The first item on the agenda is the Executive Director's Board. Thank you, Mr. Chair. I have a couple of announcements. By the reminder of our schedule, we are going on the road down to Madison State University at the end of this month on October 31st. We'll be spending the afternoon having our board meeting at Madison State University Hospital. The other work that I wanted to update the board and the public on is the staff at the board, our ACO, all year model staff is working feverishly, intently reviewing the recent submission from OneCare. Her Act from 13 of 2016, the board reviews and approves the ACO who's accepting commercial or Medicaid payments in the state as well as certifying ACOs. So the submission is on our website. I encourage folks to take a look at that and we are accepting public comments on the submission. We are targeting November 20th as a date to have that budget approved and OneCare will be in October 24th, which is, I guess, next week already to present their budget to the board. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, October 10th. Is there a motion? So moved. It's been moved and seconded to approve the minutes of Wednesday, October 10th without any additions, deletions or corrections, any discussion? Seeing none, all in favor signify by saying aye. Aye. Any opposed? Okay, now we're going to move to a discussion on the individual mandate with Agatha and Robin. I was going to just stay in my seat. So Agatha, you're on your own. Great. I can see you better from here, Robin. So thank you. Good afternoon. I'm here to give an update on the individual mandate report. Now the public comment period is closed. So closed on Friday. We were here, I was here a couple weeks ago with Jason Levittis and Robin on the line from France when we went over the working group's preliminary recommendations. And we just wanted to take a few minutes and update you on the public comments that came in, not only during the public comment period, which is when the majority of the public comments came in, but during the course of the working group's discussions this summer. So, oh. Thank you. So there's just one slide and it summarizes the public comments. We had, the working group had 18 public comments submitted by people or organizations, people on behalf of organizations. They were submitted at each of the working, they were available to be submitted to each of the working groups meeting by email or by phone. Most of them did come in by email and they were able to be submitted during the public comment period, which is closed on Friday. The summary of the public comments, the 18 public comments, and I will note that for the purposes of summarizing the public comments, they were categorized based on their main topics. So if a public comment touched on a couple different topics, it was categorized based on its main topic. So of the 18 that were submitted, the majority of them 13 were related to support for maintaining an exemption for healthcare sharing ministries. And I say maintain because under the federal structure, there is an exemption for healthcare sharing ministries and the working group recommends maintaining that exemption. The next category of public comments relates to again exemptions and creating a religious exemption for individuals who hold beliefs that are inconsistent with purchasing health insurance, with using health insurance. So in this instance, we say create because this would be creating a new exemption. Under the federal structure, there is not an exemption for this particular category of religious exemption. I would just clarify a little bit. There is a religious exemption. It's just much narrower than this particular suggestion. And this suggestion was modeled on Massachusetts state law. Right. And as Robin mentioned, there is a religious exemption for that very specific limited scope of people. They're the same people that don't participate in social security, for example. And then the last category of comments were a general kind of general opposition to a state-based individual mandate. And in that was mixed some mixed into there some recommendations for alternatives to an individual mandate and a penalty. And two of those four comments that were in opposition to a state-based individual mandate cited affordability concerns as their primary concern. And all of the comments are available on the Green Mountain Care Board website in one PDF document, also clicking here. And for those of you in the audience who didn't get a chance to see the full report that was released for public comment, that's also posted on the Green Mountain Care Board's website. The working group met yesterday to review the public comments and decided that they would not make any changes to their preliminary recommendations, so the ones that are in the report that was released for public comment. The group discussed a few minor, non-substantive changes, mostly related to grammar, typos, reordering some of the slides a little bit, but nothing substantive. No difference from what you heard two weeks ago. So that concludes the public comment period. And the working group is now on track to finalize the report and submit to the General Assembly on November 1st. So Robin, anything you'd like to add to that? No, I think that was a great summary. It might make sense to just reiterate the recommendations that are contained in the report, which are that, so there are a bunch of different components in the report related to an individual mandate, including a definition of minimum essential coverage. The working group had consensus around a definition with a small legislative change to what's currently in the statute around that, and that is in detail in the draft report. Also around the policy around exemptions. So the group discussed exemptions as a policy matter at a higher level decided to mirror the federal exemption policy with some modifications that made sense moving things from a federal to a state level as well as creating an easier affordability exemption than what's currently available at the federal level. And then in terms of, and I should say there was one dissent on one exemption in the exemption discussion. Otherwise the rest of the group was on the same page. And then as was discussed two weeks ago, there was a lack of consensus on enforcement with two different recommendations being put forth. One was a penalty modeled on the federal penalty with again a modification around the affordability exemption. The report includes a range of a flat dollar amount to be considered for affordability. And then the second recommendation that had different folks supporting it was outreach and enrollment without a penalty. So the report currently includes two different options for legislative consideration. And as we noted last time, the draft currently indicates that the board does not have a position in the substantive policy issues. And so just before we head into, I don't know if you had anything else to add, Agatha? That's it. Yeah. So before we head into any discussion, I just wanted to personally thank the members of the working group. They worked hard and consistently throughout the summer, really either meeting or doing research and homework on a weekly basis all summer long to reach where we got to in the report. And really stayed focused on the legislative request, which was not actually to discuss mandate or no mandate, but to look at the really the nitty gritty weeds of what should minimum essential coverage be? Should there, what kind of enforcement would be appropriate and really look at those more detailed questions? Which, you know, quite frankly, in a controversial area is hard to do, but people really stayed on task with that. And I guess that's really what I wanted to kind of say. So in addition to the group, I would say thank you, Robin, for representing the board well. Thank you, Agatha, as well. Report back and then very thorough. Are there questions for Agatha? Are there any questions from members of the public? I see none. Thank you very much. Great. Thank you. So the next item on the agenda is an update from the analytic team. And Kate O'Neill is ably filling in for Sarah Lennberg. Kate, you may want to introduce us to this stranger who's with you. This stranger? Yes. Oh, we happy to. Yeah, we have to send you an update. Oh, yeah, yeah. Yeah, I didn't get this. Sorry. You're right. Hard at work. It's a clip on it. Give me to the website. So hi, thanks for having us here. If you want to go to the home page, I think. So, so it's a quick update on what's going on with the analytics team. We were a small, mighty team of four under Sarah Lennberg's leadership, but we're adding a fifth staff member. That person is going to be the director of special data projects. And the first task on the on the list for that new position will be devoted to HRAP. So we're going to be getting started on that in earnest very soon. And I actually will say that we're adding that position to the data team, but it's a position that will be working very closely with Marissa Melamed. So across team effort. We are working on turning data into information to help support policymaking and regulatory efforts. And we have a few examples to show you today. One thing we want to share with you though is to let you know that we leveraged some grant funds to allow us to do an evaluation of fee cures and the products that result from fee cures. And we have posted a couple of those deliverables on our website. So I want to be sure that you know about them. And the first is so this is on the Green Mountain Care Board website from the homepage. There's this data and analytics link. And in fee cures in this section you'll see that we have a fee cures strategic plan. And that helps us to focus on how fee cures can support the board's regulatory and oversight responsibilities. And we have a fee cures capabilities document which is a handy table that describes the types of information that's available in fee cures is what fee cures can do and some of the limitations of the data that's in fee cures. So that's pretty handy. And we've also been working on developing standard reports, analytic reports. The enrollment trend report is one that you'll find interesting. It's got some snapshots including statewide enrollment by payers, statewide enrollment by age category, et cetera. And we've also taken the expenditure analysis and created a data visualization. That's what David's going to share with you today. But before I turn it over to him, I want to thank Laurie Perry for working with David in particular on making sure that this is a useful and accurate tool and to let you know that you can be on the lookout in the future for some other standard reports. We'll be focusing on statewide insurance coverage over time and also looking to develop a standard report around the hospital discharge data set. So that's what we've got on our plate and with that I'm just going to turn it over to David. Thanks, Kate. Excuse me. So as Kate indicated, my name is David Glavin. I'm one of the statisticians with the A team at the Green Mountain Care Board. And one of our goals or projects that we were tasked with is developing some ways of providing data to the public for them to be able to use. And in addition to that, also provides some different ways of looking at our standard reports that are developed such as the expenditure analysis that Laurie has developed. So I worked closely with Laurie and to validate the data. Now, this isn't the entire expenditure analysis for 2016. These are basically interactive graphs or what we'll all refer to as dashboards or visas that take some elements out of that report, specific to the resident portion of the expenditure analysis report. And within that, people will be able to navigate, look at some of the different graphs that Laurie has developed, but also there's some interactive ability to kind of filter through those or highlight particular areas. And we have this published right now through a couple of different sources. Actually, one source, which is Tableau Public. So I will kind of take you through, I'm basically just going to take you through a walkthrough of the entire database. I'm not going to really go through the elements of the analysis, as those were explained by Laurie during her presentation expenditure analysis. I'm really going to show you how the tool works. So this particular view I also want to highlight is that it's limited to just years 2012 through 2016. The limitations on that are because the visualizations could become very busy as a result if we ended up putting in more years. So we'll have that sort of as a rolling five-year look within this visualization, which I'll update annually. And it'll populate next time we come out with the 2017 information. We'll have views from 2013, obviously through 2017. And then just a couple of features specifically before I get into the how do we access it. The users can explore different aspects of the report through the interactive visualizations. They can download the data sets used to build the report. And one of the things that I find also is that through the interactivity of users, they become more engaged in the elements of the report. And it causes, I think it causes or elicits questions to rise and be able to be answered or it might be information that they might want to get back to us with and say, hey, we don't understand necessarily how this works or why is this trend occurring? So that's some of the main features that we wanted to highlight. So let me begin now with navigation and for those people who are calling in, there are two methods to access the visualization. One is through, you can Google Tableau Public and click on the link for Tableau Public. And up in the upper right-hand corner, there's a search bar and you can either put in Green Mountain Care Board or just GMCB and enter that and it'll bring up the expenditure analysis report. If it has any sort of relations, as you can see, this is a report. I'm not sure who developed this, but this will also pop up. Obviously this is a search tool, so if anything on the website has GMCB associated with it, that'll come up as well. So by clicking on the link to the expenditure analysis, that launches the actual visualization itself. And I'll point out this particular view I designed in a standard desktop view. I'm going to make a copy of this and I will also have a standard laptop view so that it'll size appropriately for laptops. We found that the scaling with some of the Tableau and the automatic version, which is supposed to scale to any portable device, doesn't really work very well. And these visualizations I don't recommend using on anything smaller than a tablet, for example. So I also recommend when viewing to also use the full screen view, which is located down in the bottom right hand corner. And then before I get into the visit itself, let me show you the other method of getting to it. You can access through the Green Mountain, the main Green Mountain care board page, go to the data analytics pages, which is where we are now, or I'm sorry, go to the data analytics page and then launch the analytics report. And that'll bring you to a hyperlink that will take you into Tableau Public, the same site that we were just looking at. Unfortunately, today I was updating this bottom sentence down here, and I broke the link. So I have to fix that when I get back. But like I said, because of the availability through the actual Tableau Public website, we can get, we can access it. So I'm going to fix it when I get back. It was just, I was updating just one portion of the, it's right before I got over here and I forgot to update the link. So like I said, I recommend that people, that people use the full screen mode. I think it's easier to look at and view. But I do want to talk about two elements. First of all, one is that the browser, and I have this, I don't want to call it a warning, but it's sort of information that the Tableau product is not, are not compatible. It'll open up in Microsoft Explorer and Microsoft Edge. But the visualizations and the interactivity itself are kind of broken. And that's partially because Microsoft is pushing their own visualization tool. And so I, they're, they're not providing the appropriate updates for this particular visualization tool. So we recommend using Google Chrome, Firefox or Safari for navigating through the actual visualization. A couple of elements I'm going to break out of the full screen mode. One thing that was pointed out by one of my colleagues is that the visualization tabs to navigate through are located at the top of the screen. And that's not necessarily evident. I think most people will look down to the bottom of the screen and you'll see these forward and backward arrows, which may confuse some people. Those are actually reset buttons or back undo and redo buttons. And I'll, I'll show you how those work. And there's also the default and full screen capabilities down here. So those are built into the Tableau public site. The actual visualization tabs themselves are located across the top. And I also have highlighted that as well here so that if people get confused they can come back to the, or they hopefully look at this page and find that. So the first page I have up is simply a definitions and data sources. This is a very high level outline of the categories and data sources that are used to build this particular visualization. So I wanted to, and also describes the population, which in this case are Vermont residents, regardless of where they receive health care, whether it's in state or out of state. So we have this in the chart up here also providing a definition for the, the population that we're describing within the, the workbook itself. One element I also want to point out is I have also created a hyperlink that will take you to the full expenditure analysis manual that will give you a much more detailed description of all of the elements within the expenditure analysis. I also noted that this particular view and this particular workbook is limited to just pages one through 12, which is the resident analysis for Vermont pages exclusively. So if you click on that, actually I think, oh yeah, it's launching. So that will launch, that will take you to the manual itself, that quick link. In addition to that I'm going to be adding also a link for the full expenditure analysis as well. So that's, that'll be updated as well. And feel free to stop me at any point as I go through these descriptions if you have any specific questions. So the next page is actually our first visualization. And in this, this is resident spend over time, this comes from a couple of different graphs that were embedded within the PDF version of the expenditure analysis. Some of the elements here that I want to point out is that there's a tool tip that pops up to kind of give a little bit more information. That's that little white box that you see pops up to give a little bit more information about specific elements within the visualization itself. So in this case I wanted people to understand that the percent change on top is for, it's the total percent change which are associated with these values here as they rise over time or decline over time. And it's from the previous here. So the percent change in this case is from 2012 to 2013. 2012 is not in there, 2011 to 2012 is not in there because we do not have 2011 data look within this visualization. So that is why this particular graphic up here is limited to 2013 through 2016 as well as the line graph over here which is discussed in percent change. Another piece of this including the tool tips within that error you can click on specific categories. So if board members want to use this visualization and they have a discussion or having a discussion they want to just highlight a particular portion of the graph. They can click on either the bar graph or they can click specifically on the line graph itself and in addition to that I also have it set up so you can actually highlight a specific category through the key down on the bottom. And another feature as well is that if you wanted to select and highlight two you can hold the control button and then we'll highlight two and then you can have a discussion about those values. Okay I also wanted to point out at this point the download functionality I'm just going to highlight and I'll be coming back to this on a few occasions. The download element within the workbook or within the visualization worksheet is located down in the lower right hand corner. And when you select that it brings up a table of elements that can be downloaded from this workbook. So you can actually download images, data, crosstab, PDF and the supporting information will come out. The image and the PDF will actually print out an entire view of this. So you could print it out into a, I think it comes out as a PNG image and you could utilize that in a PowerPoint presentation if you wanted to. Go back to the full screen. So on our next tab one of the other features that I built into some of the visits that you'll see is that you'll be able to filter by year. This particular view none of these other features highlight or do anything of shut those elements off. It just gives you a proportion of spend and you can kind of take a look at how those proportions differ over time by selecting each one of the years. I'm in contact with the Tableau development team quite a bit and one of the features I'd like to have them be able to put in here is a slide bar that you see. You can actually kind of slide in and dynamically look at those views over time more quickly than actually having to select, let it load for a second and then reset the different proportion looks for views. And also I've also provided the category breakdown for the two different major categories that we're comparing which is private versus government and what elements are being aggregated within each one of those. The next view is the residence spend by provider. First this particular view is a static view over here just giving the proportion of spend over time within each of the provider categories. Nothing occurs over here. You can highlight a specific category but other than that there's no interaction. They are affect and this is obviously not affected by this year filter. The year filter filters both the bar chart at the top and the tree diagram at the bottom and those two are interactive and related to each other. So when the filter is set for 2016 it will reset both this bar chart and the visualization what we call a tree map down at the bottom and I put a little explanation here on just what to do to change the tree map down here. I have what's called a hover action included in this and what this does is if you hover over it it will give you the breakdown of the hospital spend that $2.19 billion in a proportional view down on the bottom here.  So to supplement that I've added a little cross tab in here that color coordinates by each of those categories down below so that if one of the categories doesn't appear due to its size in the rectangular area you can actually get a look at the actual spend amounts that is in there. You know I don't have the proportion in there specifically. I could add that and I got a little busy overlap on the top so I didn't have the actual percentages within each one of these. But as you slide down and hover over each one of these it will change based on the in this case physician, government, health activities this portion gets changed over so that you and also the date will also change when you select the specific date so that people are aware of what they're looking at at a specific time. So now this case we're looking at drugs and supplies and then the title down below on the tree diagram indicates that. So and then I'll move on to the resident spend crosstab. This is actually Lori's specific crosstab this is one of the crosstabulation reports that she has within the expenditure analysis. It tends to get very busy on the eye when you look at the full breakdown so I decided to create some basically a subcategory for providers to for people to be able to get a little bit more detailed view within each one of these provider categories over here. And as you break that down it will mimic. We actually cut out one level but it will mimic the exact report that Lori has in the expenditure analysis and PDF form. This is also filterable by year and in addition to that we also have the ability to look at both the dollars crosstab and the percent breakdown crosstab by providers and spender types repair types. And then just to point out and I was going to put a little tip in here for people to actually access this little plus sign because it's not real obvious but one of the important things that I feel with visualizations and I wanted to build into this is that people to interact you know I want people to explore and kind of click on things and figure out why did I break this or what's going on here. And when you find this little plus sign here what that does is it opens this up and creates those subgroups so that you can get the more detailed look within administrative and net cost dental is obviously its own drugs and supplies et cetera. And those are also viewable with the percent. These are two separate dashboards so you actually if you want to look at you have to actually click on this percent as well. Now at this point I also want to point out if you get it if a user gets to this point and they're like all right well how do I go back. You can either click on the minus sign it will reset it or this is this is where those features that I was talking about earlier down below. There's a back button that will take you back to your previous view and in fact it will take you back all the way to the previous view. These work specifically with the particular dashboard or tab that you're on. There's also a full reset and that will reset the entire dashboard back to its original view and setting up. Including the two thousand salt just show you as well. You have two thousand thirteen selected you do a reset it will reset to the original view when you opened up the page. And then the final look that we have here is actually not a dashboard or interactive dashboard. This is a what we call a sheet within the software environment. But this is the actual data that was used to build the entire visualization. And as I stated earlier those data sources that were used to aggregate this information are located within the explanation that was located within that definitions page. This all this information is included within Lori's expenditure analysis. So none of this information we're putting out there is new information. In addition so if you go to the download page on this actually you have to be out of full screen mode to do that. Let me highlight a couple of the elements here. If you click on the download again. In this case you can either choose a data or crosstab anyways of the pdf I mean these are not interesting what you want to be able to do is load this as a data dot or data file or a crosstab file so you can either load it into new software or just use it as an Excel spreadsheet and create other tables or what you want whatever you want to do. So this crosstab and element element click on the download click OK it'll download a and open up the Excel spreadsheet and we get all sorts of errors. I think the IT recently updated this and this is exactly the data set that I worked with to build this entire report. There's one feature I want to point out and this you know anybody can use this and like I said you in one of the other features that I've also built into this is the filtering element so you can filter by year if you want to just compare a couple of years if you're just looking specifically at a group of providers that you wanted to select then that's also filterable as well and if you're in this and you want to get back you know quickly get back without having to click on each one of those buttons you can use the reset tool at the bottom to reset back to the full data set. There's one last element I want to point out in case anybody has questions to ask. There's two possibilities for downloading the data set are located down here. The second is this data and this is actually comes out as a text file actually it doesn't load into a CSV file not a text file and when I refer to CSV I mean it'll open up in Excel. This is a more detailed look at the data I recommend people use the cross tab because that's the data that's connected to this. A lot of this is other data elements that I had to build within it to make some of those visualizations work. So somebody who knows how to use Tableau would understand this. There's it's just manipulation of that original data set to have some of those views look a different way or not have things subset etc. So and then if you click on show all columns that really gives you everything that I built into it. So really this is not useful except for someone who would be who has some background with Tableau. And let me think. Finally I do want to talk about one other download element and then I think this can get a bit confusing as well. People may want to click on this download piece in the upper right hand corner. That will look download the Tableau workbook package workbook with all the data elements in it exactly as I as it as it as I built it and downloaded to the Web site here. This also comes up in the download link down below. That will download a Tableau document that can only be opened up in Tableau. There are some free reader versions. So if people want to be able to manipulate the visualizations they also have that ability to but you need to have the Tableau software. And I think I probably went a little bit over I apologize but are there any questions. Questions for David. I don't have a question I just wanted to say that I love the interactivity I think that's fabulous and I think it will be helpful for us as board members as well as for lots of other folks. Thank you. And you're welcome. Yeah I had a couple questions on if you go back to the chart that had kind of the cross tab. Yes. Page I think. This one. Yeah just a couple questions on maybe and you know how the data is provided but if you look at hospitals for instance. How are like drugs and supplies and physicians and things like that occur within the hospital are they separated out or. Not within this look not within this view. Okay so it's. They are to this degree. Are you talking about this element here. Where we do have a further breakdown so I have for example other professions. Those sub sub groups that Lori provides in the full. Cross tab look that you'll get in the that's what this is here. But the hospital just includes all spending that's in the hospital. Yeah I'm assuming that that's a question that you would have to ask. I'm not particularly familiar with the true analysis she's the expert on that so I'll defer that. And similarly when you look at the out of pocket column. Is there a way to do that by payer type I mean is there. That's not built in there. The only places I have that built in are in other views for example. Because actually it's in the. And I don't know we did. I do have to put that disclaimer we. So here I do have out of pocket spend by I think I have the reverse of what you want. I just didn't know you know those are interesting things and it's probably in the data set. Yeah I do encourage you know that's one of the things to I encourage feedback on this because this is a living document. And I'm happy to update or add extra looks if people want those built in. So if you have anything. Any other views that you want to look at or you know can it do this. You can feel free to you know email me or you can just turn around and. Yeah. And the final one and that would be. Any way to correlate. Lives. Or. You know by kind of type so obviously. That's not built in that data is not built in your life. Let me just go back. No I don't think it's not. I mean. Well this is like I said if you look at this here this is what the data set is built on. So it's built on year. Provider. The payer types and then the expenditure. Then this is an aggregate. Value for expenditures within each one of these. Sets. Okay. So that is that so what if you look at the. So if you download this it's the exact Excel spreadsheet. Or CSV sheet that I worked off of. To build this entire workbook so those are the only four data elements that are provided. Or that we're used to build this entire workbooks. Okay great. No but I think it's a great tool. Yeah there are ways that we could. You could link and launch another biz. To answer some of those questions and we could we can discuss that. You know. That's a little bit more complex. Right. Process but I'm happy to build that. Great. Thank you. The other questions. Not is there any public question or comment. Thank you very much. Okay thank you. This time we're going to switch gears. Mr. Chair. Thank you for allowing us to present this update today. My portion of the presentation will be relatively brief because we have very qualified people here at the table to update you on the various aspects of our operation. So let me introduce them. To my right is Christina Shackett who is this chief operating officer of vital. To my far left is Bob Ternot who is the CFO of vital. And to my immediate left is Frank Harris who is the strategic technology advisor. Just to sort of give you a brief overview before we launch into some of the specifics I'm happy to report to the board that we have accomplished much actually in my estimation in an incredible amount of progress over the last eight months and you will see that in our presentation as well as I believe the state's presentation. But there's definitely more to do. In short we've hit our marks in accordance to the work plan but we must continue to work hard and continue to move forward in our progress. This progress would not have been possible without the leadership that you see here on my left and right and a remarkable and hardworking and dedicated staff. We've is amazing what has happened in eight months. It also wouldn't been possible without the support from the Green Mountain Care Board, the legislature and particularly Michael Costa and Emily Richards from the state of Vermont as well as our partners out there. It's been a humbling and incredible experience as we have as we have progressed in shown progress in the last eight months. In 12 to 16 months I will be leaving this position but I am gaining confidence that Vital can fulfill, I have confidence that Vital will fulfill its role in delivering more efficient delivery of care at the point of care in healthcare reform and in the introduction of innovative technologies to assist clinicians and perhaps even the patient. I also want to thank the board because this is the only opportunity I get to thank the board for their recent action in the hospital budget process to urge both Vital and hospitals to seek ways to promote electronic consent. This will help in a large way. It's a great step and we are also hopeful in the upcoming legislative session that we will pursue the idea of a more broader resolution to the consent issue that we have been talking about for the last few years. So we would like to start this review today with Bob and financial operations review and go from there. So Bob. Good afternoon. I'm Bob Ternot, CFO for Vital. I would like to thank the board for allowing us to bring them an update of the progress that we have made at Vital. Today I would like to go over the financial statements for our audited FY17 and also our unaudited FY18 results. We are currently in process with our FY18 audit with Galgar Flynn. This is the first year of that audit with Galgar Flynn and we hope to be able to present to the board in December the results of that audit. This chart is similar to one that we presented to the Green Mountain Care Board during the budget review this spring. I've updated it to reflect the finalization of FY17 for the audit along with the latest draft for our unaudited revenue projections for FY18. We believe that, excuse me, and also I've added into that we will be very close with our FY19 projection. We are still working to finalize the FY, the CY19 contract with Diva. That contract begins January 1st and runs a full calendar year. Typically our contracts with Diva have run in accordance with our fiscal year and this is the first year that we will be using a calendar year contract. We will be back hopefully in mid-November to discuss the results of the negotiation with Diva but from where we stand right now we believe that we're very close with Diva in terms of numbers and scope. Before I leave this chart I do need to mention the tremendous effort that has been done by Vital's team this year. We completed 100% of our deliverables including 100 new and replacement interfaces which is a huge lift and it was a great success by our operations team. Can you break that down Christina, can you? Roughly 35% each year I would say this year is probably more around 40% replacement so I'm sorry. Okay. So 60% of? Yeah, I can double check the number but that's my best estimate. Okay. Again this chart is similar to the expense chart that was shown during the budget review this spring. The take away here is that the reduction in expenses during FY18 when we compare it to FY17 was the result of labor cost reductions. We reduced head count by 7 employees in between FY17 and 18. We also have deferred technology projects so that we can reevaluate our technical direction and Frank is going to talk a little bit about that following my presentation. FY19 continues this trend of reduction in expenses. This chart compares Vital's FY18 budget to the one that the Green Mountain Care Board approved in the spring of 2017 for FY18 with our unaudited results for FY18. If you'll notice we've come within 1% of our budgeted revenue for the year. In addition our expenses as I've discussed have been impacted by reductions in labor and also the pause that we took in the development of new technical projects until our reevaluation was complete. We do expect to move out on several new technology projects this year in FY19. Again Frank will address the vital technology in his section and as we mentioned in our budget review this spring the surplus that has been generated will position us well for future periods where we're facing reduced funding. Moving on to the balance sheet Vital is in a much stronger financial position than it has been in prior years. This in FY18 we closed with over 100 days of cash on hand. This has been driven by our aggressive approach to reducing expenditures. We expect to use this surplus to cover our reduced funding in 2020. Since June Vital has been working on three audits. We completed our FY17 audit following the state's review in July and we undertook an operational audit with KPMG which I'll speak about in a moment in August. And now we are working to complete our FY18 audit which is expected to complete in December. The operational audit which was conducted by KPMG was a recommendation for the HTS report. The audit had five objectives to assess the existing financial policies. To assess work practices of vitals. To also advise on steps to take to operation wise those policies to determine if there were any missing policies and also to take a look at our accounting system. The results of that audit were 12 observations which range in the potential for a control gap from high to low. There are two high, there are six mediums and there are four lows. The findings were not a surprise for us in terms of our size. We face typical issues of an organization of our size in terms of segregation of duties, operational redundancy ensuring that the processes that vital does in terms of its finances are carried out consistently when a change in personnel has occurred. We have been addressing KPMG's observations since we got the report and I'm happy to report that six or half of them are either in process or have been completed. So with this report to the Green Mountain Care Board, you can see that vital is positioned to be a stronger organization. We've made the hard decisions over the past year. Our staff has worked hard to make positive change and we are at a better place than we were a year ago. So that concludes my questions. I have one thing because I recall you were carrying about a $130,000 contingency for an outstanding waterfinding that had not been resolved but as I look at this document it looks like it has been resolved. So I'm just checking to make sure that's true. It has been resolved. We still have to work out the mechanics of payment to the state whether it's set to an invoice or whether it's a direct payment. But the state and vital are both in agreement as to the amount of the credit due to the state. Thanks. I had one as well on the financial sustainability. When you talk about 2020 losing funding and you're kind of putting money in the bank in 2018 you came up with a million dollars extra. But what does that look like for 20? Do you know what your funding will be versus your expenses yet? And then going forward how sustainable is that? What's going to happen in 21? This year you kind of put this piggy bank but that's tough to run like that. Mike, you want to take that one? I'll take that one. That's a very good question and one that we sort of talked about the three years. The 19, the 20, the 21. As we look at 20, we'll be as we're looking at it now and we're reducing the revenue that's going to be coming from us in an agreement with the state. It was a mutual agreement that we made with the state. We projected we'll have an operating deficit in 2020 where this will have enough cash to cover that operating deficit where the rubber meets the road in 2021. And there are two avenues that we pursue. One of them is talking about financial sustainability. This was no surprise to us. We have to diversify our revenues and this gives us a couple of years in order to do that. In order to diversify our revenues, find more revenue sources in order to do that. We're in the process of working through those various options right now. If that doesn't we'll have to cut again and look at ways in order to cut about half a million dollars in 2020. I'm optimistic frankly over the next two years that we'll be able to find half a million dollars in revenue in incoming revenue as we move forward. But there is the contingency plan of further cuts that will make a sustainable going into the future after 2021 if we have to. Thanks. Good afternoon everyone. I'm Frank Harris. I'm strategic technology advisor for Vital. I'm going to talk to you today about a couple of initiatives, a couple of key initiatives that we have going on in the technology area. The first one we're calling the Be High Future platform initiative. And what we're doing with this one is we're taking a critical look at our current architecture that I'm referring to our as you're probably familiar we use a vendor today, Medicity which is really in short our point of care system that provides a portal for clinicians to use and looking at healthcare data. And then the HDM data services platform the health data management platform and that's really intended to provide data for analytic activities. We're doing this. Well the first thing is that in the HTS evaluation report you're probably all familiar the question was raised about whether there was an opportunity for Vital to simplify and consolidate its architecture. And always a really good question with two components like that and so we want to look very carefully at that. The second thing is that the HDM is a self developed and one of the strategic principles that we've espoused in our technology strategy is that we're not going to develop capabilities like this unless there's a compelling reason to do that and so we want to take a really critical look at this and see is that the best path forward for us or should we be thinking about a vendor system that we could purchase. And then finally the last thing is that we always want to be taking a critical look at what we're doing. One of the things that we've said in our technology strategy is we're not going to be wedded to particular solutions. We're going to keep an open mind about how we approach our technology solutions and we want to be sure that we've got an optimal solution. So is the Modicity platform are they providing the optimal capabilities? Is there a way for us to accelerate the path and taking a different road? So the process the first thing we want to do is a feasibility study and that's what we're beginning now really this is a this would be a very significant effort for the company and for the V-High effort and we want to look very carefully at it before we do a lot of investment of time here. And so the first question is is there a high value replacement? We're going to look at the marketplace to be confident that there's a better solution out there than what we currently have. I always think about the devil you know versus the devil you don't know and it's easy to see the flaws in your current platform. A lot of times you can be looking at a new solution it looks more optimistic you gotta be really careful about that. And then the second thing is can we actually conduct a project? There's obviously significant cost both in terms of dollars and a lot of the focus of the company to change platforms and so we want to look at that carefully and then also what are the resources required human resources and any other resources needed. So we're targeting completion around the end of calendar year 2018 to complete the feasibility study and then if we determine that it's feasible and advisable to proceed we'll move on to a full RFP the associated planning effort prior to the modicity contract renewal which comes up in June of 2019. Next slide. The second effort I want to mention is the V-high transition to the cloud and really here we're referring mostly to the HDM part of the infrastructure that is currently hosted on owned hardware at a data center co-location site in South Burlington and we want to look at is there an opportunity to take a better path in getting meeting our infrastructure needs? Why do we want to do this? It's the same reason most companies are looking at this or many companies are looking at this these days. One is to avoid large capital expenditures and the obsolescence of assets that comes with those capital investments over time. That's difficult to manage but we also expect that we will see reduced costs and a much more predictable and consistent operating expense and then finally significantly improved agility to rapidly scale up or down and to only pay for what you actually use. A lot of times when companies are purchasing capital assets you've got to sort of anticipate what am I going to need in the next few years, you've got some vital capability there that manages. A big question that usually comes up very quickly when you start to talk about this kind of thing is is it secure and the short answer is yes. There's really no reason to be fearful about taking this approach. It has every bit of the security that you need but it's not magic either it's got to be properly managed just like when you're running your own infrastructure and certainly that's our intent. Many companies are running secure applications out of the cloud with personally identifiable information or intellectual properties very commonly done and major cloud vendors have consistent well vetted practices and this is one thing that's not often not intuitive. You've got a major technology company that is managing the infrastructure in a consistent, reliable way and there can be some advantages from a perspective with that approach. Our transition our strategy is that first of all, modicity is already what you would call private cloud base and they have that in quotes it really just means it's a dedicated purpose cloud. The HDM would be transitioning to a public cloud. They get in quotes meaning that it's a general purpose cloud that many companies use and we've chosen a major cloud vendor which is soft azure and the transition that we see ourselves going through first an effort that's currently underway is to establish offsite backups for all of our data in the cloud not only all of our data but all of our assets associated with the HDM the servers, etc. The next part is around design and engineering and business impact analysis so really understanding what are the critical systems, what are the recovery objectives, how are we going to do this thing then to establish disaster recovery in the cloud so to prove that the infrastructure works in the cloud and also to establish a better disaster recovery capability and then finally flipping production to the cloud and you do that in two different sites. So we're contracting for that first step for backups now and the implementation duration is about a month once the work begins. So I'm glad to take any questions. Questions? I had one. I was curious if you had any discussions with Diva or the agency of digital services about using similar cloud vendors and whether there had been anything advantageous about that. I don't know how the pricing works so I don't know if that might help with the pricing but I was just curious about whether those discussions happened and if that makes any sense. Yes. We have been collaborating with the folks from ADS pretty closely on this and expect to continue to do that. The first part of the effort is relatively straightforward to establish backups and the data is encrypted in the cloud and so it's relatively straightforward. As we get further down the road it starts to get more complicated and more decisions to be made and we'll continue to collaborate with them all along the way on this. Thank you. Good afternoon. My name is Christina Schokett. I'm the Chief Operating Officer at Vital. I need the clicker. Thank you. I'll walk you through the operational progress that we've made at Vital. The target for patient consent, that means any patient who has consented to have their information accessible within the VHI. Our target for December 31 is 35% of all Vermonters in the VHI having consented in and we have already surpassed that number and we're not stopping. We are trying to maintain that momentum and again I would like to thank the Green Mountain Care Board during the budget review. We've been in conversation with a few hospitals not only about consent but that has also generated more interest in them actually accessing the data themselves doing more of an integrated what we're starting to call cross-community access where they would actually retrieve the data electronically right within their EHR which reduces the burden on providers to actually sign on to a separate portal. So again thank you very much. Hoping to see you. Yeah. Yeah. I'm sure you'll agree that even though it's about 35% it's not really... Absolutely. Yes, I would agree. So thank you. Moving on to the actual data of the data again for those patients who have consented in. This slide shows you and it might be a little difficult to see with the colors. So the bottom line that green that shows the number of queries that the beehive or providers of the that utilize the beehive as well as anyone using the Veterans Affairs shows you the number of queries that are being exchanged looking for data on Vermonters. And then the top line is the provider portal the number of unique patient queries that providers are using, signing on using Vital Access that portal product. Any questions before I move on? Okay. Yeah, we just have a question on the trend when you look from March 18 to July, it was trending down and then you had a big jump just good and then trending a little bit. Where do you see that going? Why was it trending down? It does fluctuate and some of that is based on the need to actually look at patient information. You'll notice a lot of times as you head into flu season it gets a little bit more use. Other times it could be providers have transitioned out of organizations and then as their replacement comes on within an organization we provide that access so that might also impact the number of queries. The other thing that has been going on which is why you might see some drastic fluctuations is we've been taking the staff and going out and retraining providers and so based upon when those trainings get set up you might see a spike occur as they start to really understand how to utilize the system better. Does that answer your question? Yes. This is a slide, I think we showed this for the first time at the last board meeting and we'd like to continue this is really a critical part that maybe Vital has not told this story well in the past but one of the valuable aspects of getting data into the VHI is electronically sharing that again integrated into the providers EHR and so results delivery think laboratory, radiology and transcription information is really occurring background to a provider because it's being delivered right within their EHR and typically we send about 140,000 messages a month and that message may contain one or several test results so we're just giving you the message count and it fluctuates anywhere from I would say around 600 providers every month to basically get results. It's dropped a bit in September simply because we had a hospital go offline and so the hospital own practices are switching to another EHR and so we're working with them to get them back up and running when they do that switch. Sure. This is an aspect of the way of transferring information. The bigger obstacle the interoperability of the EHR system. This results delivery actually does not require patient consent because the provider who ordered the test is on that message and so we can safely and confidently provide that information directly to that provider that ordered the test. It really depends upon the organizations that say we're ready to move away from facts because they kind of, you know, they like the way that they've always been getting the information and it sometimes does take a way to change in the organization to get really comfortable with having something electronically so again a push to try and have that happen more and more and deliver more of those results. Thank you. Any other questions? So one of the other areas that HTS really focused on in their report is to reduce the number of duplicate records in the VHI. Again, we want to make the tools and the services that we use useful and valuable and there was roughly 35% of the records that are in the VHI are considered duplicate. Some of that was we needed to change our algorithms in order to strengthen that matching and also work with organizations to make sure that they're sending us robust data and then beyond that was actually going in and cleaning up some of the data that needed to be merged based on the stronger patient matching. So we're hoping to go from 35% of the records being duplicate to 21% by December by the end of December and by making a 40% reduction at the end of September when we began our testing we just missed our target we hit 33% of the records being duplicate. The good news is even though it's October 17th we are at 28.1% so we are well on the way of meeting our October target and by the end of October we're hoping that we're well into the November target of 25%. Any questions before we move on? I think that might be the last one and that is the last slide. Questions for any of the panelists from the board? I'll open it up for the public for any questions. Just like just have a question about what duplicate means does duplicate mean that if there's two records of me that are identical in which case I'm not so worried or if duplicate means there's two records of me with different sets of information that's pretty darn concerning. So all of us aren't too much of a difference. So a duplicate record the term that we would use would mean that there's a record out there that we can confidently say with a 95% confidence level or higher that patient record is really the same as another record that we see. If it's below a 95% confidence level we do not want to merge that record. Does that answer your question? Not exactly. I think the question is whether the content of the two duplicate records is maybe you don't know that but if I'm a provider and I'm looking at the patient and there's two or three of that person then you're not sure that you have the most recent or inaccurate record. Right, exactly. That's why we want to reduce the duplicate. A record in from one hospital and it could have let's say your name your address and your date of birth but it does not have a middle initial and then we may get another record which does have different clinical information the potential of different clinical information because it's been documented at a different hospital and we have your name we have your address we have a middle initial and we have a phone number and gender and we're pretty sure it's the same it's the same record we do really stringent testing in order to make sure that we are confident again 95% or higher that it is the same person before we we say that those two records are and I would say linked not merged so when a provider goes into the VHI clicks on that record they can see all of that data and who delivered that data which hospital correct right yes right right yeah you have it exactly right other questions or comments yes on the same topic this must be a perculean effort to reduce the duplicate counts and really two questions what's the ongoing continuous improvement process to prevent it from happening in the first place and then in terms of output what happens to counts of the linked and or merged records yeah really great questions thank you it's almost like you're living my world so so we've done a few things again we've been working with the data contributors to make sure that they understand the need to send us really clean data make sure that it's robust information again so that we can do better matching we're more confident we're getting that middle initial we're getting all of those relevant data points to do better matching we strengthened our algorithm it's helpful now that we've been operational for a while to be able to go in and say what data points are we getting where are we getting it from how do we change our algorithm to best match the type of data that we're getting in Vermont and we'll be back to talk about something called the connectivity criteria which is something that we will expect for organizations to utilize going forward really supporting that we get really good data and we're using part of that now in order to get the data to keep the matching going we've been working with our vendor to go back and clean up any of those records that we might have gotten in before those changes were made and we have to link them correctly we went from using a tool that we implemented wanted to really make sure it worked and now it works in the background 24-7 and we're able to actually stop it take a look make sure that everything is okay and we're moving forward in the future with that answer your question yeah great thank you other questions great thank you we'll be in progress so Emily if you could come down I'm Emily Richards the director of the health information exchange program at DBAH and I'm here to provide a sorry oh you can't hear me better is that better you know being a someone who testifies the green mountain care board really requires you to be able to project I don't think I took that lesson so sorry for those who couldn't hear me my name is Emily Richards I'm the director of the health information exchange unit at DBAH and I'm here to provide one of our bi-monthly progress updates on the progress that DBAH and Vital are making towards the requirements listed in act 187 so the focus of the update today is again those act 187 requirements we'd like to give you an update on progress made to date since the passage of that act as well as discuss the HIE plan which will be formally presented on act 187 okay so apologies for the repetition but you likely remember that these are the requirements that were listed in act 187 of 2018 both DBAH and Vital are on track in terms of meeting the requirements or the objectives listed in that act so starting from the top here is a work plan with timelines and objectives that was intended to report with an understanding of the activities that would occur over this year to implement the recommendations listed in the act 73 of 2017 evaluation report that was delivered to you on May 1st bi-monthly since May we've been also providing progress updates in written form and obviously coming in front of you as well so you receive them in May, July and September and the next one in each of those progress updates we've included updates to the activities listed in the work plan so you're sure of the detail behind progress being made towards the activities listed in the work plan and more recently Vital has provided the dashboard which they've just presented to you an additional requirement of act 187 was a contingency plan this was to be developed by a third party and triggered in the event that Vital could not meet the recommendations from the act 73 of 2017 report Capital Health Associates was contracted to do that contingency plan we discussed it in our last update and it was delivered on September 1st additionally there's a third party evaluation Health Tech Solutions the authors of the act 73 report came back and did an ongoing evaluation of Diva and Vital's progress which I'm hoping to talk to you about we're going to be submitting a health information technology plan which we're calling the health information exchange plan to you on November 1st hopefully I can provide a little bit of color on that today and then we're looking forward to our time with you on the 7th to talk about it in more detail in mid-January Diva will also be providing general assembly in the board with a consent policy recommendation the general council at Diva as well as Michael Costa have begun meeting with stakeholders to gather their input the Office of the Healthcare Advocate Vital ACLU and others so we're hoping that this is a process that engages stakeholders and reflects the broad range of opinions on that that change in policy and finally in mid-December we'll be delivering a report on how to improve the utility and interoperabilities of EHRs and HIE although you'll likely see that in the HIE plan as well okay so specific updates so since our last meeting together a couple of things have happened as I mentioned Capital Health Associates contracted by Diva completed a contingency plan so this contingency plan would be called into action if Vital cannot meet the requirements or is deemed unable to operate the V-High we're assuming that this activity is complete we will only revisit it in the event that it's necessary Health Act Solutions also completed their third party evaluation which we'll talk a little bit more about also in September we at Diva kicked off what we're calling the HIE plan road show and this was an effort to engage stakeholders in the HIE planning process make sure that folks knew what the HIE steering committee was up to what would be included in the plan and how HIE efforts would be governed going forward additionally as I mentioned the steering committee they're working to finalize the HIE plan this as we've talked about is a small group of dedicated folks who've worked really diligently over the last 10 months to come up with a consensus driven plan so that will be to you on or before November 1st and as Vital talked about we are working to finalize our contract that will begin in calendar year or excuse me January 1st of 2019 for calendar year 2019 so all of the sort of progress that you're seeing the activities that are will be listed in the HIE plan as essential the work that we've been doing over the last year will be reflected in those contracts so things like patient matching, the consent rate the security of the system all of those items will be touched on in the calendar year 2019 contract okay so the third party evaluation so as you likely recall um Act 2087 of 2018 included this language the results of an evaluation which shall be conducted by an independent entity with expertise in health information technology of the work plan, the contingency plan and the department and Vital's progress towards implementing the recommendations in the Act 73 report so HTS focused their evaluation on that work plan because they felt that the activities that we had listed were in direct alignment with the recommendations from their Act 73 report and just like you they've been reviewing our progress through the progress updates by monthly we've been sitting down with them to provide greater detail on the activities listed and some events you know they needed additional documentation or on individual activities but generally speaking they've been sort of reviewing the same progress updates that the General Assembly and Board have received so through their evaluation they found that HIE work conducted by the state and Vital is either complete or making sufficient progress so what you see in the green and yellow here are items that they considered complete and the blue are items that they consider are making sufficient progress so if you had an opportunity to review their evaluation it's pretty succinct they go through each of the recommendations with their feedback with either what the next step would be in their mind or why they deemed it to be complete and the yellow here you see that there's one item listed as complete but additional consideration required that is the contingency plan they noted in their evaluation that the contingency plan met all of the requirements of Act 287 of 2018 but if it were to be implemented they offered additional considerations around sustainability around CMS oversight and sort of just general policy considerations that one would want to take into account when thinking about making a change alright so I'm going to switch to the HIE plan are there any other questions about the third party evaluation so the seventh will be back to talk about the HIE plan at length but I did just to sort of set the stage for that conversation I did want to touch on a couple of things and just to kind of bring us back to the guiding principles that have sort of centered the work of the steering committee over the last 10 or so months as well so it's a document that illustrates the path forward for strategic vision and accountability so a lot of this plan is about creating a sense of credibility accountability making sure that the right stakeholders are at the table together and talking about how HIE should be governed invested in managed going forward so that was really essential to the steering committee sort of at those mystify health information exchange and I think we've talked a lot about this how a couple of years ago health information exchange was sort of a black box misunderstood And I think over the last few months We've gained a lot of transparency and accountability around to the work the HIE plan is written very simply very directly In an effort to engage a broad range of stakeholders in the planning process and not leave anyone out who's impacted by health information exchange Additionally the group really targeted the needs of people using the health care system And that was that is the primary focus of the HIE plan not necessarily the technology technology is a tool one of many But the important thing about health information exchange is the outcomes that we are trying to achieve in terms of impacting Health outcomes and the cost of care so the HIE plan is wholly focused on the people who use the health care system and their needs And we talked about this I think last time the steering committee really through their Assessing user needs engaging with stakeholders through use case process discerned that There are kind of four pillars of the HIE ecosystem and so the HIE plan Focuses on maturing each of those pillars there financing policy and process governance and technology and how where we are with each of Those pillars in the ecosystem how we need to mature what the ideal state is and what the challenges are and getting there and Finally the HIE plan includes sort of I'm not sort of definitely a checklist Which we are calling a tactical plan and this is to make sure that you know There's really achievable progress folks know who's accountable for what in the next annual period We can literally check the boxes and make sure that progress is continues to be made Okay, so this is a very simple timeline of next steps, so kind of in November We're going to come back here and submit the or November 1st will be submitting the HIE plan to you We'll be back November 7th ideally in December the HIE plan has approved not to influence you or anything But that would be great In January we're going to be inviting new steering committee members to join what we're calling the permanent HIE steering committee We'll talk more about it on November 7th, but the steering the current steering committee is proposing to you a governance model Works keeping the name the same in February we'll Fully establish that steering committee and in March they'll begin their work in executing their tasks listed in that tactical plan and Then next November we'll have an update to the HIE plan again So that's it for me You think That's an interesting question You know we've been able to make progress on a lot of different fronts and that would not have been possible with Without their partnership We've improved our contracting deliverables have become much more Clear to stakeholders Vitals been really key to Helping us think through strategy that will benefit the entire health care system Lending their expertise in health information exchange and the operation of the health information exchange the planning process So the partnership has been really key and you know, you can't say enough about Coming to the table and being willing to sort of do the hard work to get things done And I think you know everybody has been involved every member of the steering committee has done that including widow Which has been really great There's a lot of work to be done. I don't think that's any secret, you know Michael often says there's four key questions here when we think about sort of health information exchange Strategy first is what does the state want or need in health information exchange? The second is can our service providers including vital meet those needs? The third is our providers better off in our patients better and the fourth is our patients better off And you know, we are certainly heading on the first two Through the steering committee we and through the HIE plan. We were really I think begin to Clearly articulate what this is what the next steps are in terms of the state's needs for health information exchange We now have a clear process for holding vendors accountable for that But we still have work to do in terms of really impacting providers work and then you know, most importantly impacting the health and well-being of Vermonters I was gonna ask you about the governance model and Where that's where you're kind of landing on that, but if we're gonna hear that on November 7th, you can skip the question Yeah, I mean we will talk about it at length, but you know no secrets that you know The steering committee has and some of it is is covered in in HTS's evaluation The steering committee thought a lot about What made them successful and what made them able to come to a consensus-driven plan that they're really happy with that They feel like it's foundational to forward moving progress. So they've offered a steering committee at the center of of sort of of governance and really clearly tried to explain who has an oversight role How do we hold service providers accountable and who does the steering committee go to for advice and Expertise and that's gonna be really fundamental to their work together And what did you think about their recommendation to do a specific subcommittee about patient consent? Yeah, I feel I thought that was like a little bit of a moment of like Vermont We always say we're unique and in some cases. It's really true And so, you know, we have this group from out of state with from state Great experts have worked at the state level, but generally in larger states And so they came to us and they said, you know You really need to have ad hoc committees to support your your sort of central steering committee and everyone around our steering committee Table agreed that there are already groups of experts that we can lean on And they exist today and there's no reason to sort of exhaust the people who are already Volunteering their time on these committees. We just need to be really strategic about making sure we get on the schedules appropriately and plan our time accordingly And then I had one other question, which was I know you're only a month and a half into your road show But I was curious if what you're hearing is consistent with the survey findings in the contingency plan around Specifically around having the HIE data in The EMR and those other factors that they reported on in the contingency section Yeah, absolutely. And I mean, I think Kevin was at the primary care advisory group when we sat down with that group to talk about from their perspective from From the provider's perspective perspective What do they really want to see out of this plan and we heard a lot about frustrations with electronic health records and the desire for interoperability And so, you know, that's really rooted in I'd say like just sort of oversimplifying It is, you know when I'm a provider I want to log into my computer and have every data point that I need right in front of my face And I don't want it to be difficult or challenging to serve my patient I want to be thinking about their care over the the EHR and most of the comments that we heard were were grounded in that so if you Translate that or operationalize that that is I think what Christina is talking about, which is a direct feed into an electronic health record from the V high Thank you I don't really have a question. I just want to compliment both you and vital on the progress you've made I was introduced to this from situation a bit eight months ago and Here we are down the road and and looking at you all of the kind of bureaucratic oversight that you've been Maybe burdened with some might say but maybe it's been necessary here words I can say those kind of things now you know, but the contingency plans the twice month twice monthly reporting the having health tech come in for An evaluation and for me it all boils down now to almost two pages I mean there's a lot of work here, but it seems that you're you're on the road to where you want to go You've got the infrastructure put in place in terms of the contracts between vital and in you folks that are based on performance and if you go to pages two through four of the Final report of the health tech recent health tech evaluation You can see the shopping list and I'm certain that when we look at those 2019 contracts we will see embedded in them the the Portion of those 23 elements that haven't been completed yet, but you're clearly on the road in a very disciplined way to get there, so I plug You know what I've seen over the last eight months is that I think Kevin does as well. Thank you Thanks guys Appreciate all the work Hey, is there any old business to come before the board? See none is there any new business See none is there a motion to adjourn It's been moved in second to adjourn almost a favor signified by saying hi Any opposed? Thank you everyone and have a great rest


Gun smoke brought to you by L&M, the cigarette you want in the pack you want, familiar standard pack, and new harsh proof box. Live modern, smoke modern, change to L&M. Around Dodge City and in the territory on west, there's just one way to handle the killers and the spoilers, and that's with a U.S. Marshall and the smell of gun smoke. Gun smoke starting William Conrad, the story of the violence that moved west with young America, and the story of a man who moved with it. I'm Matt Mann, Matt Dillon, United States Marshall, the first man they look for and the last they want to meet. It's a chance they job, and it makes a man watchful, but a little lonely. Morning, Miles. Seventeen minutes, Matthew. Seventeen minutes had got to me since I sent that boy to find you. How's that so? A crime has occurred, Matthew. I'm dawdling over your breakfast coffees, not likely to bring the culprit to justice. The boy said somebody broke into your store last night, Miles. How'd they get in? Well, by breaking the glass in the back window. Two pains, four dollars and thirty-two cents to pay. You know, Miles, I told you a year ago you ought to put a grading bill with those windows like the rest of the stores and so on. No, but great things cost money, Matthew. So do burglaries. What does it take? Well, I've been compiling a list. Now, here's exactly what's missing. One blue blanket, retail price six dollars and forty cents. One blue denim jacket, size thirty-six, retail price three dollars and... The price is unimportant, Miles. Oh, to me they are. I have a certain respect for money. Yeah, so I've heard. What else is missing? Well, let me see. One hat, great respect and, of course, finest quality. Yeah, I know. I've got one, Miles. Go on with the rest of it. All right. One pair of boots, size six, untooled, inlaid with retail price twelve... Here, let me take a look at it. Yeah, two flannel shirts, five pounds clapper, bacon, three pounds of dried beans, pounds of salt, bucks and matches of stores. Looks like you've just grub-stepped somebody, Miles. I expect you to recover each and every one of those items. Oh, I'll try to. One canteen, one handaxe, two pounds of cheese and one... one forty-four-caliber cover, as well. More than sixty-three days, fifty-six dollars and eighty cents. What about cartridges? You know, I have them on a list. You know, I might have that. I'm expecting a case in today. Well, the gun won't be much use without them. Wonder if any place else is robbed last night. It happens. Now, what's the matter? Ah, here's something else that's been taken, Matthew. There were three bottles right there on that cell phone now. There's only two. Bottles are one. Yeah, perfume imported all the way from Paris, France. Now, what with a man? I could grub-steak himself one fifty-fifty and four. Maybe it wasn't a man, Miles. Huh? The size of those boots and the jacket would take a pretty small man to wear clothes like that. Oh, you mean a girl? You know, what in the name of heaven would she be up to? I don't know. She's gone. Yeah, what is it, sir? Will be joining. Somebody come into his store, help him up a while ago. What? Did he recognize it? No, sure. He stuck a gun in his back and made him go into the store room and locked the door on him. He said whoever it was had a real soft voice like a kid. Huh? Mr. Jones hadn't been to the bank yet, so at least there wasn't no cash. So... Oh, what was stolen? Nothing. Except a box of a .44 caliber cartridges. Let me smell that perfume again. Would you mind? Yeah, sure. Can I hear? Mm-mm. Not any scent, I know. But I sure like to. You say Miles has got two more bottles of it? Ah, I got this sample from one of them. Well, there's nothing like this around, Dodd. Couldn't be too hard to track down. Yeah, provided the person who stole it opens the bottle. Well, I'll keep sniffing the breeze, Matt. That's what we've been doing all day in this city. Sniffing and smelling around all over town. It's like a couple hounds. But we ain't caught a goof of this stuff. I wouldn't be likely to catch this. Matt, maybe this girl, if it is a girl, is already left town. Well, in a way, I kind of hope so. She might have wanted the gun just to protect herself. She wasn't protecting herself when she shoved it and willed Jonas back this morning. I know, but it wasn't... It was empty, then. It's not empty, no. Well, by God, I was just wondering who I'd let buy me a drink this evening. Yeah. As far as I'm concerned, Doc, you're still wondering. Oh, man. Well, good evening, good evening. Oh, hello, Doc. Hello, Doc. Oh, say, I understand somebody barred a few things off an old man in a tag last night. Yeah, they did, Doc. Oh, they did, eh? Crime rampant and the local law and Habitat Halloween. Here, Doc. Smell this one. Huh? Oh, yeah. Say, what do you do, Matt? Put it on your hair or use it when you shake it?  Slightly familiar. Huh? What do you mean, slightly familiar? Well, I mean, I smelled the same thing earlier today somewhere. Today. Where, Doc? Where was it? Where did you smell it today? I don't even remember. Say, Matt, what do you say we get up a coke a day? Doc, would you think where did you smell this perfume today? I don't know, let me see now. I was all over town at one time or another. It wasn't at the literary table, naturally. Or at the bank. Oh, I'll forget it, man. I don't have the slightest idea. Uh-oh, uh-oh, uh-oh. Wait a minute. Now, I don't remember. Yeah? I was talking to Mr. Dobie in the lobby of the Dodge House. And this kid was doing it. The Dodge House, huh? That's right. He leaked of the stuff. Yes, that's where it was. He rented himself a room there. But why? I'll tell you later, Doc. Tell him, come on. Okay, Mr. Dobie. Yeah, be careful about water.  Or two will, or a week ever? I don't know. All right, go ahead and knock. Let's get clear before the door opens up.      You're under arrest. What? Just a minute. Back the car. All right, get back in the room. I know you've got my whole hotel stirred up. I ain't got nothing. You've got no call to arrest me. Inside, I said. John, he wasn't like this. Dylan, it is, is it, girl? It reminds me of my own business. Who are you, anyway? What? He's a U.S. Marshal. That's who he is. A Marshal? Where did you get that shirt you were in, Miss? In the boot. What about this gun? Where do you think I got it? I don't think. I know. Now, what's your name? My name's Willie Deager. And I'm from down around O.S. Johnson. Really? What kind of a name do you have for a female? I just checked your tater's license.  Why did you break into that store last night? Who says I did? The closure where I met Stefan on the bed over there. The stuff all over this room. Every bit of it was stolen. How'd you figure it was me, Marshal? That perfume you took. Doc Adams was down in the lobby when you rented your room here. He smelled it on you. I guess I know that person who's gonna bring bad luck. There are other things I needed. Except for the person I just wanted. I've never had none before. I've only used stout men. I've just heard about it. What are you doing right away from home? I ain't running. I already run. You would have dragged me with wild horses. I wouldn't go back there. Why not? You know my step why you wouldn't ask. Why not? Work. Work a body to their death. That's all he knows. He's got a dry farm down here. He ain't never gonna be working nothing no matter what. He'll work day and night just like a man. I ain't never even owned a drill. I don't believe he's going in for frills. Yeah, I see. Last time we'd done it two days ago, I just lit out. Did you get bruised inside of my head? Yes, we will. Oh, brilliant. You make a move, Marshal. And I'll blow this stellar backbone clean through his belly. I'm not moving. My back off now, Mr. Aways from the door. I didn't run away from home just to end up in no jail. Where are you going to end up, will you? Never you mind about me, Marshal. Now you two just stay put. Oh, I'm just... I'm awful selling this to you, aren't I? I didn't have no idea what he's up to. She doesn't lay there, Justin. That's her trouble. I'm a darn fool, kid. Yeah, a darn fool, kid. With a loaded gun. Let's see now, Matthews. This shirt's not being worn. Won't have to discount it, at least. Now the same goes for the skillet, Marshal. And the blanket, canteen, and axe. It's gonna be be when you hear, Mr. Kye. No, just hold your horses, you two. I'll get the way this piece. No, sir. Wait a minute. Now, man, can't calculate this profit without knowing it first. Uh-huh. I knew some of it was gone. I think about 20 cents worth of that corner is... 22 cents. Well, at least she didn't have time to eat any bacon, Marshal. Yeah, it's about the size of it. It's always found in her room. Yeah, it was just the low-priced items, Matthews. You still got away with a $12.50 pair of boots? He hasn't gotten away yet, Marshal. We'll find it before the night's over. We know what he looks like now, at least. And we know her name. Willie Beaver. Hey, there's homestead or style, you say? Yeah. Dry-farmed on tortoise eggs. I think that's too much work, I guess. And too little of anything else. Might be hard-living, dry-farming. Doesn't play much of anything to speak of? Not much. Matthew, look, if you catch her, and you get back those boots and that gun and the other items, well, what do I mean, Matthew? She can keep that perfume if she wants it. Well, evermore. I couldn't have said it anyway if she's used some of it. Yeah, sure, Marshal. You have tires? A jar of wandering around the lawn? Well, come find it. Don't just stand there staring at me. I'm not staring at you, Marshal. Just listening to you, that's all. Oh, I'm working like a cat in a birthday. I told you that perfume isn't saleable, now.  Healing from honest dog-deering folk? Violating private dogs? All right, Marshal, all right. And if you get that gun and the other boots back, and if it does not hurt any, then you're done on jacket, too. Well, I'll give that child a dress, right out of my stock. My land of wishes. Well, it's not a matter of sentiment. No, it's just that it isn't fit for a young girl to go into court dressed like a man. It's no decent. Yeah, sure, sure, Marshal. I know what you mean. Just a proper respect for appearances, that's all it is, isn't it? Oh, I'll confirm the both of you. You're trying to accuse the man of charity when he hasn't done anything out of it in his entire nature. Well, I'll give it back to your pig office, haven't I? Yeah, come on, Chester, let's find out. So, helping, Marshal, I didn't know. I didn't have a least-eyed desire. It wasn't your fault, Jason. Now, Chester, you sent somebody to find Doc. Yes, we did. The Dyson boy went second, Mr. Dyson. The node was a girl that just opened the safe and didn't let her have the money. I wouldn't have shot no girl. Not if I'd known. You couldn't have been expected and not just a girl. It's been bent over, faced, dressed like she was, pointing that gun just as rough today as any man I ever seen. Yeah. And you know, I always keep my gun stuck right between the safe and the desk, just facing something like this. So, I made like I was going to open the safe and... Are you sure, Marshal? Are you sure she'd keep this? Yeah, I'm pretty sure. The killing is good. I never done nothing so bad in my whole life. No help, Marshal. I didn't know. Look, anybody else would have done the same thing, how it couldn't be helped. You're done blaming yourself more than do it.  I reckon maybe I'd better. I reckon I'd just get outside a while. Hold this. You woke up pretty bad over there. Yeah, I guess most anybody would be. You're done, you poor young man. How she paid for it? There's no point leaving her there on a dirty floor. Let's lift her up on the counter. All right. Let me get her shoulder. You know, she wasn't fine. She has got a bruise on her head. I guess they're poor dead theater, all right. Poor little thing. All right. Let's lift her. Oh, what's that fellow on her jacket? Must be on there. Yeah, I know. On the frontier, even the roughest of Nestor families had to scratch awful hard to tear a living out of the dry, parked earth. Yet next week, a lone ranch woman has to kill the one person who might have helped her. Gun post. Produced and directed by Norman McDonald, stars William Conrad as Matt Dillon, U.S. Marshalls. The story was specially written for Gunspot by Les Buckfield with editorial supervision by John Messon. The music was composed and conducted by Rex Corey. Sound patterns by Tom Hanley and Bill James. Featured in the cast were Ben Wright, Sammy Hill, and Lauren Stumpkin. Harley Bear is caster, Howard McNeer is doc, and Georgia Ellis is kidding. We are proud to announce that Lex Corey won the annual Downbeat Magazine Award for the Best Original Scoring of a Regularly Scheduled Radio Series as musical director of CDS Radio's Gun Smoke. Join us again next week for another story on Gun Smoke. This is the CDS Radio Network.