this point. So that's kind of where we're at with the sawtooth one. Did anybody actually attend that meeting while I was on vacation with the sawtooth community that could add any color to that? Hey Tracy, so I attended on the second half while I let Peter first talk because I saw like he was on going for the first half. Okay, Peter. Yes, we me and the room kind of covered the entire meeting. I was at the first half and I remember reiterating the points that we've been talking about here as well regarding maintainer, liveness and activity. So basically in the first few minutes, maybe the first 10 minutes of the call, we were talking about the basic stuff that we hear in the TOC always talk about. And I showed up, I was there and I reiterated these things and they seemed receptive to it. I did not get any sort of pushback and that was it. So from my perspective, the meeting went well. I felt like I was being listened to and we were in agreement about these principles or ideas. Okay. Thanks Peter. Are there anything to add? Tracy, so the previous meeting was different from the rest of the calls that I previously attended. And it was also run by new members. And there were discussions of some code being discussed, some code mergers, the PRs, but I could not find any of those references anywhere. So that's the summary. Looks like there is some interest from new members who are not maintainers currently on the existing branches which are released. Whereas there is interest from the current maintainers on new site of code. That's the summary. Okay. So I guess I will reach out and just remind them that there are some outstanding comments on this that need to be resolved before we can merge this and we'll see if we can get some answers to those questions. Then I guess the other report that we have is the basic report. I didn't see anything. I think everybody is doing some reviews this morning and we can probably merge that one at this point because there's no open questions. So we'll get these things merged that have been gotten in the reviews this morning. All right. Any questions or comments on the reports that have been submitted? So I guess there is one question from the Basu team on their quarterly report to the TOC. This is most likely a question to Ray or Sean, maybe. Yes. There was a question on the Basu report. Sean, if you could go to the files changed, we can take a look at that particular question. So it's right here. Scroll up just a little bit or down however you look at that yet. Have we been able to complete the Ask Around Circle CI funding by the Hyperledger Foundation? So Hart, I don't know if you have an answer to that question or if we can get an answer about Circle CI funding. Yeah. Sorry, Tracy. For the Basu stuff, we were working with them to get some funding from the Ethereum Foundation unblocked, which is overdue at this point from our CIP grant that we're going to spend on among other things, the Circle CI funding. So I'm actually talking to Matt about that in three hours. Okay. Great. Perfect. Yeah. That being said, there's still some room to do. We're still expecting to see more unification and more policies on tooling and we're expecting to get some directives from the LF. Okay. We will wait for that information when you guys do get it. I'm sure you'll present it here to us to let us know about what that tooling is going to look like. As it trickles in, we will. Yes. Thank you, Hart. Thank you, Tracy. All right. So for the upcoming reports, we do have the fabric and the catheter report that are due today. Peter did say that he's going to get us the catheter report later today, probably. The fabric report Dave is currently on holiday and he did mention that he would submit that report once he comes back. So I'm glad he's not doing that while he's away. And then we do have the next thought to the report coming up on the 27th, so two weeks from now. Peter. Sorry to interrupt. I just wanted to say the catheter report is now in. I literally just did it this morning as in the document was ready. I just have to submit the pull request. No worries. So we will all be taking a look at that then later on today. All right. So as far as discussion today, we do have the project annual review policy that I think is ready to be voted on. I did make the changes from the last meeting where we did request a few changes come in. They are specifically around the annual review timeline is going to replace the Q1 quarterly report. I did add a secondary TOC member to review and collaborate the findings of the TOC lead reviewer. And then I also updated the template based on what we did discuss in the June 22 meeting to make it more clear and remove some of the negative language that was in that particular template. So I think that one is ready to be voted on, but I would like to see if there's any remaining comments before we do get to a vote. So I don't know if it's probably a dumb question. So we are saying this is going to be in practice from next June or when are we saying it's going to be? Yes. So the expectation would be that the Q1 of 2024 report would be replaced by an annual review. I think that gives us time to also look at the project lifecycle in badging and see if there's any sort of changes that might come out of that that would impact potentially the status, right? Because the central review says that we'll look at the status to make sure it's in the right status. So if we decide on the project lifecycle that we're going to add any sort of backward arrows that we don't currently have, then that could be something that would be taken into account as well in the Q1 annual report. So thanks for the question, Arun. I think that's a good clarification. Other comments or concerns about this particular poll request? All right. If not, do we have a motion to accept this particular poll request and implement annual reviews as of Q1, 2024? Motion. Thanks, Peter. Do we have a second? That was Arun. Was it a second? All right. Thanks. All right. Let's go ahead and, Sean, if you would take us through a roll vote. That would be great. Absolutely. Trace, let me check to make sure I have everyone. All right. Great. In the matter of the project annual review policy, Arun or no, how do you vote? We have lost Arun. Sorry, yes. Wait, that's a yes vote. Arun, how do you vote? Yes. Bobby, how do you vote? Yes. Jim, that's a yes for me. That's a yes. Thank you, Jim. Peter? Yes. Rama? Yes. Thank you, Rama. Stephen? Yes. And Tracy? Yes. That's a unanimous vote. From the attendees, that's a unanimous vote of yes for the project annual review policy. I'll put those notes in the GitHub page after the meeting ends, Tracy. Okay. Good. Thank you, Sean. All right. Next item on our agenda is the Encourage Projects to Set Annual Goals. This is a poll request that Arun and I put in to the project proposal. I think it was the incubation best practices. I forget what this document is called, but it basically just says, yeah, Arun, if you want to talk to it, I forget what the particular file was. Sure. So this goes into projects incubation, entry consideration, along with all the process that I've currently listed for a project that we're saying a project must follow when they enter in. Because of the annual review process that we just voted for, we are now going to say it is required for projects to set annual goals. And the words are used in a way that projects are told that they will be asked questions on their annual goals. However, there is provision for them to deviate away from it, because we all understand that priorities could change between the year. However, we want the project team to reset or reassess, probably in the next cycle. So that's the summary of this proposal. And that's it. All right. So, Sean, if you wouldn't mind taking us to the files changed on this just so people can see that wording again that Arun just described to us. Any comments or concerns about this particular item? Okay, I will take that as a no. Can we get a motion to add this language to the incubation entry consideration? Sure. A motion? Oh, sorry. That's fine. Can we get a second? Second. All right. Thank you for that. So, can we also, Sean, just do a roll call vote on this? Absolutely. For the encourage projects to set annual goals. Arun, how do you vote? Yes. I'm sorry. I skipped. I know. Arno, how do you vote? Yes. Bobby, how do you vote? Yes. Jim, how do you vote? Yes. Peter, how do you vote? Yes. Rama, how do you vote? Yes. Steven, how do you vote? Yes. Tracy, how do you vote? Yes. Thank you all. Again, unanimous yes for the attended TOC members. All right. Great. So we will get both of these merged in then as well. So I think the other item that we have on our agenda is the security task force. Before we get there, I think Bobby did ask for 10 minutes, and I would like to, since I think we have time, allow Bobby that 10 minutes to talk about what was it, the documentation task force that you're working on? Is that correct, Bobby? Yes, exactly. So thank you very much, Tracy, and thank you for always running a great meeting and allowing us this time. So the task force for both documentation and onboarding has been reporting back to the TOC monthly or whatever. So this summer now that we have mentees and learners working on the whole project as a whole, we're going to spend the rest of the summer meeting our goals. So the team right now would like to present what those goals are so that when we come back at the end of the summer for a presentation, we can tick off all of the documentation and onboarding task force expectations. So I'm going to turn the meeting or the presentation over to my mentee who is awesome. So take it away, Arunama. Thank you so much, Bobby, for interesting me with this role. So hello, everyone. My name is Arunama Chaudhary, and I'm an LFX mentee for the documentation task force and will be working under this project with my mentor, Bobby. So let me share my screen. So starting bit to ensure that the Hyperledge of Projects have the best possible documentation. We as a team under the documentation task force have divided ourselves into five into six subgroups that we will be working under. Each subgroup will provide support in a specific area. So the subgroups are Github Templates, Github Read the Talks, Templates, Best Practices, Onboarding and User Crides. And all the subgroups will work collaboratively to address any of the documentation gaps and assist the project mentees in any way possible. Some of the shared objectives are to enhance the overall quality and consistency of the documentation across all the projects, to provide support to the project teams in utilizing the available resources effectively, to streamline the documentation process for a better efficiency and productivity, and also to empower users through user-friendly and comprehensive documentation. So let me start by explaining what each of the subgroups is all about. At first we have Jan Luka. He is the chair of the Github Templates and he will be introducing, he will be giving us a brief on what the Github Templates subgroup is all about. Okay. Hello everyone. I'm Jan Luka, an Italian software engineer and I'm passionate to open source and blockchain technologies. I'm also some skill in blockchain fundamentals and in solidity smart contract language. I would like to contribute to hyperledger project supporting for example the development teams in creating or updating the documentation. And that will allow me to improve my skill in blockchain, especially in hyperledger ecosystem. And in particular I'd like to support the Github documentation if possible, and that activities and starting from requests. So I'll be open to requests for the development team during this summer. And thank you for this opportunity. Thank you, Jan Luka. So next we have the Github Read the Talks group which is led by Tripur. Tripur you can go ahead and explain what the Github Read the Talks group is all about. So hi everyone. My name is Tripur Joshi and I'm a technical writer and a researcher. I'm leading the Read the Talks group and I want to say this is a really great opportunity for me as I'm always interested to contribute to open source and working with Bobby has been really great. She is a really great mentor and what we are going to do this summer is we have started working with Solang and their documentation and we are enhancing their user documentation experience by making it more user friendly and by making it more beginner friendly and increasing the visualization in the documentation. And side by side as suggested by Bobby, we are also making a standard user documentation on which if any hyperledger remember, sorry, should I continue? Please do. Yes. Okay. So I'm also making a standard user documentation in which if any of the beginner technical writers want to take telly their documentation what is missing, how can we improve it and in the upcoming projects and all as the first documentation is always written by the coders if there is no technical writer. So it can help them to take off some things that they may not be aware of. And this is how we want to make the hyperledger community more like have good user documentation and steamlight the iteration process for them. So yeah, thank you everyone for listening. Thank you so much, Tripul for giving us an idea of the GitHub Read the Talks group. So next we have the templates group which is led by Kajal. Kajal, can you please go ahead and introduce yourself and the group? So, thank you Arumama. Hello everyone. I'm Kajal Kumari. I'm currently a final year student in India. So I'm an anger developer and also a technical writer. Like I have contributed in various open source programs in development and documentation field. So I'm very excited to contribute in hyperledger projects this summer. So I have also talked and identified some projects as Bobby told us to find any projects need documentation help or anything. So I talked to some of the projects and I also like went through their projects and understood what help the project can make. So I'm the chair of templates. So like we all know the onboarding of beginners or the member on our website is very important. Like if I'm not able to understand the website then I won't come again there. So we'll be providing the standard and a consistent approach to documentation across various hyperledger projects at the various stage like for user case for white templates for the graphic set or for the presentation. We'll be providing a template like templates having unique requirements and specifications. So our team will work closely with the project team to develop customizable templates that align with the specific need of the project. And by offering such well-designed templates, we strive to streamline the documentation process and enable project team to focus more on building and ensuring that vital information is documented effectively and the users or any person who visit their website who wants to know more about the project they can get more idea. Thank you. Thank you so much Kajal. Next we have Victoria who will be explaining us the best practices group. She is also leading the best practices group. So Victoria can go ahead. Hello everyone. I'm Victoria from Nigeria, a front-end developer and a tech provider. I'll be working with Arunima and amazing mentor Bobby to work to improve the documentation standards for the hyperledger community. As the best practices lead, our goal for this summer is to identify and promote industry standard practices for documentation within the hyperledger ecosystem. This ensures consistent documentation and it also improves them with ability and maintainability of the documentation. Now these guidelines, we are going to cover various aspects such as the structure, the style guide. We're going to use the code snippets, versioning and then for maintaining the already existing documentation. By adhering to these best practices, project teams will be able to produce documentation that is of the highest quality, ensuring a seamless experience for users and developers. Thank you so much. Thank you Victoria for giving us an idea of the best practices group. Next, we have the onboarding group which is led by Akanksha Rani. Akanksha, you can go ahead and introduce yourself. Surely, surely. Hello everyone, myself Akanksha Rani and I am also an LFX mentee for the hyperledger onboarding project this year which is mentored by John, John, Niku and Peter. I'm a huge EIMM enthusiast and web developer by passion and I am an open source contributor. Currently, I am pursuing a bachelor's degree in engineering and I'm also very engaged in learning and expanding my skills. I will be also updating about onboarding stuff in this call. Firstly, talking about the goals. I have divided the onboarding part in six subparts. Our goal would be including firstly the research and analysis that we'll be doing on different users that will be approaching the hyperledger site. Then we'll be planning and scoping out how we'll bridge the gap between a user who is coupling for the first time or the second time on the hyperledger website. Then we'll be designing and working on the development of the new site along with Ben because since we have a rebrand now, there are some designs which are sent by Ben. With alignment with that, I'm working on the design part and we have started on the main website. Other than that, we'll be working on testing and feedback and we'll be working after that. We'll be collaborating and finally we'll be doing the refinements with the feedback of mentors. We also had a call. The onboarding team had a call with Aaron where he also gave his feedback and we are working on the feedbacks he gave along with John and Nico. I think we'll be definitely making an impact by creating a better website and a better platform of hyperledger for new users like the business users, the developers, maintainers and enterprises because these are the three personas that we have divided our main focus into this time. So, I hope that I really contribute my best and work along with the hyperledger team. Thank you. Thank you, account shop for giving us an idea of the onboarding group. Next, we have the user guide through which is led by Agnes. Agnes, you can go ahead and introduce yourself. Hi, everyone. My name is Agnes. I'm a technical writer and backend developer. I'll be helping the documentation team come up with user guides for different projects. What a good user guide might look like and I can share as mentioned taking into consideration the different users that we have in terms of personas. So, I'll be working with both the onboarding and the documentation teams just to make sure that user guides cater to the different personas and as clear as possible. Thank you. Thank you, Agnes. So, that's the end of our presentation and it was, this presentation was nearly a brief of what all the six subgroups under the documentation task force is all about. Thank you, everyone. And if any of you have any questions then you can let us know now. I just want to say great job, guys, and I can't wait to work with you this summer to reach these goals. So, I'm getting excited. I'll talk to everybody on Monday and thank you for doing this. Thank you so much, Poppy, for all the assistance. All right. So, now everybody on the call knows that they're going to be reached out to by this group of people to have conversations about documentation, onboarding, potentially getting some help. I did see a lot of questions coming out and discord from folks about what can I do to help. So, now you know why you're getting asked these questions and hopefully we'll be able to get our documentation in great shape by the end of the summer. So, thank you for that. We're looking forward to really seeing what you guys accomplish and getting that read out at the end of the summer. So, with that, we are now up to the security vulnerability disclosure task force discussion. I know that, Hart and Arun, you've been working on this a lot. So, I think at this point we'll hand it to Arun and you can take us through what you guys have done and what the next steps are. Thanks, Tracy. I'll pull up the document comments quickly. Okay. So, we have had several discussions on this and within the TOC meetings as well. And the previous summary that we had on the TOC call, we saw a hard put up this document and then we took this over to the OpenSSF working group calls on which runs on Wednesdays. And they were very gracious to review the entire document and they have had several iterations. I mean, several people going through this revision of the document and suggesting improvements over. So, majority of the comments that the OpenSSF team has been suggesting us is the emphasis that we need to lay out on the embargo list and the kind of words that we can use or the language tone that we can use, suggesting the importance of the actions that the embargo list should take and the role that they play. And in addition to those, the suggestions also came in around the roles and responsibilities of the security representatives within each project. I know like previously within the RTOC call, we had discussions of having a couple of members identified from each project who are who enter incubation phase and then have those people go through or be a security front for the project. And the OpenSSF team also emphasized that there is need for us to have an expert. And when we say expert in security, it could be from different means, right? So, for instance, there could be someone who is a cryptographer and we may need to jump in as needed and when the role demands, we can pull in additional members. So, there could be specialized areas where somebody could have their security expertise on and it's up to the security team so that they coordinate well with the person who raised an issue. And the OpenSSF team has also emphasized more on the back and forth communication that should happen with the person who has raised the issue. So, the summary of that discussion or the comments that you can see over in this document is that we should communicate well in advance with the issue reporter and we should identify at least if it is a bug or if it's a security issue. If it is a security issue, then the security team who is working on it should follow up further and create a CVE. And not just that, like once we, like the ones that is reported, then there is also expectation in terms of doing a private branch. I forgot the exact term used, but a private patch deployment, I believe is the right word. So, doing that private patch deployment which allows us to develop and perform tests for that particular security vulnerability that has been reported. And then there were also discussions or suggestions around which tools should we use in order to notify about these issues. And for instance, like at a hyperledger level, we could create or we could start using GitHub security advisory which we received. And the security team who is working on those received issues, they are responsible for that. So, that's the summary of different discussions and the importance called out from the OpenSSF team during their review. So, I also assume like at least majority, if not all of the TOC members have read right through this document. So, the idea is that the document will be placed as a template and each project can further improvise on this. But these are the mandatory or recommendations going in from the TOC. And few of the optional areas are called out specifically. I remember, for instance, there is an option of the embargo list which has been called out that embargo lists are optional. So, the embargo list is optional in the sense that if the project team is too small or like they don't have enough support, then it's optional for them to have an embargo list. I'm sorry, I had some disturbance at my apartment. So, the next steps for us from the TOC is that we proceed formulating this like the template which we see over here will be put up in markdown as a recommendation in the TOC for the projects and under incubation. And then each project will be asked to go and update this into their repositories. So, I believe there were a couple of comments around what's the responsibility of the project teams in terms of if they have different repositories such as Ares, whether they should have different responsibilities across different repositories or should they have a unified approach across all of their repositories. That's one thing that I did not see a conclusion on. I also saw like Hart was open for suggestions from the team members. Is there a spot you specifically want me to scroll to, Arun? No, Sean. I think all the comments are addressed. The ones that you see over here is just about a few things that Christopher raised. It's the language which is already called out and yeah, we can always improvise on further. So, if you can see like Christopher is also emphasizing that embargo list plays an critical role and they have been provided with information that is otherwise confidential in nature. So, that comes with additional responsibilities. Otherwise it's the document is in a shape which we can proceed and vote upon. So, Tracy, it's on us to proceed to the next step. If TOC agrees to this process then this will be put up as markdown in the repository. Okay. That's great news, Arun. I think this is definitely taken shape and I think it's great that it's been passed through the open SSF. Any concerns or questions on the security vulnerability disclosure policy that we would like to make sure gets into the document prior to the markdown being created? Any discussion from the TOC members? Arun? So, I don't have any concern. I think this is great. So, thank you, guys. Just one thing. In the introduction it says something about we expect this document to be linked from Security MD file. I would make this stronger. I think this has to be, if it's a policy that applies across the board, Security MD files ought to point to it so that Security MD file is what most people are going to see first. They find the vulnerability, they go to the Security MD file that tells them what to do, how to report it. It's important that this Security MD file points to the policy. So, it's got to be a must, not just like, yeah, maybe, should, or expect. It's a bit too weak. It's a very minor thing. I just wanted to say that. All right. Thanks, Arun. Any other comments, discussion? Peter? I also think it's great, and especially it is a great idea to take it to the open as a self and thumbs up and also sorry that I wasn't, I couldn't be as involved with the creation of this as I wanted to be. Thank you again. All right. Thanks, Peter. Any thoughts on kind of that question that I think Arun posed, which is for projects that have multiple repositories like Aries that maybe the work is somewhat separate thoughts and kind of, you know, whether or not there's a single policy for Aries or potentially multiple policies for Aries? I haven't thought, but I would love to get the other TLC numbers thoughts, especially people that this is going to impact. Yeah, it's interesting. Aries is almost, at this point, it's just the way it's evolved is almost separate projects. You know, the three major pieces of it are operating more or less independently. And so it is interesting from that point of view. We're going through it right now because we've got a vulnerability, but it and it is in a common dependency, which is interesting. So we're we're living this right now. We'll see how it goes. So Stephen, does that imply that you think three separate policies or potentially four for the common dependencies? Or does that imply that a single one would be good to cover all of them? Or maybe you don't know yet? I guess by what you're saying is the embargo list, for example, might be different. Obviously, the policy is the same across them all. What you're saying, I think you're saying is just that the embargo list might be different for the sub components of the project, the four you're right for. Gotcha. Yeah, that makes sense. That makes sense. So maybe that that you have a single policy, but it says for this particular component, this is our list for this particular component, this is our list. Exactly. I don't think the policy at all should change. I think it should be completely the same. However, the application of it might be different across the different code bases. All right. Any other comments? Arun? Thanks, Tracy. So I just want to again repeat and probably call out all the maintainers. If not already seen this, please share this among your group, the other maintainers that you are aware of. Because once the policy is enforced, it will impact all the projects. And especially around the responsibilities from each project. And since these are security matters and we are publicly claiming certain aspects of how we deal with security issues, there is impact to both the project as well as the foundation itself. So that's all. Arun? Yeah, when it comes to this implementation, I think this may be worth adding a question to the report quarterly report template asking, have you implemented this policy, right? Because I think this is something we're going to have to track, similar to what we did for other things. And it doesn't have to be forever, but we might also want at some point to put some some deadline. Like, you know, we want all the projects to have adopted it by whenever we decide. Because otherwise, you know, and honestly, I'm thinking of SOTU, for instance, you know, which has not been very responsive on the quarterly report. I don't know that'll be responsive for this either. And at some point, I think we need to put our foot down and say, look, this is a requirement. If you want to keep belonging here, you have to lay by the rules. Yeah, I like that. I don't know. Steven? About the embargo list, this is a quick detail question. I assume all maintainers, maintainers are notified and so on. They're not embargo list is beyond maintainers, right? That is correct. I think I'll try to answer that question in non-political way and also try to be nice. Okay, so you're right, like embargo list is outside the scope of maintainers. However, the language that is put up here allows for maintainers to have a say and including a specific group of people or an organization in the embargo list. Thank you. All right. Any other comments, questions? Discussion? All right. I will take that as no. So, Arun Hart, anybody else who was involved in this, thank you for the work. We'll look forward to the Markdown poll request coming into the TOC repository once it does. We'll definitely bring this back to a vote for the TOC members to vote on. One of the things that did come to mind as we were discussing this is with the call out to kind of communicate this to the other maintainers that might not be on this call, is there a way for us to do that? Is that the maintainers discord channel? Should we be putting something on the TOC mailing listing? By the way, this is coming. Please do review within a comment. Just curious if there's any thoughts on making sure that people realize that this is going to be a requirement as Arun stated, right? That is going to be needed by each of the projects. And how do we kind of communicate that beforehand versus waiting until we approve it? Any thoughts on kind of the best communication mechanism for that or just, you know, attempt to communicate as widely as we can? Peter? I would say as widely as we can. And the idea I just had is on top of the discord channel and the mailing list that could also open issues in the GitHub repos and say this is just a notice. You can close it as soon as you've read it, but we want to make sure that you see it and then the information itself. All right. Thanks, Peter. All right. So then I guess with that, if there's nothing else, I'll make a call to see if there's anything else anybody would like to discuss before we close the meeting. Peter? Just a quick one. I know I'm a little behind with the automation, the pipeline automation task force, but we will schedule a meeting for next week. So everyone who is on that, please keep an eye out for me messaging about it. Actually, Peter, that's a good point. The automated pipeline task force discussion is next week. We can definitely use the TOC meeting to have that discussion in more detail, if you would like, instead of setting up a separate meeting since it is next on the agenda. That's great, but I also wanted to set up a separate meeting just so that by the time we get to the TOC call, we have some conclusions and updates and maybe we can take the discussion even further down the road. That's ideally I'd want to do that. No worries. Perfect. So we'll keep an eye out for that. Thank you. Yep. Anything else that anybody would like to bring up before we close? No? Okay. Well, thank you all for the participation discussion presentations today. We will talk to you again next week. Thanks all. Thank you, Tracy. Thank you to USC members and thank you to the presenters from the onboarding group. That was awesome. Yes. Thank you, guys. Thank you.