meeting. The first item on the agenda is the executive director's report Susan Barrett. Just a brief report I wanted to just thank again the folks down in the upper valley at Madison House Bill we were down there last week. We heard from their accountable community for health which was very informative and folks on the board what we do when we travel to different areas of the state is we split up in the morning and Maureen and I had a nice visit at HCRS and I have no idea what that stands for but it's the DA in Springfield and then Tom and Jess went over to Dartmouth and had a meeting with them and Robin and Kevin visited with Madison. So it's nice to get out and learn more about their community. So thanks again for that and also just a scheduling note our November schedule is posted on our website and I'd encourage folks to take a look at it. We have at least one day an all-day meeting so just take a look at that schedule and that's all I have to report thank you. Thank you Susan and speaking of that meeting. Next item on the agenda are the minutes of October 31st is there a spooktacular motion? It's been moved and seconded to approve the minutes of Wednesday October 31st without any additions deletions or corrections any discussion? If not all those in favor signify by saying aye. Aye. Any opposed? Okay if Sarah Kinzler could tee the afternoon up for us. Hi all can you hear me well? Yes. For the record this is Sarah Kinzler GMCB director of strategy and operations. I was tasked in 2017 with staffing the board's work related to vital health information technology and health information exchange. As a reminder the board has three major oversight activities in this area and the first is to review and approve vitals annual budget which we did in May. The second is to review and approve the HIT plan now known as the HIE plan and the third is to review and approve annually connectivity criteria that describe criteria for connecting and prioritizing connections to the VHIE. So today we're going to deal with these second and third responsibilities. So before I turn it over to Diva and Vital to do the bulk of the talking today staff have developed a handful of principles to guide the board's review or to support hopefully the board's review of these deliverables. There are four related to the HIT plan listed here. Really we want to we want to ensure that our review is based on the statutory criteria for the HIT plan. In Title 18 as well as the board's principles for health care reform we want to ensure that the HIT plan the HIE plan is consistent with with recent legislation to support vital oversight and HIE oversight so Act 73 and Act 187 most recently and we want to make sure that the HIE plan is consistent with national best practices and that it incorporates feedback from promoters. In addition we have two suggested criteria or principles for reviewing the connectivity criteria. The first is that it's well aligned with the HIE plan. We talked about this in late February when Vital originally came to us with their annual connectivity criteria and we asked them to hold off on that so that it could be reviewed in the context of the HIE plan and then the second criteria is about operationalizability so making sure that the criteria that we receive are clear enough that providers Vital and the state can all use them to enhance the behind make sure it's working well. Lastly I want to provide a quick process reminder so we received the HIE planning connectivity criteria on November 1st November 2nd through the 15th or a special public comment period so I would invite members of the public to visit our website to provide written comments specifically on the plans. Plans also posted there on November 19th. I'll come back before the board and provide actual staff recommendations that take into account the presentations we hear today as well as any public comment we receive and our hope is that we'll be able to vote on this on the 19th. Does the board have any questions? All right and I will turn it over to Diva. Thank you. So I've learned that I'm not very good at throwing my voice in this room so I'll try to sit closer. I'm Emily Richards the Director of the Health Information Program at the Department of Vermont Health Access and also be joined with Michael Costa who's what we call program sponsor who's also the Deputy Commissioner at Diva. So we're here today to present Vermont's Health Information Exchange Plan which was submitted to you on November 1st which you all are aware is a requirement for us to do annually and we're required to do a comprehensive update every five years. So we'll just start with the bottom line first. So over the past year you know we've been focusing on sort of getting ducks in a row responding to the recommendations from the Act 73 of 2017 evaluation report that you're all familiar with and we've testified to you on a number of times. So you know a big part of that the output of the evaluation report and the work that we've done in 2018 in response was the development of a governance body. To think about how we get stakeholders represented and at the table and how we do strategic planning in a statewide and representative way. So this circle kind of walks us through from execution to implementation. So starting at the top right here submitting an HIE plan was first that describes the HIE vision and promotes accountability and we'd like to spend the next hour or so walking you through what we hope was the achievement of both the description of vision and the promotion of accountability. In line with that the execution of contracts and budget that reflect those HIE plans and visions and I know that Vita will be back here in December to talk to you about our calendar year 19 contracts. Only Michael Kostak can get an applause. Welcome to the HIE presentation. We're just getting started. So it's just introducing this concept of focusing on execution today to be ready for innovation tomorrow and I'll let you catch your breath. So Vita will be back here in December to talk about their activities for 2019. Sort of the performance measures that we'll use and the alignment with the HIE plan in that contract. We're going to continue to use the HIE steering committee to assess community needs, examine results and refine a vision. So we'll talk to you about a proposed governance model bringing us into 2019 and having a fully sort of centralized or single HIE source that has responsibilities for statewide planning and implementation. As part of that they've committed to gathering input from stakeholders existing stakeholder groups. We started that this year but we plan to build out that engagement strategy next year. And finally to continuously refine medium and long-term HIE plans and visions and visit our technical plan which we'll talk about at more length today but to give folks like the Green Mountain Care Board and the legislature sort of a checkbox of accountability to make sure that we're doing what we said we're going to do in alignment with the broader HIE strategic vision. So again I apologize. I had this on my calendar for 120. I really hate to make the board wait and I apologize for that. I'm sure Emily's already talked about what you received in the HIE plan. What you received hopefully is a document that does two things. It sets forth a vision for what we want which we think has been lacking for some time in HIE and a way for policymakers and regulators to hold us accountable for the performance of that vision. We're going to go through what's inside the plan over the next hour but we do have the expectation that we're going to deliver this every year on time to you as regulators in that this vision will become more specific and more granular over time. I think one fair criticism is that it needs to be a little more specific and I think we're committed to doing that work in partnership with stakeholders. I want to say most importantly thank you to everybody who helped make this report a reality. In particular the people on the 2017 steering committee. I think everyone listed on the slide on the screen right now put in a tremendous amount of time. It wasn't the type of committee where you showed up and you offered your input. There was a lot of homework between meetings as we tried to really build an HIE plan from the ground up being focused on people and what they need and providers and what they need not merely technology. With technology being a tool not the ends in and of itself. So thank you to everybody there for their help in this project. So I think what we also want to concern that we had was okay so this group people came together we developed use cases of how people might need HIE to empower providers and empower people. How do you make sure you're not just doing that in a vacuum. Vermont is a great place to do stakeholder engagement. And so we were very fortunate to have the following groups weigh in on drafts of this plan by state primary care of the Rant Medical Society. The board's primary care advisory group which was especially lively and its feedback to us. The Medicaid Exchange advisory board vitals board the leadership of our agency VH staff that works with HIE every day and Sarah Kinzler and folks on the team here at the board. You can always do more stakeholder engagement. We're hoping that stakeholder engagement is something that happens throughout the year as we turn this plan into a document that guides our efforts in 2019. So so the steering committee one thing that I think they did which is really valuable we don't talk enough about is that they created norms for the committee's work this year and into the future.  And I think you know we've had this annual obligation to offer an HIE plan for a long time and that hasn't happened. And so we wanted to make sure that we were establishing a culture where that could happen in the future. And so I think the committee did an excellent job of trying to create norms for how they worked and that translated into HIE needs and the HIE plan. Most importantly we tasked the committee with demestifying health information exchange right if nobody knows what you're talking about you're not going to be successful. And so we've tried very hard and hopefully we've succeeded to some extent and talking in a more thoughtful and clear way about where we've been where we are and where we're going. We really want to put people ahead of in the health system ahead of technology so it's really a people-focused document. We wanted to talk about all the things that go into a successful HIE program. The fact that it's an ecosystem is not just one thing. And then we wanted to be able to demonstrate to policymakers and regulators and our funders at CMS what does progress look like and make sure there's clear alignment between that progress and our desired outcomes. And so the way we did that is we created an initial library as we've talked to this committee about use cases and talked specifically about what our HIE needs are. We wanted to make sure that we're focused on delivering a timely incredible project and then really set the foundation for a multi-year effort for success at HIE. Just taking a look at this program in 2017 when I started this work with Emily and the team it was very clear that we weren't three months away from value. We really had to start again and try to build for the medium and long term and hope people had the patience and the persistence to have a payoff in that regard. So in pursuit of that sort of shared norm that the steering committee established to demystify health information exchange as you notice we start the plan which is simple definitions and that's what the readers on the same page about our strategic aims for the plan. So we start with health information the administrative and clinical information created during care to support care coordination reimbursement reporting etc. And then we move on to the verb and the noun of health information exchange which we found even with the subject matter experts on our steering committee can really confuse the conversation so that when we talk about the verb we mean the action of sharing health information exchange often among health care facilities and when we talk about the noun we mean an actual actual organization that's electronically aggregating and managing health information exchange. So we have one health information exchange in Vermont as you know it's operated by vital and we call it the V high throughout the plan. So as you noted before the plan is structured in this way to focus on the basic essential elements and as Michael noted we we worked diligently to make sure that the language was as clear as possible and explaining these complicated terms. So we start with a history of health information exchange in Vermont to do kind of a 15 year look back and provides in context for where we are today. A lot has happened in over a decade. Then we move on to establishing a framework for success which has two important components first the HIE ecosystem or the essential components required to support HIE success and then the three tiers of HIE technology which is our strategy to clarify a lot of misconceptions around return on investment or what we should be pursuing in terms of technical investment for HIE. We move on to governing HIE in Vermont. We offer a proposal for sort of a permanent governance structure assuming that this year's steering committee was wholly focused on strategic planning and the next steering committee iteration will have a broader range of responsibilities. We included a look at HIE's sustainability which is really a discussion of the need for financing model and the considerations we would undertake to make that model. In the tactical plan you'll see that building a sustainability model as well as a technical plan road map are included in the 2019 work which will be demonstrated through the 2020 plan. The HIE plan also includes objectives and a tactical plan that's to make things real and hold accountable parties accountable for what they're going to accomplish in a one-year period and really give the reader a focus on you know the milestones that we would need to meet in order to achieve sort of a visionary state and finally we offer some HIE planning considerations. So thinking about what will influence future planning and what we really need to focus on going forward. Okay so starting with a history of HIE. So as I mentioned the sections included to provide some context for the largest strategic plan and we look at from 2003 to present. So we've walked the reader through all the way from the establishment of initial data collection registries at the Department of Health to federal policy that got us focused on the adoption of electronic health records and the concept of interoperability to the statewide focus and resourcing. So the HIT fund, the establishment of the HIT plan and vital and where we have been in the last couple of years. All of these highlight the important relationship between governance financing policy and technology. You see that littered throughout the last 15 years as we've all tried to sort of mature this ecosystem even if we weren't using that term. There's been a general understanding that all of those pillars are really essential to HIE success. Okay so let's start now or let's move on now to the HIE ecosystem which is really a focal point and again it's that environment required for HIE to effectively function. So this is based on four pillars. You know as Michael mentioned and we've mentioned in previous testimony the steering committee spent a great amount of time pulling together use cases or look at needs across the health care system. They also reflected on the national length landscape and the history here in Vermont and nationwide. And what they discerned is that there's four parts of this ecosystem first being and this is in any particular order but financing which is a model that basically to efficiently use resources and invest in the right things that are going to drive achievement of shared statewide HIE goals. Policy and processes are to facilitate system-wide goals. We can think of the consent process or excuse me content process at vital as an example of process in the consent policy as an example of policy and governance a formal governance body to support statewide planning and then at the center here is technology. So all of these exist to support statewide goals without mature maturity of each of the pillars. We can't assume that we can achieve any sort of HIE vision. I would have to think that as the board considers for example Vermont's health care reform efforts you know one of the challenges is that you're not just talking about the thing itself but all the things around it right and so when I think about operating a public health plan in Vermont right now you know we think about the health of our Medicaid beneficiaries but it's hard to think about having success with those beneficiaries without thinking about the blueprint for health and VCCI and the ACO and the health information exchange and similarly here with HIE people want to talk about the technology but we really tried to focus about all on all the scaffolding that has to go around that building. Do we know what we want and how are we testing that through our governance structure? What type of policies can support that ecosystem growing appropriately like the consent policy? How should the financing work? Right now the state has made a tremendous investment in HIE but that funding needs to be renewed each and every year which makes medium and long-term planning challenging and so we've tried to put as much if not more emphasis on the scaffolding that needs to be up and successful as we have on the technology itself and I'd like to think that that's a welcome change and how we think about the program. So shifting gears a little bit and you know with the shared understanding now of the sort of the structure of the building I'd like to talk a bit about the goals. So you know as mentioned we talked a lot about use cases as an articulation of how individuals rely on and use health information and need the exchange service. So you know use case is kind of an abstract term. It's really just a story about someone and how they interact in a role and how they need something. So each use case includes the statement as a blank I want to be able to blank so that I can blank. It's a really simple articulation of you know for example as a provider I want to be able to get real time ER notifications so that I know where my patients are and I can respond accordingly. Something along those lines and in the use cases they built out you know on the challenges with getting technology to support that statement and what an ideal state would be when each of those individuals was playing that individual role. So we sort of divided up the steering committee across the continued continuum of care folks volunteered to aggregate different use cases and we came together and we assessed that and what came up through a look at over 50 use cases that is that they could all be rolled up into 3 goals that really represent our vision for health information exchange. So the first is to create one health record for every person and that's pretty self-explanatory but we're saying that it's to support optimal care delivery and coordination by ensuring access to complete and accurate health records. So this is in service of reducing provider burden by aggregating the data that people need that providers need in one useful place and I think useful was a term that we talked a lot about at the steering committee making sure that utility of the data is reflective of each of the needs. And providing patients with a comprehensive understanding of their health and care. In Vermont today we don't have a specific patient portal that would show a patient their longitudinal health record and we don't have that for providers either. So if we're talking about sort of the vision or the you know the kind of north star for point of care support this is the goal. Now when you think about sort of the purpose of health information exchange you can often be you know people talk about sort of two pronged benefit one is point of care support or you know the doctor having or excuse me the provider having the data they need at their fingertips to provide good quality care and the other is to have health information so we can meet a variety of analytics needs. So the next two goals are in that second realm of analytics and we start with a look at practices. So the second goal here is to improve health care operations to enrich practices with data collection to support quality improvement and reporting. So there's a few benefits we can align data aggregation and quality efforts to support real needs reduce the extensive burden associated with reporting which we heard throughout. It's a significant number of the use cases and allow providers to analyze their own data and put information into action. And this is happening in pockets today in Vermont. So if you think about for example by state primary care association they work on something called the model for improvement with the FQHC's. So they call together a bunch of different clinical information put it in an analytics tool that has great easy to understand visual visualization and they teach practices how to use it. They say you know choose a dimension of care or choose a patient population. And let's ask questions against how behaviors are impacting outcomes and really puts the ability to use data in the hands of providers. And so this final goal again in line with that sort of analytics need is a look at more of a population level. So using data to enable investment and policy decisions. And what we're talking about here is bolstering the health systems ability to learn and improve by using data to guide investment and inform policy making and program development. So putting data in the hands of programs serving population wide needs and giving them population wide data to do analysis and understand programs impacts or plan and enabling data informed decision making you know at the legislative level at the regulatory level. I think goals one two and three illustrate what we mean we say we want this to be more refined and specific over time. When it comes to goal number one we know exactly what that is. We want one record for each for monitor. I think for two and three the next steering committee has worked to do to make those more specific and to get items in the tactical plan that are really specific about that. I think a lot about the administrative burden panel that the board hosted a little bit back. We saying in improve health care operations. What specific things could we do there to actually reduce administrative burden. So I think part of the work for the next year is to make each of these goals more refined and more specific over time. And you know to that end in the plan there are milestones to create sort of a look at what incremental progress might look like towards each goal or sort of the major areas that we need to hit in order to achieve each goal. And I think those will need to be refined and looked at. You know we need to put some more definition around things even a longitudinal health record as the H.A. steering committee has more time to work together. So the three goals they are representing sort of the highest level of vision. And then we look at the pillars of the ecosystem in a similar way trying to define what each are. And then you know each will mature and we're assuming that each will mature through incremental steps. We know that we need each of those pillars. But the ideal state for each is going to be unique. So we've offered what's like sort of a mini maturity model for each of the pillars of financing and governance and policy and process. So this is an example of the financing maturity model. So we're starting with the current state of dedicated public funds from Vermont and federal government broadly supporting the V.I. and other H.I.E. initiatives. So as you read in the 2017 evaluation report a significant amount of the investment that's going into H.I.E. now is coming from the public sector. And you know so if we looked at what incremental progress in the development of a sort of sustainable financing model would look like. The next step is detailed in the 2018-2019 plan and we've got a midterm goal and a long term goal that looks like a sustainable public and private financing model that takes into account the appropriate ratio for each. So moving on to technology here. Technology is unique when you talk about H.I.E. I mean we you know it's part of the scaffolding but it's been such a primary focus for so long in H.I.E. in such a myopic way that we wanted to spend a good pit of time trying to shed a lot of light on each of the areas of technology that are essential for H.I.E. success. So the steering committee started out looking at how nationwide we talk about the sort of component parts that would be needed for to support any H.I.E. goals and they started with the office of the national coordinator who has he's the principal federal entity for health information exchange and they have something that they call the ONC stack and it's a look at how what the sort of foundational components of technology are what sort of intermediary components are and what are end user services. And so we built off of that we sort of remontized it we reflected on the use cases and what we need and we built something similar. So here you see a three tiered architecture architecture that's basically a system of standardized component parts at the bottom and I should say that all of these are supported by financing policy and governance. So the ultimate value to users is going to be seen in tiers two and three you can look at end user services and say reporting services are consumer tools. Those are the interesting things that we talk about that allow us to actually use this health information right. But in order to enable tiers two and three we need to have those foundational services in place. So the steering committee assumes that foundational services would likely receive the greatest percentage of public investment with a mix of investment coming to the exchange services realm and the end user services sort of using a consumer demand model to be developed. Okay. And that same section and in the vein of demystifying health information exchange and really providing some clarity around HIT and HIE. We've broken down each of those component parts with first a look at sort of like an overview of the section pointing out where there's redundancies and inefficiencies but the reality of the current state. We've offered a visionary state to say okay this is today but in the ideal world this is where we'd be. And then articulated the key challenges for getting to that visionary state. So this is an example of consent policy and management. So you know we describe that Vermont's consent to share rules require people to opt in to exchange information across the VHIE and we know that the ideal state would be simple management of consent preferences to enable transfer data supporting a person when and where they need care. And then there's a discussion of both the challenge of managing consent preferences electronically which is well articulated in the 2017 evaluation report. And also an issue with exchanging sensitive data types particular substance use disorder data. Because many electronic health records and the VHIE can't separate out the sensitive data type sort of an all or nothing either your records included or if you have substance use disorder it's often not. Okay. And I'm assuming you guys are going to jump in if you have questions. So please let us know. All right. So moving on to the the tactical plan or sort of like how we make this real section. You know the 2017 evaluation offered us a number of recommendations for how to progress forward. We paired that with how we thought about those foundational exchange and end user services and our need to build a scaffolding. And we built out a tactical plan that identifies who's accountable for what why they would be doing something in the specific activity they'll be doing. So in 2018 and 2019 we're assuming that we're going to be making some progress in establishing a permanent governance body. The HIE steering committee making progress on consent management. And that's both there's a look at policy and the technical management data and making progress also and data quality and identity management. The steering committee is also responsible for initiating long term sustainable financing financial planning. So starting to build out that financial model for HIE and developing another plan which will include the technical roadmap. So I really wanted a checklist. You know I was involved in the HIE steering plan and I wish that when we published the report there was actually a perforation on the side. And we could rip a checklist out where people in the state house and here at the board and inside the agency and others could simply go through what we expected to do and measure how we actually did. I guess I think that is a key element of establishing credibility and confidence in the program. And so this just gives you like an example of the checklist that's part of the tactical plan. This is a portion of the tactical plan and it clearly lays out who's the accountable party, what the area of focus is and then the actual activities for 2018 to 19 until the agency submits the next HIE plan next fall. We've tried to be as specific as we can in creating the tactical plan. So there is no question about what we intended to do during the year and we'll have a way to have a straightforward dialogue about how we've done. I think it's easy to get lost in the HIE in just HIE in general and we wanted to make sure that there is some sort of touchstone for people to go back to to say, okay, this is what they were trying to do. This is their progress so far to the extent that their checking boxes off is okay, can we ask the better question of is anybody better off to the extent that we're not checking boxes? Why did that happen? And really simplify it for folks. And the steering committee, along with the agency, is in charge of making sure that that progress happens, led in part by Emily and her team, and then refinding these goals as the next version of the tactical plan needs to be developed for the 2019-20 HIE report. So when I first came to this work, I spent a lot of time asking folks, what do we want? Believing that if we didn't know what we want, there was no way to be successful. It would not be possible for vital as the HIE operator to succeed if it doesn't know what its client wants. And so, you know, we also are not comfortable that the agency itself knows exactly what is needed in HIE in Vermont. And so it's imperative that we have a stakeholder group. And now that we've successfully used the stakeholder group wants to develop this plan, we think there needs to be a more formal governance model and we intend to implement one. And so the governance model is focused on serving the needs of HIE users. We're going to keep building and refining those use cases. We want to keep strengthening that relationship between authority and accountability and make sure we're engaging a broad range of stakeholders. You'll see in the HIE plan other than the steering committee, we do not recommend creating new stakeholder bodies. It's our belief that there are plenty of stakeholder bodies in Vermont and we just need to utilize their wisdom and their time appropriately. And so we're going to do that. The proposed governance model we take from the research from the Office of the National Coordinator and experience in other states and hopefully we'll be able to use that successfully as folks reconvene in January of 2019. Since previous reports have identified that the stakeholder, that the lines of authority are not that clear about who is responsible for what in HIE, we're hopeful that we want to take a little time in the HIE plan to talk about roles and goals. And so we think the HIE report does a reasonably good job of trying to create clear roles and goals for Vermont's HIE governance model. And these blue boxes here just ask some questions about where do people go to do certain things and then what we expect of them. So we want to make sure that stakeholders know that the place you go to talk about HIE and set priorities and propose policies that HIE Steering Committee and that steering committee should develop and execute and evaluate the HIE plan and monitor that performance supported by DIVA's HIE unit. We need support. Where do we go from that? We go to the stakeholder advisory groups, just like your PECAC. Who's responsible for oversight, the Green Mountain Care Board? And we expect to have a continuous dialogue with you about HIE matters throughout the year, not just when the report is due. Who provides HIE services, both the V-High operated by Vital and there are other ways to use and get HIE services. And then how do we hold providers accountable? Well, with the V-High, for example, we've moved from grants to deliverable space contracts. So we're trying to make sure that we're using our contract as a tool to make sure that the taxpayers get what they paid for and eventually get value out of the HIE. We think by abiding by the roles and goals on the slides that we can create clear lines of authority and accountability and just have a more straightforward conversation about how HIE works here in Vermont. Now, who will be on the Steering Committee? I think one fair criticism of the Steering Committee that we've talked about in previous testimony is that it was pretty narrow. We really reached out and asked folks that we know care about this work and have experienced in this work and that we knew would be willing to put in the effort to help us get the program back on track and what was a fairly unusual situation. And the fact that we hadn't had an HIE plan approved in quite some time. I think the HIE Steering Committee is expected to grow in 2019 and cover more of the care continuum. If our goal is to have an integrated system of care, I think it's wise to have a stakeholder group that reflects that integrated system of care. So as you can see up on the slide, we'll be taking a look. There'll be someone from the Agency of Human Services. I expect to continue on as chair of the group, folks from the Department of Health, from a payer because we particularly think that payers have been underrepresented in previous conversations about statewide HIE, a minimum of three provider representatives from the list that you see below, a person who engages with the health care system, the ACO is a key strategic partner in reform, the blueprint for health, which has typically been a locus of HIE activity, and then non-voting members from the Green Mountain Care Board, the Agency of Digital Services is our technology partner. Emily's team in the Health Information Exchange Unit, Deva and then folks from Vital as the HIE operator. We have a legitimate concern about the group getting so big that you're not able to get your work done. That's always the tension, right? You want a group to be inclusive at the same time. You want it to be able to continue to do actual work that's meaningful and help guides the program. But we're excited to try this and see if we can maintain the same level of work and productivity that the most recent Steering Committee had. I think one other thing I would say about that Steering Committee is they're going to have to work through their clear responsibilities of developing and executing the HIE plan. They're going to have to grow and evolve based on our experience and our work and whatever technological innovations are out there in the health care field because as everybody here knows health information exchange and technology is not a settled field. There's a lot of development and a lot of disruption right now. We want to make sure most importantly I think that we're all in consensus about what the right investments are to make in the future. And to be quite frank I think one of the most difficult things we're going to have to do in 2019 is to take the current health information technology fund and the spending in that fund and the projects that are contemplated in that fund and ask ourselves do these investments make the most sense? Is there any duplication here among for example the ACO, the blueprint for health of Vermont Department of Health and other folks in the community and how do we get to a point where we're investing in what matters and not duplicating activity particularly because there are federal pressures coming down the road where the federal government is paying less for HIT over time at least under current law that we'll have to deal with. We want to make sure that that group is considering and developing and vetting policies that support our HIE goals and then engaging stakeholders in their work. We think of that group ends up being a silo that's not a good thing for them or the HIE program generally and so they need to help us get outside a conference room at AHS and get out into the community to figure out what folks really need and how this work and this investment could add value and make a difference. I think I also want to say thank you to Emily and her team. I think their work has changed quite a bit over the last two years and it's becoming more focused on supporting the Steering Committee. I'm one of those people that believes that if you're going to invite people in to be on the Steering Committee and you're doing it well, it requires a lot of effort on behalf of staff to properly support that group and make sure that the effort is worth their time invested. And so Emily and her team have, I think, a formidable challenge in making sure that Steering Committee is well supported in 2019. Thinking a little bit about sustainability, I think this one is important but it's also a difficult one because people always want to talk about money first. That's my experience. Thinking about my experience in taxation and in health care and overseeing Diva's balance sheet. People want to talk about money first. But in HIE, I think we really want to talk about value. Want to talk about how this is helping providers and Vermonters receive better care and be better connected. That said, though, we do need to keep our eye on the ball as far as financial sustainability. And the best we've done right now is to be able to ask ourselves some very key questions. Will the state continue to invest in HIE? What criteria to use to evaluate our current investments and our future investments? What level of investment is actually required based on the statewide need that's articulated through these use cases? What's the appropriate balance between public and private funds? I think at least the Steering Committee has discussed or envisioned a future where there is a mix of public and private funds. There is now in the HIE. We'd love to grow that mix but we want to have a hypothesis about what the right balance is. And then how can we really make sure that these foundational services that we need to focus on are being properly reused? I think if you think of the ONC stack, which I can't believe I just said the phrase ONC stack, Emily finally got to me. The long story short about that diagram is we've spent, in my opinion, about 12 years in this program thinking about what cool things we could bring to health care practices. We have not spent enough time thinking about those foundational things that make this program go. And so we have to get those basics right and make sure that people are building on top of that structure in a meaningful way. And we have to think hard about that when we think about what the financial need is for this program over time. And as I said before, we do have some federal challenges financially, just like we have state challenges financially, where some of the vehicles by which the state of Vermont and other states draw down federal funds for this type of work are either going away or going to be curtailed. Now, who knows what Congress is going to do in 2020 or 2021? I do not have a crystal ball on that. But we are concerned about the expiration of high tech funds, which is where we get our 9010 federal funding in 2021. It's unclear what care coordination dollars are available. There are potentially some other federal sources of revenue for this work, but it's unclear what the sort of four corners of that are. The HIT fund under current law expires annually, which requires legislative action. And so that introduces some uncertainty into the program. And then so far, consumers do not have a financial relationship with a publicly funded V-high. Essentially, this cost has been borne by the state in a small group of V-high customers. And it's going to be tricky to ask people to start paying something for something they've typically got for free. And that's, I think, why we've been trying to focus a little more on value. Because until you're offering practices value or consumers value, it's hard to envision turning the light switch and asking them to pay for HIE services. So our big key future questions, which may be on your mind as well, can we demonstrate that value in the HIE operator in the HIE to the system? Can we, in the expanded steering committee, use the HIE plan as a management tool? There are plenty of plans written by state government that just serve to sit up on a shelf. We're really hoping that's not the case here and that we can use this as a management tool. Can we get the HIE program in the steering committee to be well aligned with our overall health system goals and avoid duplication? Again, I think those are going to be some very difficult conversations, but also necessary conversations. Can we figure out the right mix of revenue sources as the federal government walks back some of its financial investment in HIT? And then my personal favorite, when is the technology going to deliver on its promises? And I think that one's nearly entirely out of our control. My personal belief is that the best thing we can do as Amazon and Google and other huge technology players run full speed into health information exchange and technology is to get this program to a point where it's very competent over a number of years so it's poised to act and invest well as the technology shakes out in a way that's meaningful for providers. And so I think we could be really useful in thinking about what small things can technology do to reduce provider administrative burden? What small things can technology do to clean up the data that's out there on Vermonters? How do we use health information data to support decision-making for payers and accountable care organizations in the state? And if we start to get that health system focus starts to pay dividends, we'll be in a really good position when the technology starts to sort itself out because it doesn't appear to be at that level of development quite yet. And with that, we're grateful for all the time we spent in front of the board over the last year talking about this and we'd be happy to answer your questions. Thank you, Michael and Emily. Questions or comments from the board? You want to go first? Go ahead, Tom. Well, thank you for this. I am near the ending of my first year here and this is a much better exposure to HIE than when I first started about a year ago in the high tech solutions report was the material that we're having to read. I'm kind of looking at slides 13 and 14. And I'm trying to sort out in my mind the timeline that might be involved in, say, getting from the current state to the midterm goal. I do think once you get to the midterm goal, the final stage seems pretty clear in sight. So getting to that midterm goal is certainly the better part of the challenge. And then as you move up the building blocks of success from foundational services to exchange services, in my mind I'm thinking maybe we're talking three to four years down the road. And in that timeline, hypothetical as it is, I'm wondering about the turnover of the steering committee. This is, I think, a solidly crafted vision. But it's also a vision that has a lot of cat herding in it. It's not hierarchical. It is a process that engages a lot of people from a lot of different perspectives. So as a regulator, I would hope to be able to look out in the landscape at the steering committee and see stability there that offers up kind of a constant drumbeat and to keep us on track, quite frankly. So I'm wondering what your thoughts are about Timeline and the structure of the steering committee in terms of sustaining it on a stable basis and without a lot of turnover in its membership. So on Timeline, I want to make sure that people understand this is my speculation and not a policy pronouncement. But I will tell you that when I've thought about this, Board Member Pelham, I keep thinking about the confluence of our 1115 Medicaid waiver and the all-payer model, which inspire in 2021 and 2022, respectively, and think that our long-term vision here probably dovetails with the next iteration of those agreements. So you are thinking three to five years out towards 2022, 2023. And that gives you time to say, OK, we're competent to run this program. Vital is competent to run the HEE. We're credible in being able to deliver on the value and the tasks inside the plan. And given that culture we've created, now we're ready to think. We're now ready to get to our long-term vision and figure out what the next version of HEE is in Vermont. So that's just my thinking on it. I think you're 100% right. That consistency will be very important in this. You just have to do the work on this. And I think it's hard with a rotating cast of characters to do that both from a management perspective and a steering committee perspective. I think for us the expectation we're trying to set for the incoming steering committee members is, one, this is going to be real work. It's just not just showing up to keep tabs on the program. And two, it's a multi-year commitment. And I think that also means that the team that supports this has to be really good about identifying people during the outreach that could plausibly get on the board so that when you do onboard someone, it's not totally new to them. Yep, I know you guys insist. I know this is the table people come to to have this conversation. I generally know what you're trying to accomplish. And you can plug people in. And so I think we just need to continue to build that ecosystem and community of people that understand about it, care about it, and can continue to work on it. Could the non-voting members, for example, be viewed as a minor league to the major leagues? And so as time goes on, that you're cultivating people into the steering committee in a way that if they can see should occur, you've got a backup bench? Well, we haven't looked at it that way. I would say that the meetings are open, of course, and that we'd encourage anybody who wants to come to be there. The non-voting members are really, in my mind, technical advisors. There's someone from the board. There's someone from Emily's team. There's someone from Vital as HIE operator. So it's more they're there to ensure alignment and technical assistance rather than serving as a minor league. But it is a concept worth considering, and we'll take it back and think about whether we could set up something that led to that kind of pipeline for people to be effective HIE steering committee members. And in terms of the Green Mountain Care Board, would you envision the steering committee and its reports and updates coming to us and saying, not just approving iterations of this plan, but saying, here are some specific things that you can do in the hospital budget process. I know what I think it was Jess in the hospital budget process kind of emphasized the point of consent and urging in our decisions that hospitals engage with Vital in a stronger way in terms of consent. Would you see that kind of demand on us as appropriate? I would say I want to be very respectful of the hospital budget process because I don't want to wander into something I don't know as well as the board. But I would say that I can imagine a situation where the steering committee is making common sense recommendations about how to better integrate the system. And I'll use a diva example because it's our shop. I could imagine a point in the future where the HIE steering committee says, if you really want providers to be engaged in this and you want to create incentives to have them involved, we recommend that you change your Medicaid provider agreement to reflect certain expectations about health information exchange. To me, that would seem fairly inbound. And so I think it's fair to analogize to the hospital budgeting process, but we'd want to make sure that the steering committee was being really thoughtful as not to wander into an area that they don't understand quite as well. And finally, just one more. What happens if the legislature, when you have a final resolution with them on consent, is not, goes against the opt-in, the opt-out proposal? Because it's so foundational that if at some point we're standing in the hall of the State House and the legislature is acted and it's not in a manner that promotes the HIE plan to consent, that seems to be a pretty fundamental problem, I would think. I would approach that situation the way I'm trying to approach many other things in the HIE program, which is to ask myself two questions. One, what does success look like? And two, is the financial investment worth it? I think that without serious reconsideration of the consent policy, what success looks like is different and whether the investment in worth it is potentially different. And so I think we'd be back in front of you and inside the agency taking a very hard look at this program and about whether success looks the way we want it to look and whether the use of taxpayer dollars is appropriate. And I think I'm happy that the HIE program has got to the point where I think we can be credible in having that type of discussion because it's a really serious thing to consider. And I think we're going to continue to go down this road on HIE and we'll be back here to talk to this board about the consent report quite soon and we'll be ready to talk about it in January with the legislature. Thank you. Thank you. I thought your report was very well written and clear, so I wanted to say thank you for that. Welcome. Kind of on a similar theme to Tom, in thinking about both maturity and really accountability and oversight, I would encourage, I guess it's really given your answer to Tom's question around making recommendations out of their processes, I would encourage you to think a little more outside of the box than I think some of the at least initial graphics in the report at least imply to me. So an example of that would be on page 19 where you have the clear roles and goals because as you said, so much of this ecosystem is outside of state government and quite frankly to me what's even more foundational underneath your foundational components of HIE is the electronic medical record itself or other mechanism making the data electronic. And I think a lot of the challenges at the HIE level stem from the fact that the EMR technology isn't really ready to fully exchange data, that there are too many different electronic medical records with too many different standards and that that makes your foundational components all that much more complicated. So I would be I would might some feedback would be I would I would hope that the steering committee is also thinking about if there are other ways to impact that. And when we get to the connectivity criteria, one of the areas that I wanted to discuss related to that was that we use that connectivity criteria when we consider certificates of need for health information technology investments that meet the CON criteria. Now those are large investments and it doesn't hit all EMRs obviously, but that sort of key use of those criteria wasn't mentioned anywhere in the HIE plan or in the connectivity criteria materials. And to me, that's another clear both oversight and accountability component that could be used in furthering the goals. So that wasn't really a question. It was more just some feedback. I guess in terms of I would encourage you to try and think more broadly outside of your immediate scope of your contracts with vital, particularly around both the oversight and the accountability. Thank you for the feedback. I entirely agree. I think there are two things to be equally true. There are two pieces that are missing from the report that are incredibly important to this endeavor yet also feel like boiling the ocean. One of them is the relationship of the electronic medical records. The other is just basic health literacy, right? It feels like if those were two things we were going to tackle with this report, boy, we're in for, we're probably not going to be successful. However, what I like and what I think is necessary in 2019 to your comment is that now that the HIE plan in the steering committee have sort of an orientation to the field, it needs to develop its view on how does this program work relative to the real world with electronic medical records and what, if anything, can it do or have to adjust to given basic health literacy problems, right? Because there's another just an interest in mine is patient registries, right? When I have a couple health care conditions, I would love more information about specific for monitors with asthma, right? And that to me, my own personal opinion is that there's a future of health care that's probably five or 10 years off that does a lot of that. And so I think that now that we have the program in better shape, we need to figure out our orientation towards those two issues. As far as the connectivity criteria, I would just say that's a matter of ongoing discussion between vital and the state. It certainly figured into our contract negotiations with vital to the extent it's not reflected in the report point well taken, but over time we think these things are going to come together. I think what I would add there is I'm grateful that stakeholders have bought into this concept that we needed to clarify a lot in HIE and set expectations and build some foundational understanding. But I think we're really well aware to your point of the need for more granular targeted discussion in this coming year. Yeah, and just to be clear, I think it was a really appropriate time to kind of take a step back and redo the foundational vision and goals and really trying to lay it all out in a simple way because I think you're right that HIE and HIT all gets lumped into this big category of things that are difficult to understand. So I think you did a great job of laying that out. And your point's a really good one to thank you. I just have one question on the makeup of the steering committee. When you talk about the provider representatives, what type of functions were you thinking those representatives would come from? Do you mean functions like as in roles on the street? Well, yeah, what I'm thinking is you probably need to have some real technical expertise. So whether you have some chief information officers in there, it seems that a lot of the committee may be people who are the end users of it and not necessarily the ones who are actually going to have to be managing that. So I would just kind of caution to say how are you going to guide that when you pick representatives? So I think it's fair to say that it's very hard on a steering committee or in any job to find one person who can do everything, particularly in health care. I think one expectation we want to set is that whomever is in those representative spots, they don't need to know the answer, but they need to know where to find the answer. And so for example, we have a very good partnership with by state primary care. We don't expect their team to be able to answer every question we have about health centers in primary care in Vermont. But we do try to hold them accountable for providing us with an informed view about how, for example, chief technology officers in their group of folks view this. And so I think we're looking more at that people who can who have the type of relationships where if there's one meeting that really focuses on a CTO's view of the world, that we can understand their view and get them in there for that rather than finding one person who's going to be able to do all that work. I don't know if that helps, but that's how we're thinking about it. OK, thanks. I don't believe I need to ask. Some of my questions were already answered. I just want to thank you. The report was incredibly thoughtful and well-ordered. And the presentation was great. So I feel like I have three other questions. Thank you. Thank you. So I don't have any questions either. My only comment would be that I was there in 2006 when this whole thing began. Actually, it began before that with Greg in the back room at Laus. And certainly, we thought we would be much further ahead than we are today. I'm hoping that whoever is sitting in these seats 12 years from now is saying the same thing. Again, thank you for an excellent job on the report. Are you going to be sticking around? For a bit. Yes. Good. So we'll ask Mike and Christina to come to your work. Whenever you're ready, Mike. Mr. Chair, members of the committee, thank you for allowing us to present our material today. To my right is Christina Scherkat. I'm Mike Smith from VITAL. As I said, I thank you for the opportunity to present the connectivity criteria today for your approval. As you know, we've been focused on data quality as well as data accessibility in the last few months. And as I mentioned the last time, we have seen a lot of progress in both of those areas. But we should. And it's required that it's a never-ending process to continue to improve upon what we do. So there is always more to do. And one of those things to do is to improve data collection and quality at the source and throughout the network. And certainly, connectivity criteria is an integral part of that improvement. So if I, if you don't mind, I'll let Christina take it from here and walk through the criteria. Good afternoon. Thank you again for having us. And I will. So Sarah and Emily actually set up this first slide for me. So I'm not going to go through it in detail. What I would like to do is maybe focus on the last two bullets about the connectivity criteria, establishing that connection to the VHI, and why we're here today. The current criteria is outdated. And we do need to keep up with the times. And at the same time, make sure that it dovetails nicely and is integrated, as called for, in Act 187 with the HIE plan. And I believe that we have done that with this new criteria. When I say that it's outdated, even though it was established in 2014, if you take a look at the initial criteria, the very first stage laid out that organizations had to either be using Vital Access, which is the provider portal, or Vital Direct, which is the secure messaging system. And in this day and age, there are other avenues to access data. And you may recall the last time I was here, I was talking about cross-community access, which is a way for organizations using their own EHR to leverage that EHR and access the data and see it right within their own electronic health record. So it's a bit outdated, and we needed to update. So let me just give you a little bit of an idea of what happened in this evolution. So again, the original criteria was established in 2014. And the revised criteria was not just Vital reaching out to a few organizations. We worked very closely with the DEBA connectivity team, as well as the HIE Steering Committee, the certain health care organizations that we have a close relationship with and provide feedback. We also worked with the by-state organization and many stakeholders blueprint. Even if a certain member was not on the HIE Steering Committee, for example, a technical resource, the blueprint was engaged. So that we had good feedback from all to help with this revision. Again, the V-High connectivity criteria in the beginning was very V-High focused. I walked you through one of the outdated criteria. And it was more about how can a customer use the V-High? And what we wanted to do with DEBA and the HIE Steering Committee's help is really identify how can the customers and stakeholders really be central to all of this and allow them to measure their technical capability, but really keep an eye on the quality of data and allowing them to understand the uses of the data, the benefit of using the V-High connectivity criteria, and really encourage them to embrace the connectivity criteria and the V-High. The original criteria has three categories and four stages. It may not have been very complicated, but when you look at it, if you're a health care organization, it may, especially if you're not very technical in nature, it might have put some people off in the fact that, oh, I must be technical in order to understand the criteria. And we really wanted to make it very simple. And something that allows organizations to understand it very quickly. So it changed to three tiers and shows how organizations can advance through that criteria and become more sophisticated and more engaged with their V-High. Lastly, the customers and stakeholders may not by reading the initial connectivity criteria may not have been apparent as to what those benefits were in using it. And they didn't really quite know how to adopt it. Even if they understood what some of the technical jargon meant, and if you look at it, we mentioned XEA, XCPD, XDS.B, I know what those things mean, but an organization, especially if you're a practice manager or a COO at an organization, you won't know the technical portions. So how would you even embrace and adopt this criteria? So we wanted to make it easy to understand and, again, allow them to understand what is their role and responsibility in using the criteria, using words that would make sense to them and not technical jargon. Understand what the objectives are in even meeting the criteria and have them understand once they are contributing data to the VHI, how can they use it and how can health reform programs that they participate in use their data. Then lastly, this is truly new. The criteria itself, which you have a copy of, which shows you the three tiers. We've incorporated worksheets or assessment tools within the criteria. And that was a very purposeful approach. The criteria we would expect to not change very often, just to keep up with the times. So where there are specific areas to collect data based upon the use cases that Emily was talking about, Emily and Michael in the HIE plan, what are the new uses that are being gathered and going through the HIE steering committee, we want to make sure that we have worksheets that allow for that type of dynamic change and capturing data and sharing that information with organizations. So that's new. Any questions before I move on? So on this slide, just to point out, again, it's a really simple advancement through the criteria. So tier one is the baseline connectivity. And it's your first measure to be able to say whether or not a health care organization or customer, as we've called them in the criteria, are even able to connect. Can they and should they connect? We want to be really focused on the investments that's being made in selecting organizations, engaging them in this process, and spending the money to actually make the connection. So we want to establish that baseline. And we use something called the baseline connectivity criteria that is called out in the connectivity criteria. In the past, you may recall, I was here maybe about a year ago, talking about the VHI interface connectivity criteria. It was called the VIC back then. It was the first iteration of what we are now calling the baseline connectivity criteria. And it's the first worksheet that is now in full use, where we work with the organizations, score the organization, whether or not they're able to technically connect, and whether or not they support robust patient matching. And then we create notes for them where we see opportunities for them to advance to the next stage. So that's already in use. Tier two gets to what are some of the common data elements that we know the programs and our customers want to see a comprehensive data set across all that we know organizations are able to contribute. It's not a heavy lift, but those are data elements that help progress to reporting on population health and those types of payment reform programs. And then tier three is, again, an expansion upon tier two. They are data elements or data sets that are very specific to stakeholders. For example, the blueprint for health might have social history information that they need to collect. And one care Vermont may have a different set that they would be looking at. So it allows for those differences. And again, this is the advancement to get to really a more comprehensive data set that meets all of the stakeholder needs. So this slide, let me just orient you to it. So again, on the left, we have our advancement through the stages. And then on the right is the table. And I'm actually going to walk you through it from the bottom up, from tier one up. So on the left, we have what is the criteria? What are we trying to achieve? What's the objective once you are able to use that tier in the connectivity criteria? And really, what is the value in meeting that criteria? So I've already stated, tier one is really about patient matching. We do not want to connect an organization if they are unable to allow us to match. The last time I was here, I gave you an update on what we've been doing in order to improve the patient matching and deduplicating records. We want to make sure that organizations are sending good data so we're not needing to continue to clean up. We know that we're getting good data for matching. And then the data is structured and able to be transmitted. And by that, we mean for a message that is sent to the V-High. There are standards, HL7 standards. And we have specifications. We work with the healthcare organization and their vendor to say, here's what you need to do just to be able for us to even receive a message that's carrying data. And that allows us to say, we are now able to also send that data in that structured way downstream. So from there, once the organization can meet the criteria, we will implement those interfaces and we will do the patient matching. And that data is now available for use at point of care. And that's the value side. The clinicians can actually view the data within the Vital Access Provider Portal or again through cross community access being able to retrieve information from the V-High directly from an EHR. Providers can see that data and use it at point of care. It also supports the electronic results delivery, meaning laboratory radiology and transcribes reports can be delivered to electronic health records for viewing right integrated in that EHR by providers. And again, patients are properly matched. So the provider is looking at the right record for the right patient. So moving up, tier two gets back to what is a core data set that throughout the state we want to make sure healthcare organizations are able to provide through that interface and that the data is standardized. Meaning if you are sending, I'm always going to use hemoglobin A1C, it just always seems to be the data element I select. If you're sending a hemoglobin A1C, are we able to recognize, and especially if we send that data on, that it is a hemoglobin A1C. So it needs to have a standardized code set assigned to it and we can work with the healthcare organization and the vendor to do that. The objective is we want to get uniform data. It would be great if all practices and hospitals are sending hemoglobin A1C. It allows us to be able to, not us specifically the VHI, but the stakeholders to be able to measure that type of diagnostic result throughout the state for all of their patients that they're trying to manage in their populations. Then the data can be used beyond the point of care. Again, within the analytic systems for the stakeholders blueprint, one care Vermont, the Vermont Chronic Care Initiative, whoever we are supplying data to. Then moving up to the tier three, this is again maybe specific to certain health reform programs or use cases. So what are those expanded data sets? Like I said, maybe some social history that's needed by a specific reporting system and they will be engaged in this effort along with vital when we're working with the organization and again, making sure that that data is standardized when we're getting more data. We should always be able to understand what that data element is and then we can aggregate that data. That data can be now analyzed across all organizations and really allows for expanded use of the data. For example, one of the values would be to provide de-identified data for research purposes or being able to get enough data to be able to identify should there be some policy changes or where do we want to go as a state? So before I move on, that was the quick walkthrough. Any questions? So as you can tell, the connectivity criteria is all about data quality and right now we are more focused on the baseline connectivity, making sure that organizations that are currently connecting are able to meet tier one, making sure that they are capable and should be connecting and again that the patient data is robust. So calendar year 19 and beyond really needs to focus on tier two and tier three and this is where Diva and the HIE Steering Committee as well as those customers that we've spoken to have been very helpful in this area. Focusing on that one common data set, identifying what that data set is and those worksheets that we're going to be using to communicate to the healthcare organizations and scoring them on. That's just about ready.  And then again, tier three consisting of an expanded data set but that's all within the worksheet that I will be submitting to you when it is finalized. Give us an example of a specific stakeholder. Sure, yeah. So a stakeholder could be the blueprint for health because they are receiving the data. It could be one care Vermont. It could be the Vermont Chronic Care Initiative. It could also be an event notification system. So a stakeholder to me are those types of programs or systems that are using the data downstream or upstream. I never know which one is to use. Whereas a customer would be those who are actually contributing the data and that would be a healthcare organization. Does that answer your question? Well, it's a start. If you could take it to the next level because let's stay with the blueprint for a second. Sure. What would the type of data that's specific only to them be that would be provided under tier three? I have to stop and think for a minute. So they could possibly be looking for some different social history information. They could be looking for a substance abuse evaluation is the, and I'm not really quite sure if this is a perfect example, but I'm going to use it at this moment in time. I'll know more when I see the final worksheet. It could get down to do you have three or more glasses of alcohol every day and there's a specific evaluation that they use. They don't seem to be as focused right now on medications whereas one care for month might be more focused on what's in the medication list. So that would be an example, probably not a perfect example, but it's just what I can supply off the top of my head. Again, when I have the finalized worksheet, you'll be able to see what those differences are. So the calendar year 19 contract that Vital has with Diva plus the connectivity criteria will be the tactical effort in order to really drive the data quality. And I'll walk you through how we would actually put this into action. That's probably the more exciting part of the connectivity criteria, right? So using the chronic activity criteria, we would use that to assess the site in determining, again, are you able to make tier one? Can you meet the specifications and technically connect? And are you sending good robust patient demographic data to ensure that we are matching? And we'll also look at a data quality analysis using the tier two and three worksheet. Can you send that common data set that the state would like to be able to ensure that you're documenting and sending to the V-High? Again, using hemoglobin A1Cs, those type of diagnostic tests, problems that are being reviewed across the state, whether it be diabetes, coronary artery disease, hypertension, those types of things. And then we will put together a work plan with the organization and their vendor to implement those interfaces and continue to work with them to send that good quality data. And by good quality data, what I mean is again the ability to recognize that they are sending the data element or data set that we would be looking for versus the accuracy of that data. Typically a diagnostic result, the value of that result is whatever the lab produced or whatever the provider documented. And then we would implement the interfaces, have the or go through that connection and testing as well as get an attestation from the organization at the end of the implementation that we're all on the same page. It has been implemented and we've implemented that work plan for tier two. Tier three would be by incorporating the blueprint and OneCare Vermont to make sure that they're also at the table to collect the data that may be specific to their program. Any questions? Well, of tier two, I think it seems like with so much of the state moving towards the Epic system that there could be more commonality than what currently exists, especially if they figure out so that Dartmouth and UVM system are talking to each other, so I'm curious. What role has vital play up to this point at people implementing the Epic system that UVM reached out and had thorough discussions with you? So we've worked with UVM and tell me if this answers your question or not. So we have worked with UVM because we're currently actually collecting data from them and they went through a similar process to make sure that the Epic system at their instance, their implementation was actually sending the right structure of their message. We were able to work with them to say what are you documenting and are we getting those data elements within the system? So we've done that work with UVM already. We will be working with them at the time that they're implementing within Porter to do that retesting now that they've done an implementation at additional organizations at Porter and CBMC, I believe, are where they're expanding. Does that answer your question? Kind of, but say that I'm a little rough on what I do and my records are probably with my local doctor and probably at RRMC with CERNA.  Yeah, so now you're on the access side of the house which is why the data quality is important because we wanna make sure that, and we hope this doesn't happen to you, but should you be jogging and fall? And you end up at UVM, that they're able to access your record right within their EHR and see a comprehensive set of data. Again, not to say that we hope this happens but say you were jogging and you hit your head and you were unconscious. We would want to have the provider be able to access your health record with good quality data, again, a comprehensive set of data to find out are you allergic to anything, what medications are you on and be able to care for you appropriately. So yes, through cross community access that would be directly from the EHR to be able to pull the data and see that good quality data or for those who might have an EHR or not have an EHR at all, be able to use Vital Access which is that log on to the provider portal, it's the product that we offer. Does that answer your question? Yeah, and UVM as you may recall, they're the first organization that we are working with for this cross community access and we are looking to expand that across the state. We're also using something called single sign on which is and Northeastern Vermont Regional Hospitals is using this technology right within their EHR. They press a button and it brings them into the provider portal. It is still the provider portal view but to the provider it's seamless. They just press a button and there it is. It would be able to locate your record and present it for the provider to view. Does that help? Yep. Okay. So I had a question as well and a follow up. In terms of what really the EHR market has out there right now, are there EHRs that providers that can get that wouldn't satisfy all three tiers? Cause it seems like the tiered approach is about improving the quality of the data and the types of data that's exchanged but from a technology perspective, are there choices that really wouldn't meet all three? So we've been working with electronic health records that are probably the more advanced health records at the moment. They're the hospitals and primary care and because of certified EHR requirements they have that technology to be able to meet more obviously tier one and tier two. We still do have some vendors who should be able to connect that we struggle with. One is e-clinical works. We've put into place a file extract just recently with a couple of the practices to be able to extract the data in a non-standard way but still in a way that supports tier one and tier two. I do expect that there as we expand across the state that we will identify EHRs that are maybe only at tier one and not at tier two, which is why the work plan is very important. We want to make sure that the organizations that are paying their vendors in my opinion, very good money, that they are able to say to their EHR vendor, this is what we need to do in order to support interoperability, to participate within a health reform program and we are requiring you to help get us to tier two and then tier three but we're actually putting in place a work plan with the organization that they can speak to because right now I think they struggle with what it is that they need to share with their vendor and this is in written format, it's very clear they can hand it off and they can even set up the call with the vendor with vital engaged and we hope with some of the stakeholders also part of that conversation. So would you, the reason I'm asking the question is I'm trying to envision using the connectivity criteria in a certificate of need process because we have done that in the past when it meets the criteria obviously, the project. So if you could, and you don't have to do this now but if you could also help us think through a little bit the appropriate ways to use the connectivity criteria when we are reviewing those large purchases. Yes, absolutely. That would be, I would love that to be able to use it within the certificate of need and I think later on in my presentation I talk about so when you're doing that as your role as the Green Mountain Care Board, I'm hoping that the healthcare organizations are a step before that using the connectivity criteria leveraging it with their vendor so by the time they get in front of you they know exactly where they stand and for those organizations, I believe we spoke about this last time that Mike and I were here, the number of vendor switches that are going on, organizations that are moving from one electronic health record to another for very good reasons. It could be that it's just not supporting their documentation needs, their reporting needs. It could also be due to cost. We want to make sure that they use this connectivity criteria at the time that they're selecting or even beginning to identify what will their selection process be to move to an electronic health record so that they don't spend money, begin the switch and then find out that they're only able to hit tier one. That wouldn't do anyone any good. Thank you. You're welcome. I'd like to follow up. To be sent that there are small providers that don't have access to some of these larger, the resources to buy some of these larger packages and they can only get tier one. Sounds like the suggestion is to put some of the onus on their negotiations with the vendors. Does Vile have workarounds you described as Vile extracts? Are there workarounds for some of the smaller providers in the state that maybe in their negotiations they have no leverage with the vendor? A little leverage with the vendor but Vile can step in and provide a workaround? Yeah, so the tier three. So that is one way that we were able to do this Vile extract and I do have to give kudos here to the Blueprint for Health. We worked very closely with them in order to find out they were getting a Vile extract and so we wanted to leverage that type of a Vile extract. They're using it for their purpose but we need to be able to use it for an expanded use. And so how can we do that? And it's not a burden on the healthcare organization. It's something that they're already doing but we can think about how to get to connectivity criteria in a really creative way without spending a lot of money. I do expect that through the HIE Steering Committee that we will uncover more of that as we look at what the use cases are and really start using the connectivity criteria and what comes out of some of this connectivity criteria assessment to determine where should we focus next. But I do believe that there are other creative ways to be able to get data and look forward to that. So I will move on. So these last two slides are more to just show you that we have been focused on this connectivity criteria working with customers and stakeholders throughout the state to make sure that it really does support the core mission of the VHI which Mike has stated. We're really focused on setting the foundation right so that we can continue to think of what are advanced uses of data and advanced uses of the VHI but let's make sure that we get our foundation right. So again, matching patients, being able to get a comprehensive set of data and driving towards data quality and holding those EHR vendors accountable. One last thing that I'll add about this is again being able to get to tier two we wanna help healthcare organizations have that conversation. We want to support them if they switch vendors. We've heard a few times that when organizations are trying to sign on the dotted line of contract with their vendor they would like to have something written that they can say this is what you need to meet and if you don't then you are not meeting your contractual obligation. There needs to be surface level agreements that you will actually meet this within a certain timeframe and I believe that this connectivity criteria can help support that as well. And then lastly supporting the HIE plan which in Act 187 the connectivity criteria integrated into the HIE plan and really needs to support that. And Emily and Michael walked you through all of the goals that they're trying to achieve and this just pretty much reinforces that with the added point of we really do want to help healthcare organizations and the state maximize the technology investments that they're making and identify what are the priorities and again more of that will be coming out of the HIE Steering Committee and we hope that again the information that comes out of assessing organizations helps in setting that path forward to identify who should be connected and where should we focus our efforts next. Thank you. Thank you. Sarah do you want to say anything before we go to all the comments? Well I have some preliminary staff recommendations to the board where I can walk us through the principles that I initially presented but if you prefer to go to the public comment. Which would you prefer? Do you want to preliminary staff recommendations? I think it's helpful for the public to hear preliminary staff recommendations about spanking comment on that specifically. But I'll be speedy at the time. Thank you Kristina. Thank you. Mike I know you were there in 2006 too. As was I. The difference is though that Mike has gray hair now and I don't have hair. So I'll move us pretty quickly through this. Now that we've gotten a chance to hear from Diva and Vital I thought it would be helpful to go back through the principles for a review that I presented earlier in the meeting and say you know how do we think the HIE plan and connectivity criteria live up to those principles. So there we go. So there are a number of statutory requirements for that for the HIE plan in section 93 51 which is this the statute that requires the administration to produce an HIE plan. The statutory criteria include supporting effective efficient statewide use of electronic health information educating providers in the public supporting interoperability proposing strategic investments in technology recommendations around funding mechanisms incorporating existing initiatives and specifically mentioning the blueprint and MMIS as well as addressing issues related to governance and security as submitted. I do believe that the HIE plan meets these criteria with the exception of proposing specific strategic technology investments. And as you heard from Diva this was a particular choice that they made given the national kind of HIE technology market environment as well as the spot that we're at with governance. So I think with that exception the HIE plan meets this criteria well and I think there's some significant benefit to us from holding off in that area. The second criteria is around alignment with the principles for healthcare reform in section 93 71. I think that the HIE plan is broadly consistent with these principles. I've named some here that I think it's particularly relevant to and I'll just call out a few right now in terms of supporting system transparency efficiency and accountability. I think enabling the flow of clinical information to support these objectives by decreasing duplicative services through a longitudinal health record for example or by enabling measurement and evaluation the second and third goals that Diva mentioned I think that those would enhance our ability to achieve that principle. Principles four and eight focus on the central role of primary care in our healthcare system as well as the importance of the relationship between individuals and their providers. I think that the HIE plan goals of longitudinal health records in particular and the HIE plans discussion of consent policy really speak to that principle. There are a number of others. I'll skip to the end and just say that I think one of the strongest elements of this plan is that it's a consensus document produced by a group of very knowledgeable people working across government and private organizations who have all come together to develop a plan for the state that kind of provides a foundation for our work moving forward. So principle number 13, the partnership between consumers, employers, healthcare providers, hospitals and government. That's one that I think is particularly important. Third, I wanted to make sure that these principles were usable in the long term. So spoke about whether the HIE plan is consistent with other relevant legislation. But this year I think it's important for us to focus on Act 187 of 2018, which required DBA to produce a work plan and to achieve a work plan related to HIE oversight and it's worked with vital. And in particular, there's a section of that work plan that's specific to developing an HIE strategic plan. There are four activities in that section. DBA has met all of them as of November. Lastly, I wanted to make sure that we thought about to what extent this plan incorporates the perspectives of remonters as well as incorporating national best practices and exemplars. We heard from DBA quite a bit about how the HIE plan incorporates and vermontizes, I think was the word, some national models from the Office of the National Coordinator for HIT. The steering committee also worked, you'll see in the plan with experts from Colorado, Michigan and Oklahoma, which are all states that have particularly successful health information exchange programs. And then in terms of seeking feedback from vermonters, we also heard from DBA about the department's work outside of the steering committee to engage other stakeholder groups and incorporate their feedback into the plan. So I think all of those speak well for the plan. And then secondly, looking toward the connectivity criteria, there are two criteria that we developed to think about whether these would meet the state's needs. The first is about alignment with the HIE plan or state's health reform goals. I believe that the connectivity criteria do that. I think Christina described very well how the connectivity criteria are in alignment with how the HIE plan is thinking about health information exchange in Vermont. And then second are the proposed connectivity criteria operationalizable. I think we've heard quite a bit today about how these criteria could be put into practice through enabling contracting with HIEHR vendors, excuse me, by helping practices and other healthcare organizations assess themselves and move up those tiers of connectivity. So I think to wrap it all up, my preliminary staff recommendations in advance of hearing public comment would be that we approve the HIE plan and the connectivity criteria as submitted. As we talked about earlier today, I'll be back on the 19th once the public comment period has ended. And after we've heard some public comment today to report back to you on what we hear and give a final staff recommendation. Thank you, sir. Any questions before we go to the public? Okay, we'll open it up to the public for any comments or questions. Ken. I've had the opportunity to sort of follow this conversation on health information has changed since about 2005 or 2006. And different people have different lenses to look at a project. And I guess I would have to say that the word disconnect is the word that I would categorize an awful lot of the work in language of the last 15, 17 years, it's a long time, including presentations before the We-Map Care Board by other staff. And the disconnect that, you know, the purpose and goals, I think a lot of it already, no one would absolutely argue against some of the purposes and goals. But I would just say that there's been a real disconnect between those goals and the application in the real world. And this is not a project that's been a stellar project. And I would have to say before, you know, at some point, I would kind of ask, what's your level of confidence after hearing this presentation that you really see a strong turnaround, particularly given the evaluation that was done eight or nine or 10 months ago that I was reviewing recently. And having said that, you know, the word disconnect is often, there's so much thrown here, you know, a lot of good work went into the presentation. I would just recommend that everybody read an article that's in the New Yorker this week. And I think it's titled something like Why Doctors Hate Their Computers. And it sort of puts in what I call simple English language, some of the comments that I heard were, you know, hinted at, you know, that they were in this article, one of the things that's expressed, which I thought, you know, was destructive because like everybody in the room on the patient, as well as a consumer and a policy advocate or consumer advocate, you know, that doctors will amending the fact that they don't have time to look at their portals where consumers and patients are just bombarding them with all kinds of questions and requests that it's become almost impossible to do. So it's sort of like, what happens when the real world hits on this project? So I guess my only comment or question is, could you identify one thing, perhaps, other than Mike Smith, that gives you a high level of confidence that there's gonna be a strong turnaround in what this project has been able to deliver for about $40 million? So I would point to a number of things, especially the work done by Michael Costa and his team assembling the stakeholders to try to, you know, focus the vision more. But I can tell you that in 2006, that was one of the people that took the bait hook line in Sanker that in five years we were gonna be able to do some amazing things. So maybe I'm not the best guy to be answering your question. And I hope it's just not hopeful optimism. I hope that there will be follow through. I do worry, as I pointed out, Mike has some gray hairs on his head, so he probably won't be there to see the full final fruition of vital if and when it grows up. And so that scares me. I do think that at least the right questions have been asked. And a lot of that is due to the work that Michael and Emily have done. Following up on HTE, HTS, I'm not good with those. Other board numbers? I can just add one of the things that gives me optimism is the changing of the contracts and the incentives and deliverables. So I think to the extent that Diva has arranged different types of contracts with Vital that are performance-based, I think that changes things as well. Yeah, that's a great point. The thing I would add is, as I said earlier, so much of the electronic medical record technology components are outside of the state's control. So I think the combination of the connectivity criteria which focuses on usability and data quality with the vision and roadmap outlined by the HIT plan positions us well. With that said, if the technology itself doesn't improve, there's only so much I think the state can do about it. If the EMRs continue to be basically built to be proprietary so they don't interconnect to make money for the technology companies, there's nothing that state government or an organization such as Vital can do. I think they're working on the right track to focus the resources that we do have and the work that we're doing as a state to be as successful as possible. But I also don't think we can hold them accountable for technology company lack of success in really pulling this off. I would just add one more thing, sorry. The opt out work that's gonna happen in the legislative session I think is really key to the success of this. I think if we continue with an opt in policy, that's good. I think if we can move to opt out. There are five states that don't even have any policy. It's just assumed. Yeah, I was gonna say exactly what Jess said and that's why I asked that question to Michael when he was up front is what happens if a legislature punts on this and his answer I thought was appropriate as I interpreted it which was it's a business decision if we don't have that foundational component of this overall strategy in place that has a huge effect in terms of the value of this to customers down the road and it could be a difficult time where we have to say this thing just isn't gonna happen. As you read the report there's $100 million that's already gone into this over the years as I understand it and from the federal government from the state and the possibility with some extra millions of getting to a point where we achieve what Sarah was talking about in terms of efficiencies in the system and things that make the system more affordable we should be able to see that in our rate setting process and in our hospital budging process. I believe these efficiencies are potentially real and they will manifest themselves at some point. I am curious as to how we might measure that as we go along to get kind of true insight into it but I think as Jess said as we go along there are some major benchmarks and one of them is consent and absent consent the resolution of that issue then I think the rest of the plan might be in jeopardy. It is unfortunate that so much money has been spent we're only to this point and part of that I think whenever you have 90-10 federal match to state dollars that enough questions aren't asked that's just a slide. Are there other public comment questions? Walter? Kevin's mentioned the year 2006 a lot and in 2006 I was fighting for my life against the disease killing me and the US healthcare system in Vermont at the same time and one of the problems I had one of the numerous problems I had was medical records and information and as a patient I remember one time at a hospital in Vermont that the hospital lost my medical records and I had to go scour the hospital with the patient and I found them in a drawer and another time the hospital didn't send the records down and I had to drive up 40 miles I was all yellow to get them and bring them back. So I'm in favor of the medical records and the health and the electronic because all of that could have been saved if it had been in place then. I'm trying to, I'm struggling to figure out why something so simple is so complex that we have two hours of presentations here on everything that, to me, I hear doctors complain about it all the time they're following with their computers and all of this didn't work this doesn't connect with that.  I hear that all the time on the front lines so I'm just wondering if there is a way to make this simple so that we all could understand it and utilize it rather than have this hugely complicated umbrella of steering can make it easy all the rest of that. Well that's what their mission is is to try to figure this out. I wish that there was one person we could call up and say straighten this out immediately but that hasn't happened in technology and take a look around us look at what happened with the exchange.  I knew the exchanges were going to be a flop to me because it was the whole thing crazy to begin with but they were a flop nationwide just here. That's just to me just speaking as a condition and as someone who had been up against what the system could do without the medical records. I had doctors forgot that I even had an appointment and I had to go find them. No, that's exactly why this path was started back then so that a Vermonter could go in anywhere in the state. A medical provider could access their records, make sure that they're not doing something that's already been done, make sure that they're not being given a medicine that's contraindicative, things like that. I think that we all share your frustration Walter that here we are all these years later and we're not there but I think we have to continue to try to provide the tools to make us get to that ultimate point where it's actually a success because quite frankly, I don't see any revolutionary improvements in the quality of care or the cost of care without a good flow of information all the way around. I'm with you there, I'm right beside you on that one. And I wish I had the technical expertise to be more out to the people across the room for me and this is one of those times where you really feel like you're lacking in your ability. It reminds me back in 2006, Jim Letty looking at me and saying, I'm putting you in charge of the technology piece because nobody else understands it and I'm like, well hello, do you think I do? So, you know that there's been so much money spent, the state hired some of the best experts in the country when it comes to IT and we still haven't been successful so I've got to tell you though I'm more optimistic today than I have been in the last 10 years so I can hope. Is there other questions or comments? Yes, Georgian, you got to be help. So I'm Georgian Harris from by State Primary Care Association. I think I just want to echo your last comment in that we at by state who like others in the room have been on this same technology conversation for quite a long time and I feel like what we consistently hear out of our members is are there guardrails, are there guidelines, are there rules of the road? Because they don't like a doctor doesn't know which side is up of an EMR. So in particular this plan I think resets us on a better path that's more forward thinking, more flexible and in particular acknowledges that no one entity within Vermont's healthcare system can control a piece but if you bring all of those bright minds together you can have a shot at trying to have a coordinated effort and in particular our providers are as was referenced earlier those that don't have a lot of additional resources to expand on giant technology and we have three in this year alone who over the past 12 months who are in process of migrating to new systems and it holds their entire world offline for six to nine months so we really appreciate the thoughtfulness of this, as I say, plan for a plan and then the setting up of a new process starting in 2019. Thank you, Georgia. Is there any other public comment or questions? Okay, is there any old business to come before the board? Seeing none, is there any new business to come before the board? Seeing none, is there a motion to adjourn? Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you everyone, have a good day.