IHS Health IT Modernization Listening Session - January 15, 2021

IHS Health IT Modernization Listening Session - January 15, 2021

Show Video

Jennifer Gillissen: Welcome to the Indian Health Service information technology modernization project. My name is Jennifer Gilson with Kauffman Associates and I will be your facilitator today, and I'd like to welcome Mitch Thornbrugh from IHS Mitchell Thornbrugh: Thank you very much, and good afternoon everyone and maybe good morning for just a few of you on the west coast and Alaska. Welcome to the Indian Health Service Health Information Technology modernization project listening session for January 14 this. Is this the second and final Jonathan Ferguson: listening session related to Mitchell Thornbrugh: The dear tribal leader letter that was sent out soliciting feedback from our tribal urban and federal stakeholders in December. Mitchell Thornbrugh: I do want to mention, though, while we're soliciting the this is the second and final Mitchell Thornbrugh: listening session we continue to have open consultation and the urban confer regarding modernization itself. And so we do anticipate additional listening sessions on other topics as we move forward. But we are preparing to receive that feedback by January 24 regarding any

Mitchell Thornbrugh: Feedback associated with the approach that I just may take to the modernization project. But before we get underway. I want to turn it over to Mr. Jeans RAL for an open prayer. Mitchell Thornbrugh: Mr Sorrell. Anna Whiting Sorrell: that's put on a suit and grandfather creator, we give you honor to allow us that they can participate. This day give you thanks that you grant us just day to day we continue to strive to work in bless our families, in our lives. Anna Whiting Sorrell: We ask God creator Anna Whiting Sorrell: And a great spirits to be with us watch over us take care of us. Anna Whiting Sorrell: Take care of our families and all of our loved ones, take care of the world grandfather creator that you have so pleasant and they given to us. Anna Whiting Sorrell: We ask that you we honor you and protect you and ask for your protection for us, but he's prayers and all of our prayers grandfather creator, I offer to you.

Jennifer Gillissen: Thank you, gene. Jennifer Gillissen: So we do have a couple of technical notes for today. There are two icons located towards the bottom part of your zoom screen. One is the chat bubble, which can be used to interface with folks in the platform. Jennifer Gillissen: For questions and comments. The second is the start video so we can see everyone on camera all phone lines have been muted. If you need technical assistance. Jennifer Gillissen: During the webinar, please type, the issue into the chat box and one of our texts will respond to you. Please note that the webinar is being recorded. I will turn it back over to Mitch

Mitchell Thornbrugh: Thank you. And again, my name is Mitchell Thorn brew. I'm the Chief Information Officer for Indian Health Service and I'm a citizen of the Muskogee Creek Nation. It's a pleasure to be here again with you today, virtually Mitchell Thornbrugh: A lot of activity that is ongoing related to the coven pandemics so appreciate everybody's attention and time on this important topic. Mitchell Thornbrugh: Regarding the modernization of our health information technology infrastructure. I know how. Everybody is busy right now providing care in their communities and supporting

Mitchell Thornbrugh: Just all the various activities across the country. So again to appreciate everybody's attention to this and your, your input during the meeting. Mitchell Thornbrugh: This is really a great opportunity to hear the feedback and questions directly from our Tribal and Urban stakeholders. And so we really value. This time, and we're going to spend about 20 minutes 25 minutes Mitchell Thornbrugh: Giving you a quick update and some background, but we will leave the majority of the meeting to hear directly from you. Mitchell Thornbrugh: And right now the IHS vision is on the on the screen. We like to start our sessions. Keeping that in mind that we want to have healthy communities and quality healthcare systems through strong partnerships and culturally responsive practices as our vision. Next slide please. Mitchell Thornbrugh: And as an to reinforce the IHS strategic goals and objectives. Mitchell Thornbrugh: And some focus on Objective three dot three with the modernize information technology information systems to support data driven decisions and obviously having a modern Mitchell Thornbrugh: Mature Health Information Technology Infrastructure is extremely critical and we're seeing that every day as we leverage our electronic health records, our health information exchanges various data reporting systems to make sure that we can Mitchell Thornbrugh: Manage the pandemic and improve outcomes for our patients and our communities. So I think now more than ever. The, the need for modern Health IT infrastructure is at the forefront of everybody's mind. And so I'm happy that we're talking about this at this time. Next slide please.

Mitchell Thornbrugh: So just a couple of brief updates and we're going to hear from mitre a little later, but want to make sure everybody understands that Mitchell Thornbrugh: IHS has partnered with the mitre FF RTC and the FTC is the federally funded research and development corporation and this particular FF RTC is managed under Mitchell Thornbrugh: The CMS under the innovation center. So just wanted to make sure that we highlight that partnership. We're really excited. Mitchell Thornbrugh: With the level of expertise from across the industry that being healthcare government and experience with the VA do D implementations for their own modernization. Mitchell Thornbrugh: Just really excited about the level of expertise that miners able to bring to help us start up our program management office again the program management offices that critical first step to managing a program and project of this size. Mitchell Thornbrugh: Also wanted to provide a brief update on the interoperability pilot. So in the FYI 2020 funding, there was a request.

Mitchell Thornbrugh: To to prove out our interoperability with the VA do D as well as our travel partners. And so we did launch the four directions hub. Mitchell Thornbrugh: To be that interoperability pilot, as well as a potentially legacy data solution. Mitchell Thornbrugh: And that's currently being piloted for a health exchange with connectivity to the VA do D and the and in really any of the Office of the National Coordinator or OFC certified commercial EHR. Mitchell Thornbrugh: That pilot is ongoing. But we've had lots of success there and we're beginning. Some of the point to point. Testing directly with the VA. So we're we're excited where that's headed

Mitchell Thornbrugh: Also wanted to announce that we've had a lot of discussions and close partnership with the firm and the Federal HR management group is the VOD and VA. Mitchell Thornbrugh: Shared body and that gives us a direct line of communication regarding their project status updates lessons learned and also the ability to coordinate any of those Mitchell Thornbrugh: Established methods that they've they've produced. I also want to highlight that the final report and technology roadmap were published Mitchell Thornbrugh: In 2019 and the link to that is in the presentation for your reference as well as articles and artifacts from the HHS IHS health IT monetization research project that concluded last year. Next slide please. Mitchell Thornbrugh: Before I talk about funding. I also did want to announce that in December, we were able to recruit and select Mitchell Thornbrugh: The chief medical information officer for Indian Health Service. And so I'm happy that

Mitchell Thornbrugh: To announce that we selected Dr. Howard Hayes for that position. And so we're excited to have that critical position filled as well. Mitchell Thornbrugh: But with that want to talk about our current funding, just to reiterate, an FYI 2020 we were appropriated $8 million. The cares act of 2020 provided additional 65 million Mitchell Thornbrugh: To help accelerate the program and then our FYI 2021 funding levels have been finalized at 34 and a half million. So we'll update this slide, but since our last. The last time we talked the F5 2021 appropriations have been finalized. And again, that was at $34.5 million. Next slide please. Mitchell Thornbrugh: And with that, I will turn it over to Sarah Gilmore to hear from the miter FF RTC april kaplan: You're going to turn it over to April Kaplan from the Fr. april kaplan: There and I it's there and I work super closely together. Thank you everyone for being on this call. I'm April Kaplan, I'm a senior staffer with the MITRE Corporation

april kaplan: That is partnering with IHS on this project, and it is an honor to be part of this this effort. I just wanted to take a moment to just explain what the FF R DC is and why we are working with IHS so mitre is I chest is and HHS is federally funded research and development center so we april kaplan: Work on behalf and alongside the federal government's so we are not a traditional contractor. april kaplan: In the way that most people think of contractors. We sit on the same side of the table as the government to work on their behalf.

april kaplan: To improve and provide programs and services that benefit you know the benefit that populations that are served by HHS agencies. So we were created by government for government we address problems with key challenges in this particular case it's the modernization it modernization efforts. april kaplan: And we have brought on multiple partners, which I'll explain in our next slide, who we brought on to help this april kaplan: But we provide innovative and cost effective solutions for government problems. And like I said, in this particular case, we're talking about the it monetization. april kaplan: Setting up a PM. Oh, developing and governance structure and helping on the interoperability all things that might or has worked across each agency and other federal agencies to help do april kaplan: We don't develop any commercial products, anything we work on with the government is owned and is the government's property. We are a nonprofit we function as a nonprofit as an independent private nonprofit, which allows us to bring in other stakeholders. We work with a variety of april kaplan: We work with april kaplan: Federal government, primarily, but certainly and tribes are responsible for implementing programs and policies and certainly are the ones on the ground that see that programs, policies through and see the impacts of that. april kaplan: And I'm talking quickly with my new york voice because then we want to definitely hear from all of you, but by all means will would love to hear any questions you have about mitre as we move forward. But I'm going to move to the next slide.

april kaplan: Because I want to take a moment to talk about who's part of this effort. So why mitre has great expertise on a lot of issues. We don't claim to be the experts on everything. april kaplan: No one entity is the expert on everything. And so we have the privilege and honor of working with a series of alliance members and that's a pretty vast group of april kaplan: organizations that we work with. But in this particular case for working with it. I just modernization. april kaplan: We've brought in Grant Thornton Kaufman and associates and safety net operational solutions and april kaplan: They don't necessarily need to read directly off the slide, I think it is important to emphasize the variety of expertise that the that the group has that we're bringing to the table. april kaplan: Because doing the it monetization. It's very important that we understand, you know, obviously the operational pieces, but we also understand the cultural

april kaplan: And health impacts truly on the ground and tribal communities. So why mitre has a lot of expertise. Like I said, Grant Thornton brings operational organizational transformation and certainly healthcare background. april kaplan: Kaufman and associates brings organizational transformation as well, but a great understanding of Indian country and the reach of working in Indian country which is really important. april kaplan: And safety nets operations solutions bring health data, information technology table and community and health IT experience as well. So why we have some cross cutting

april kaplan: Expertise we each also bring some very unique expertise to the table as well. And these partners, along with april kaplan: input from tribal communities and IHS and other federal agencies and lessons learned from past experiences with other federal agencies. april kaplan: Makes it a really good group of folks to work with. And now I'm going to turn it over to Sarah let her finish out explaining mitre and who we are and what we what we bring to the table and then certainly will, will entertain questions. So Sarah, it's all you. Sarah Gilmour: Thanks. April. Thanks, Mitch.

Sarah Gilmour: Good afternoon and good morning to those of you where it is. Morning. Sarah Gilmour: My name is Sarah go more and I am very honored to serve as the project leader of the collection of teams from the wider perspective as well as our alliance partners, a leading this effort. This I wanted to share with you a little bit about Sarah Gilmour: The, the cross section of expertise from a little different perspective than was shared Sarah Gilmour: On the previous slide that April mentioned we we recognize Sarah Gilmour: That this is a Sarah Gilmour: Very important. And we're honored to be a part of this endeavor with I chess and the broader community to support the HIV modernization initiative. Sarah Gilmour: And we we recognize the that this is more than just an EHR implementation and there is a broad set of expertise needed we've collected composed a team with quite a wide variety of experience. Sarah Gilmour: And in healthcare in it in acquisition with relevant EHR implementation experience, but also with knowledge of Sarah Gilmour: Data and interoperability and some of the other ancillary support services that really make the delivery of Sarah Gilmour: A unified healthcare system.

Sarah Gilmour: It will operate together. It's, it's not just a single dimension and for that purpose we are bringing to bear quite a Sarah Gilmour: Variety of expertise. So we can not only understand what you need to do for healthcare delivery in the enabling technology, but what it means in your environment, given how you have facilities across Sarah Gilmour: A chest, the tribal communities and the Urban Indian organizations, we also recognize the impacts that health policy have on enabling technologies and that the targets of Sarah Gilmour: Enabling or improving health outcomes. So that is another area of expertise that we believe is important to for for planning and adding to the foundation that has already been set, excuse me for the, the, the program. Sarah Gilmour: As Sarah Gilmour: as was alluded to. We've. We do have some experience from God and VA implementations as well, but also we have Sarah Gilmour: folks that have either worked with healthcare systems. Sarah Gilmour: That are across the nation Kaiser Permanente, as an example, but also folks that have have helped with implementing Sarah Gilmour: Cerner for the Alaska Native Sarah Gilmour: Population and folks that have worked in various health care systems across the country. So physicians, as well as

Sarah Gilmour: systems engineers and technologists, who have supported different health system and health IT implementations. I myself have a background in Sarah Gilmour: A wide range of systems engineering ACQUISITION PLANNING Sarah Gilmour: A large program enterprise program planning, as well as applying technology in the healthcare domain, as well as other domains financial services. Sarah Gilmour: Other civilian agencies such as Department of Homeland Security and logistics systems so Sarah Gilmour: I look to bring all that to bear along with the team members to help you innovate and bring the right solution to meet the multifaceted needs for IHS. Next slide please. Sarah Gilmour: And just to Sarah Gilmour: highlight some of the work that we're doing as part of partnering with all of you.

Sarah Gilmour: We are look the we are organized and standing up the program management office as Mitch mentioned to take those next steps as outlined in the roadmap that was presented in Sarah Gilmour: Lots of great work was was has already been done to set that foundation and we are excited to take the next steps with first and foremost standing up the program management office. Sarah Gilmour: And the appropriate operation management operations to execute monitor and communicate the status of the program and how we're proceeding. Sarah Gilmour: Another the second task areas around governance and setting up the set of Sarah Gilmour: Bodies that will work together to support decision making collected advice collect input, make sure that we have the right forums for looking Sarah Gilmour: Across the whole landscape of needs and having those represented as we go forward. The third task area is around acquisition and program planning to make sure the right products and services are acquired in alignment with the the decisions made, and Sarah Gilmour: The plans that are outlined based on the approach that is it, everyone is in agreement with moving forward. Sarah Gilmour: The last. The fourth area is around

Sarah Gilmour: More of the engineering and architecture, the analysis and planning to get all those pieces and the necessary specifications, how they interrupt rate together. Sarah Gilmour: To make an effective integrated solution of the enabling technology to modernize and improve the health outcomes. And then the fifth area is around organizational change management, which includes stakeholder engagement and communications to make sure we are effectively. Sarah Gilmour: You know, understanding in in the needs and the impacts that the changes are going to have on Sarah Gilmour: The whole community at the various stages in the life cycle from new ways of thinking about how we work together for a unit to to again. Sarah Gilmour: Look at ways to unite and find some commonality that can be leveraged that this community has done that in many different ways. And as an exhibit of that and we want to continue to build on that.

Sarah Gilmour: And also as new capabilities are introduced, making sure that Sarah Gilmour: People have the right training and understand Sarah Gilmour: What is Sarah Gilmour: How to use new technology and what the impact is new things and change we we experience it every day but also Sarah Gilmour: Sometimes it's human nature not always to be ready for that change. So our goal with that task areas is to help with that readiness and prepare folks for any changes and impacts. Sarah Gilmour: That the new capabilities will will provide. And that's a quick summary. Again, thank you all so honored to be part of this, and I will turn it over to Mitch Mitchell Thornbrugh: Thank you, Sarah, and thank you, April for for Mitchell Thornbrugh: That overview. I want to start off by talking a little bit about the high level timeline, just to set expectations.

Mitchell Thornbrugh: This is the same timeline that we established during the modernization research project, and it really just to set that expectation that even with an aggressive schedule and and timeline for some of our, our deliverables, it's still going to be towards the end of FYI. Mitchell Thornbrugh: And possibly into FYI. Mitchell Thornbrugh: Before we would see a site or any initial capacity converted to a modernized Mitchell Thornbrugh: Health IT infrastructure or replacement for the RPM s infrastructure. So just wanted to set that high level timeline. That's one of the most common questions and and we're right now in the, in the middle of establishing that P mo.

Mitchell Thornbrugh: Getting the acquisition plan together as well as moving the project forward in the five task areas that we just heard about from the monitor team. So, next slide please. Mitchell Thornbrugh: So the modernization research project identified for high level approaches to how I chess and tribes, can an urban's can approach the modernization. Mitchell Thornbrugh: And the first one stabilize our PMS is really almost a prerequisite, at some level, recognizing this will be a multi year project. Mitchell Thornbrugh: And not everybody will convert it once that we still have a long road to support the existing our PMS infrastructure and we want to make sure that the thousands of users and millions of patients that rely on our PMS.

Mitchell Thornbrugh: For high quality care have the level of support they need so we will be looking at making those logical enhancements. Mitchell Thornbrugh: Doing the things that prepare our PMS on our sites for a transition to a modernized infrastructure and That activity generally follow falls under that stabilize our PMS approach. So just wanted to highlight that that portions of one have to be addressed because of the multi year Mitchell Thornbrugh: Approach to the project. The second I'll approach is to rewrite our PMS. And so that's to take the code and rewrite those legacy Mitchell Thornbrugh: That legacy software and create the, the new functionality and modern nice infrastructure that we need based on a rewrite of our PMS.

Mitchell Thornbrugh: The third approach as a selective replacement where you take portions of approach. Number two, you obviously wouldn't leave the, the old Mitchell Thornbrugh: legacy code in place, but you do modernize portions of RPS and augment that with commercial solutions and the fourth approach is a full replacement of the core infrastructure. Mitchell Thornbrugh: Or the core replacement of the RPM s code base with a commercial software to do those functions. So those are the, the four high level approaches. Mitchell Thornbrugh: That I chess will have to make a decision on how we will approach modernization and this is where we're looking for feedback from our tribal urban and federal partners around Mitchell Thornbrugh: thoughts and questions around those approaches. And so with that, I think we'll open it up for questions at this point. Jennifer Gillissen: Thank you. I you can enter your questions or comments into the chat or you can unmute your phone line by clicking the microphone at the bottom left corner of the zoom interface and you can go ahead and ask questions.

Stewart Ferguson: Mr Ferguson. Can you hear me okay Mitchell Thornbrugh: A story. Yes, I hear you. Stewart Ferguson: Hi, Mitch. And so I want to commend you guys this is this is of course a giant, giant project and the years in the making and will be yours in the building. Stewart Ferguson: I think the question that I have is. So you mentioned that it would be the end of FYI 22 or into FYI 23 before you start to see a build. Oh. Stewart Ferguson: So you know as tribal organizations, what can we expect to see happening this year and probably more importantly, how are you going to engage tribal partners to make sure that we're feeling included and unable to share not only our experience, but our but our needs, going forward.

Mitchell Thornbrugh: A stir a great question and that. Thank you. It's good to hear from you. Of course, Stewart, you've got lots of experience and Alaska and have done much of this work yourself so you know that's one of the key. Mitchell Thornbrugh: Strengths that I think I just has is with our travel partners who have led and this area. And again, we want to make sure we leverage the leadership that tribes have already shown Mitchell Thornbrugh: And really learn from the the pads that have been blazed by your leadership and other leaders across the country as they've moved forward with modernizing infrastructure in their tribal communities. And so, you know, we're not expecting to have Mitchell Thornbrugh: Conversions until late Mitchell Thornbrugh: Early Mitchell Thornbrugh: We do anticipate the build will start in earnest. At the end of this year and be completed through you know the end of July 2021 through 2022 depending on Mitchell Thornbrugh: The approach and the acquisition package and solutions you know will obviously dictate some of that build environment. But what we learned

Mitchell Thornbrugh: From the industry from our tribal partners and those with experience doing this is that can be anywhere from 12 to 18 month build process. And so we want to make sure that we have adequate time to do that. Mitchell Thornbrugh: And so really the timeline is to help set that high level expectation of you know why that takes so long. So not everybody Mitchell Thornbrugh: That has has done this work may may realize how much work is involved with building that infrastructure. Mitchell Thornbrugh: But, but we wanted to recognize that. And so the timeline just recognizes that and again that by 2022 is when we're at the end of FYI. Mitchell Thornbrugh: When we're hoping to start initial capacity or pilot sites, you know, with the modernization. I shouldn't say pilot sites, but those initial sites. Mitchell Thornbrugh: To come to convert from RPM as to whatever the modernized solution is. And as you can see from the approaches you know there's not an approach that doesn't include some sort of conversion. So we know that conversion and go live is going to be a part of that plan, regardless of the approach.

Mitchell Thornbrugh: As far as the in making sure that we have tribal stakeholders included, we're going to continue, as I stated at the beginning to have additional listening sessions on various topics that we continue to have open Mitchell Thornbrugh: tribal consultation and urban confer on the modernization topic as a whole. And in general, and so we do anticipate additional outreach there. Mitchell Thornbrugh: But will also continue to reach out to our stakeholder groups that were established under the modernization research project and so Mitchell Thornbrugh: We have the information system Advisory Council which you and some other technology professionals set on to help make recommendations to the director about technology and so will continue to leverage that body as well as the Mitchell Thornbrugh: direct service tribes Advisory Council, the tribal self governance Advisory Council and the urban groups, you know, in addition to that, we have lots of stakeholder groups across the country with the on the federal side with the NC CMO or partner NCC councils. Mitchell Thornbrugh: And so we'll continue to interact with them as well as making sure that we're meeting with our area directors. Mitchell Thornbrugh: To make sure that we're field any questions that may be coming up through them and providing them good information to share and local and regional meetings as well. So it'll take a lot of effort. Mitchell Thornbrugh: To keep that engagement high, but that is our desire and we think we've set the demo and the associated tasks and the work plan to address that.

Mitchell Thornbrugh: But we do know that it's a pretty rigorous path. And we know from the modernization research project that you know the many of the stakeholders will be meeting with quarterly Mitchell Thornbrugh: And and while that doesn't sound like very often when you multiply that out, we end up having, you know, half a dozen meetings, a month where we're providing updates and to various groups. Mitchell Thornbrugh: As well this moves forward. Mitchell Thornbrugh: So that answer questions through it. I couldn't ride as fast as you were asking that question. Stewart Ferguson: Well, I appreciate it niche and thank you. Yeah. And I'm just like to say that, you know, I know that folks in Alaska and in many other places I've experienced with moving to Stewart Ferguson: To a costs EHR would would really like to participate because yeah we we do feel it with a lot of experience. So I appreciate you, including us. Thanks.

Jennifer Gillissen: Thank you, sir. We do have four questions in the chat box. The first one is, how will the selection process work for sites that want to be involved with monetization process. Mitchell Thornbrugh: So the, you know, once we make a decision on an approach, we will develop an acquisition plan to meet that goal. And so when we talk about a selection. Mitchell Thornbrugh: Typically what we're talking about is from a federal standpoint, you know, the Federal system will have to make a procurement. Mitchell Thornbrugh: And that could be water or a host of solutions, depending on the approach. And so it's really that acquisition plan. Mitchell Thornbrugh: That will determine what that selection will look like. And that will be a very inclusive process. The last thing we want to do is to have a small group of people select, you know, an EHR. Mitchell Thornbrugh: But through that acquisition plan, we will have an appropriate level of engagement with our federal and tribal stakeholders to make sure that their voices heard about priorities functionality.

Mitchell Thornbrugh: What's most important in the way that we approach it. But, you know, regardless of the the system that we select this is really an opportunity to address the way we support. Mitchell Thornbrugh: Health IT ACROSS THE COUNTRY. So there's opportunities for us to improve the stability of whatever solution we have through how we design those support models. Mitchell Thornbrugh: Making sure that we have adequate levels of training and and honestly, making sure that we have adequate levels of financial support.

Mitchell Thornbrugh: That it takes to run a modernized health IT infrastructure and we know that that's different than what we have Mitchell Thornbrugh: currently deployed for the resource patient management system and so that we do hope that this becomes an opportunity to address long standing needs for additional staffing support and systems in a way that improves the stability and coordination of care across the country. Mitchell Thornbrugh: Thank you for that question. Jennifer Gillissen: Thank you. We have another one is, how can this process also work at modernizing tribal HMT platforms and infrastructures, or is this part of the current package. Mitchell Thornbrugh: Thank you for that question. So as we stated earlier, and we heard from Dr. Ferguson, who's already modernized in Alaska. Mitchell Thornbrugh: We, you know, we understand that the the landscape is a moving target for modernization and it has all the complexities associated with tribal self governance and 93 638 regarding choices that tribes may take to Mitchell Thornbrugh: modernize their own systems and whether that's to reuse our PMS, or to go off and and use commercial off the shelf software using their own funding sources and so Mitchell Thornbrugh: We're really taking a holistic look at what that means for IHS. And so we're looking to build the modernized infrastructure around data.

Mitchell Thornbrugh: Care coordination and health information exchange rather than a single EHR. Mitchell Thornbrugh: So we do contemplate that our travel partners have already invested in commercial solutions and we want to enhance that investment and not detract from that investment. Mitchell Thornbrugh: And with that being said, there are also partners who rely on us to make sure that we provide appropriate high performing Mitchell Thornbrugh: Health Information Infrastructure. And so we really have to balance the way we approach that

Mitchell Thornbrugh: And so again, I would say that we're focused on a data centric model where the electronic health records sets on the periphery of that model. And is it a peer level. Mitchell Thornbrugh: With our partners and so Indian Health Service we envision needs to operate select and operate and enterprise EHR in a way that's efficient and effective and can stabilize our current models. That being said, we understand that tribes. Mitchell Thornbrugh: Can make their own choices or have already made their own choices about electronic health records. And so we wanted to make sure that that their choices considered a pure level in the infrastructure. Mitchell Thornbrugh: So they. If we select an epic or an action or whatever. The solution is. But that doesn't devalue what our partners have had selected. Mitchell Thornbrugh: But it also creates opportunities for for tribes who partner with us directly and leave their chairs to either use the solution that we Mitchell Thornbrugh: Set forth or are able to move forward and select their own solution depending on the recurring funding levels and monies that might be made available. Mitchell Thornbrugh: Through the federal budgeting process as recurring dollars out to tribes. So, very good question. I hope I touched on the high points for that.

Jennifer Gillissen: Thank you. So the next one is dependent because right into our need to have a better functioning EHR tribes that are still on EHR aren't receiving the IHS support needed to continue to provide good care. Well, there will be additional support for those private programs and phase one. Mitchell Thornbrugh: Yeah, absolutely. So when we talked about stabilizing RPM, so that you know your question really gets to the heart of the challenge. Mitchell Thornbrugh: And that's recognizing that the pandemic is pushing the limits of our current infrastructure and it's it's Mitchell Thornbrugh: exacerbating known issues. It's highlighting new issues and we have a great team that's working very hard to stabilize that our PMS system. And we've seen Mitchell Thornbrugh: You know patches come out recently well over 100 patches in the last year and enhancements to those solutions, but most importantly Mitchell Thornbrugh: You know, we were able to deploy the 2015 certified health IT Mitchell Thornbrugh: Package for RPM. So that was an important milestone again signaling our pursuit of quality reporting and the support industry standards around how an EHR should function.

Mitchell Thornbrugh: But additionally we had packages and releases associated with being able to report vaccine administration that work is ongoing, to be able to report testing as required from HHS, the MS and others. And so we know that Mitchell Thornbrugh: Why that's important for us to keep stabilizing our PMS front of mind and specifically, we know that the level of support that an individual site has varies widely across the country. Mitchell Thornbrugh: The way the the RPM system is distributed and and managed and supported across the country creates lots of opportunities for individual vacancies to really Mitchell Thornbrugh: Be stabilize the way our PMS runs at specific locations. And so we're trying to overcome that, with additional training with additional enhancements that will reduce the overall support burden. Mitchell Thornbrugh: You know, automate as much of that support as possible as far as configuration and interfaces. But overall, we will have to come up with a robust RP MS stabilization plan to make sure that we're addressing that over the next, you know, Mitchell Thornbrugh: Seven or eight years while we have thousands of users and millions of patients relying on our PMS. Jennifer Gillissen: Thank you. So we have a

Jennifer Gillissen: Comment as well as question and it's a two part. So I'm just going to read all of it to you. Jennifer Gillissen: I would like to hear how tribes are going to be involved in the project management, particularly those sites still on our PMS. Jennifer Gillissen: This is you need to be a do D and other conversions in that tribes operate over 50% of the agency. Jennifer Gillissen: We are not stakeholders. We are governments and partners on this and just to elaborate, it is not simply a communication slash answer questions effort tribes need to have a participatory role and decision making as a project implementation forward. Mitchell Thornbrugh: Yeah, thank you for that question. I see that that came from Miss Melanie for killer so appreciate that the way that question was asked. And you're absolutely right.

Mitchell Thornbrugh: With tribes operating significant portions of the infrastructure, you know, we do need to find a way to address that from a project management standpoint, we are creating the charters now. Mitchell Thornbrugh: And we're looking at opportunities for not only tribal stakeholder engagement. But how do we bring those Mitchell Thornbrugh: thought leaders those experienced professionals across the country, whether they're in a tribe and urban or a federal setting to make sure that we have the strongest team possible to help make these decisions.

Mitchell Thornbrugh: So this does come down to some Federal procurement activities. And so we're exploring, you know, and looking to push the boundaries on how we can bring in Mitchell Thornbrugh: Partners into those conversations. We are also leveraging the existing knowledge base and information that's out there and hopefully we can engage through listening sessions and tribal consultation. Mitchell Thornbrugh: You know, be able to receive those ideas and get you know understand the the landscape and challenges of the many different partners and how our decisions. Mitchell Thornbrugh: Will affect them. So I don't think we have a perfect answer to that yet. Miss for killer. But again, this is, this is an opportunity to hear directly from you, Will. How do we get to that level of decision making that you would like to see tribes involved in Jennifer Gillissen: Thank you. There's a follow up from a different person is how will tribes be represented on the governance structure. Specifically, will there be travel rep seeds on the governance committee. Mitchell Thornbrugh: Thank you. I see that questions from Melissa our good to hear from you as well and great question. So the governance structure can be somewhat challenging we're exploring all the options.

Mitchell Thornbrugh: To look at either a fox exemption or potentially a aka committee to make sure that we can have appropriate representation on that. Mitchell Thornbrugh: governance structure. So, we are opening that up as an we have heard consistently from tribes through the monetization research project, a little bit as a Follow one from the spore pillar and this is a great question Melissa that we know that we want to see tribal seeds on that committee. Mitchell Thornbrugh: I would also say that I think that's somewhat inferred by Dr. Ferguson's questions earlier as well touched a little bit on how exactly will will get that partnership situated. Jennifer Gillissen: So we have a few more questions will virtual Telehealth medicine be part of this monetization, or is that a separate initiative.

Mitchell Thornbrugh: So it's a little bit of both. We think that there's a huge need for virtual Telehealth visits, whether that's, you know, more than telephone Mitchell Thornbrugh: Maybe not always synchronous video but but some level of virtual healthcare delivery, the pandemic has really highlighted that that's an opportunity to increase access in our communities. While it does Mitchell Thornbrugh: exacerbate the digital divide, and put pressure on our rule connectivity. It also is a way to deliver resort virtual resources into very remote Mitchell Thornbrugh: areas of the country and communities that might not have access to that level of care, otherwise. So we think that that's going to become a very powerful trend.

Mitchell Thornbrugh: Going forward, and there's current efforts to expand that now, but we also recognize that we want to make that a critical capability as we look at modernization. Mitchell Thornbrugh: And so it's a little bit of both. There will be ongoing efforts now to expand virtual care, but we will be looking towards the future and making sure that any modern infrastructure is well prepared and well situated to support, virtual care. Jennifer Gillissen: So we have another one, as you know, many tribes have already chose that are in the process of choosing a new age it system. Jennifer Gillissen: Is is withheld much of the H I T funds from being shared with tribes. When and how will all HTTP funds be district sorry disperse to tribes through travel shares to assist us in our HR IT infrastructure endeavors. Mitchell Thornbrugh: Yeah, great question. Um, so, you know, we talked a little bit earlier about the complexities of 638 and the need to establish Mitchell Thornbrugh: You know, a replacement for our PMS. And so as we continue to to look for recurring funding sources we are looking to identify the level of need across the country.

Mitchell Thornbrugh: So that that information can be shared in the budget process to make sure that long term, not only do we have the the money to convert the RPM is infrastructure, but that we have Mitchell Thornbrugh: appropriate levels of funding coming back through the agency and two tribes to maintain and support what we feel like would be appropriate for a modernized health IT infrastructure and as, as we've said Mitchell Thornbrugh: At the beginning of the meeting, you know, the long term sustainability of Mitchell Thornbrugh: A modernized health IT infrastructure is going to require resources. It's going to require resources to stabilize RPM. So it's going to require resources to replace Mitchell Thornbrugh: You know RPM s and it's also going to require resources to make sure that our tribal partners. Mitchell Thornbrugh: Have access to those funds to make sure that they can maintain their own infrastructure. So we don't have those answers yet, but that is definitely front of mind.

Mitchell Thornbrugh: For the project team and we continue to try to support those conversations with our findings and we know that the acquisition plan. Mitchell Thornbrugh: That I chest is going to undertake over the next several months is going to go a long way to really identifying what level of support is needed across the country for modernized HELP IT infrastructure and we hope that that Mitchell Thornbrugh: Again plays back through the federal budgeting process with support from tribes and others to make sure that we get a, you know, the level of funding that we needed that can be redistributed tribes through shares and through existing methods to make sure they can support their own infrastructure. Mitchell Thornbrugh: Thank you.

Jennifer Gillissen: And you have a more humble them modernization process help support those urban clinics already on a co T, specifically in terms of data collection for reporting currently there's a need to have clear communication on those needs as they change. Mitchell Thornbrugh: Yeah, absolutely. And so we've seen lots of impact in this regards to the nippers investment. Mitchell Thornbrugh: You know, we're working with additional costs across the country or commercial off the shelf software to make sure that we can onboard them and and provide the level of data either gathering or reporting or both in many cases in various venues, and then there's new Mitchell Thornbrugh: needs arising that we're looking for how we can approach those challenges. You know, we talked a little bit earlier about the covert 19 pandemic and the need to do vaccine reporting as well as some other Mitchell Thornbrugh: Testing and reporting and we know that those have impacts, not just on the the RPS solution, but on the way that we transfer data whether it's just an agreement or if we're having to set up an aggregator as we have Mitchell Thornbrugh: For some of our solutions. And so we are looking to the modernization project to start to fill those gaps where we see them forming Mitchell Thornbrugh: Thank you.

Jennifer Gillissen: Sure. We have a few more inhibit once the acquisition plan is established, what plans does. I just have to conduct a pre solicitation conference or conferences. Jennifer Gillissen: To ensure the interested parties clearly understand the IHS need and allowing quality teaming arrangements to be established in pursuit of the requirement. Mitchell Thornbrugh: Yeah, so, and I would welcome any input from mitre here if you want to get into any more details that you want to share about how the acquisition plan works, but I would just say that yes Mitchell Thornbrugh: The acquisition plan has to address those. And so as we move forward and finalize that acquisition plan, which is, after we make the decision on our approach that we will make sure to address that clear communication with the industry. Agree. Nothing further than we would expect opportunities for that as part of the acquisition plan and the details of that are yet to be determined.

Jennifer Gillissen: Okay. Thank you, Sarah. Jennifer Gillissen: The next question we have as well to help it system allow for electronically connect patient records for community based service providers such as travel organizations and to how I just incorporate security and safety measures in the process of working on the project. Mitchell Thornbrugh: Yeah, great, great question. So yes, we are focusing on how we will call it connect to community based services community partners and specifically were asked in the

Mitchell Thornbrugh: Funding language to make sure that we can connect to the VA God and tribes, but we also know that that extends to our community partners. Mitchell Thornbrugh: Whether that's partners that we use for personal referred care or if that is just partners that are in our communities. And we know provide care to our patients as our patients come back and forth. Mitchell Thornbrugh: You know, between those health systems and so community exchange through health information exchange technologies is critical. Mitchell Thornbrugh: It's part of our stabilization plan to improve our PMS his ability to exchange information as well as Mitchell Thornbrugh: Wanting to maintain that ability in a modernized infrastructure. And so I would point to the four directions hub pilot that we're currently undertaking and testing with the VA and God for connectivity. Mitchell Thornbrugh: But that solution will also provide mechanisms for our PMS, to be able to communicate with community.

Mitchell Thornbrugh: health exchanges regional health exchanges and some state based exchanges and so the partnership with E health exchanges is a critical one that establishes a lot of connectivity. Mitchell Thornbrugh: We're also going to look very closely and really leaning into connecting the common well as well as some of the other national health information exchanges, so that we can meet our tribes and partners, where they're at. But we do anticipate Mitchell Thornbrugh: You know having dozens to hundreds of connections to health information exchanges across the country. And while that's an RPM ass. It's very distributed Mitchell Thornbrugh: And the four directions hub is going to help us with that. But then in a modernized environment we do anticipate being able to do more national high level connections to get a lot of data moving

Mitchell Thornbrugh: Quickly and great second question or the other side of that coin is how will we incorporate security and safety measures and the process of working on those projects and we're using modern standards, even for the RPM system. Mitchell Thornbrugh: So we're making sure that those exchanges are secure auditable that we have the security lined out in the dorsal like agreements with the data use and reuse agreements and so that people are establishing Mitchell Thornbrugh: You know the reason for requesting the information that it's coming from an appropriate request or and that we have those security agreements in place, as well as the technical connections that facilitate Mitchell Thornbrugh: Those users logging in and asking for that information. So that was pretty high level, but it'll be a little harder to go deeper than that. Mitchell Thornbrugh: At this time, Jennifer Gillissen: Thank you, another message we have aside from stabilization or the other three approaches equally under consideration or is there a predisposition towards one of them based on analysis today. Mitchell Thornbrugh: Yeah, really, really good question. So stabilization is really kind of a prerequisite. We still need to take one of the other approaches. Mitchell Thornbrugh: You know, the closest that we came to a recommendation was the analysis from the modernization research project and it came short of Mitchell Thornbrugh: Telling us which approach to review, other than to say that they were all three were ballot approaches. So I would say that the you know options, two, three and four on the table and Option one is somewhat of a prerequisite. Jennifer Gillissen: So we have a number of questions again about projected budget implementation. So maybe another review of that high level timeline and funding, Mitch.

Mitchell Thornbrugh: Sure. Mitchell Thornbrugh: Was there a specific question. There may not be in sync with the chat questions. Jennifer Gillissen: Okay, well they're asking about projected budget over how many years implementation, etc. Mitchell Thornbrugh: Yeah. And so at a high level, the, the modernization research project, you know, look to establish you know what what it would take. Mitchell Thornbrugh: And we know looking at VA parity and the modernization projects that can be anywhere from three to $8 BILLION OVER 10 years Mitchell Thornbrugh: But we really until we get to an approach when we start to nail down an acquisition plan and we start to think about the in depth planning around the capital to improve infrastructure site by site. Mitchell Thornbrugh: Then we're, we're going to have a hard time, you know, nailing down a more exact estimate Mitchell Thornbrugh: But we know that it's a significant amount of funding, we know that we need annual recurring funding for operations. And we know that we need

Mitchell Thornbrugh: Capital to do the work to convert and the work to convert you know is training offsetting labor. Mitchell Thornbrugh: That may be lost at a site during conversion and training, making sure that the site's infrastructure is at a level that their bio medical equipment their Mitchell Thornbrugh: imaging systems and all those ancillary systems that you don't always think about lab etc are able to connect to a modernized health IT infrastructure and then their site remediation where the cabling wireless Mitchell Thornbrugh: Computers even may not be what they need to be to to handle the modernized infrastructure. And so all of those things have to be Mitchell Thornbrugh: Brought to bear and we're going to use some methods to project, some of that and to tighten that up through some of our research work or through some of our planning work, but ultimately that that will come down the site by site implementation plans that will be further into the project. Mitchell Thornbrugh: And so you know that that at a high level, just is some of the challenges with with getting, you know, to in the weeds, you know, in any budget projections, but we are thinking about what those buckets look like and make sure that we are Mitchell Thornbrugh: Not only thinking about what that means for our infrastructure, our current level of investment as opposed to what we think Mitchell Thornbrugh: Is a reasonable level of investment to maintain a modernized infrastructure. But we're also pulling some lessons learned from the BA in the EOD about some of their planning. Mitchell Thornbrugh: Around those costs and we know that there were some lessons learned around site remediation. And so that's why that's top of mind for us as we are planning as well. Jennifer Gillissen: And good year for the new solution to be available to implement via track.

Mitchell Thornbrugh: Yeah, so we don't anticipate having any conversions until the end of FYI 2022 or early FYI 2023. And again, that gives us time and FYI to complete an acquisition plan selective and and then we need 12 to 18 months to build that solution before anybody's converted to it. Mitchell Thornbrugh: And I just wanted to circle back on the the budget question and the, you know, we continue to to advocate with our tribes to share their Mitchell Thornbrugh: Information regarding what they think those costs would look like. And then we continue to point tribes and stakeholders and partners back to the mechanisms that they have in place now for the Federal budgeting process. Jennifer Gillissen: And then we have a couple more for the services work will this follow my Indian direction and will the procurement of the product be separate from the procurement of the services.

Mitchell Thornbrugh: So there's there's absolutely an opportunity to make sure that we support. Mitchell Thornbrugh: You know, an appropriate acquisition plan. Mitchell Thornbrugh: I don't know that I can you know commit to any of those details other than to say yes, you know, we are looking at how such a large acquisition is appropriate, not only to to stage it correctly, but to bring the right partners in and create opportunities across the country. Jennifer Gillissen: Thank you. We have a few more. Will there be a capacity to collect tribal or started tribes specific data and share relevant data sets with the African tribes. So that tribes can learn more about how their travel membership is impacted by specific public health issues. Mitchell Thornbrugh: You know, without getting into too many specifics, you know, as we look at how we collect data or data use agreements with tribes. We want to be respectful of how we reuse data. Mitchell Thornbrugh: But I would say that yes, you know, part of a modernized infrastructure is the ability to provide appropriate public health reporting community based reporting.

Mitchell Thornbrugh: I just want to make sure that that when I say that I intend to be respectful of tribal data sovereignty and and you know we were we're not saying we're going to share everybody's data with everyone. Mitchell Thornbrugh: Which is the flip side of that concern that comes up with this question, but we certainly want to have an appropriate infrastructure to be able to quickly and professionally aggregate data and provide public health reporting to our partners. Jennifer Gillissen: Thank you. So we have another question. One of the key findings in the strategic options report was determine the appropriate topology and architecture for the system supporting analytics, whether it be locally or essentially deployed, how is that being addressed and FYI. Jennifer Gillissen: And analytics solution needs to be built concurrent with or ahead of the EHR deployment. Mitchell Thornbrugh: Yeah, so we're, you know, we're having those discussions. Now, and part of it is the nippers investment is is very structured in the way that it meets some of the Mitchell Thornbrugh: Requirements of that program that we're funded a certain way, but we were really looking at what that means for modernization and so we're seeing the convergence of Mitchell Thornbrugh: The nippers discussions, the public health reporting discussions and then what would an analytics solution look like that's agnostic to an EHR.

Mitchell Thornbrugh: But I would say, you know, that's part of that modernization work that the the PM. Oh, and starting to engage in now so that we can document those discussions. Mitchell Thornbrugh: But, but I agree with steward with the the influence in the in the question that an FYI 2021 and 22 as we architect the solution, not only do we have to be data centric in the way we handle health information exchange. Mitchell Thornbrugh: And the, the modern the connectors between the modern electronic health records that will be in the ecosystem. We also have to mature our analytics platform to be a EHR agnostic. Jennifer Gillissen: Thank you. Another question is, when conversion happens will legacy information be available in the new system.

Mitchell Thornbrugh: Yeah, that's a great question. So this is one of the challenges that we're already hearing loud and clear from our Mitchell Thornbrugh: partners who have modernized from the industry also my experience in this arena is that many times, the only solution is to freeze the RPS data. Mitchell Thornbrugh: And that falls short I think of what we all would expect out of a modernized system, but there's really limited solutions. Now, and so we feel very strongly that we have to create Mitchell Thornbrugh: A solution that we host, but also a solution that tribes and our partners can recreate Mitchell Thornbrugh: To make sure that we can extract the the valuable data out of our PMS, put it in a low code or no code environment where that information can be sustained for future generations and either Mitchell Thornbrugh: Quickly imported into a modernized solution or referenced, you know, in the future, back to, you know, a database type system. But again, the idea would be as to mature that from where it is now, which is, you know, freezing. Our PMS. Mitchell Thornbrugh: Has some challenges because you really start to get locked into package levels those get locked into Mitchell Thornbrugh: Support models for the database. And in this case, enter systems.

Mitchell Thornbrugh: So you start to run it, you know, into conflicts with being able to upgrade RPM. So then you have run into problems upgrading enter systems and then you're going to run into problems upgrading the Windows operating system or the Mitchell Thornbrugh: System that it's sitting on ultimately leading to needing to turn that system off because you can't secure it. And you can't leave it on the network running, even in read only mode. Mitchell Thornbrugh: And so we know that there needs to be a long term solution for the legacy data repository, and we do plan to address that in the modernization project.

Jennifer Gillissen: Thank you. Another question is, I appreciate the recognition to include calls for the entire it you system as part of our budget request. Jennifer Gillissen: We are entering national budget formulation next month with IHS will we at least having preliminary estimate to advance to HHS and to the President for 2023 Mitchell Thornbrugh: Yeah, I think the, the only number that that we've had is that three day BILLION OVER 10 years Melanie were, you know, until the Mitchell Thornbrugh: Conclusion of the acquisition plan, we'd have a hard time supporting any other number. And I would say that that number is really just a representation of VA parity and Mitchell Thornbrugh: I hope that's helpful. Jennifer Gillissen: So another question I received is data used it versus using a single HR. How often will that data be reviewed and use to implement this balance. How will we know we are successful in that process.

Mitchell Thornbrugh: Yes, that is, that question and chatter manager to restate that Jennifer Gillissen: No, it came to me directly. It's a data used versus using a single EHR. How often will that data be reviewed and use to implement this balance. How will we know we are successful in that process. Mitchell Thornbrugh: Okay, I'm I'm I'm struggling with understanding the question there. Mitchell Thornbrugh: You know, I would say that my assumption is that the question is around how do we know if our data is being reused. And so, you know, we will have transaction records and know how many times that either an HIV connection. Mitchell Thornbrugh: Or our central data repository is used for reporting, you know, the HIV is more of the real time patient care coordination center model. Mitchell Thornbrugh: With the data reporting being more of either a nippers function or as as Ferguson mentioned in this question earlier, a function of reporting from an analytics platform.

Mitchell Thornbrugh: And sorry if that didn't touch on the question might need someone to restate that. Thank you. Jennifer Gillissen: Thank you. I'll let you know if they restate it Jennifer Gillissen: Those are the questions that we've gotten so far. Again, you can enter your questions into the chat or you can unmute and ask questions. We do have another one that came in was some of the work that was described as a CMO slide go out for for procurement example, the orange or G change. Mitchell Thornbrugh: Yeah, great question. And so the partnership with the miter FF RTC you know really allows IHS and mitre to bring a lot of resources in the industry to bear quickly.

Mitchell Thornbrugh: To create a lot of capacity. Early on, we've been very clear with my daughter and my daughter's been very clear. They're helping with some of this initial stand up of resources, but we we recognize that we want to Mitchell Thornbrugh: Long term, you know, go out and solicit partnerships and subcontracts to shore up the program management office. So each task is coming up with with some of those deliverables now. So part of the Mitchell Thornbrugh: The work of the CMO is to structure. Those acquisition packages, not just the acquisition for what we would call the replacement of our PMS, or the modernized infrastructure. Mitchell Thornbrugh: But also a lot of work to make sure that we have partnerships and capabilities that we procure to make sure we can meet those various tasks. Mitchell Thornbrugh: And so specifically tasked five around organizational change. We know that that's extremely critical

Mitchell Thornbrugh: You know the replacement of an EHR and the upgrade of the health IT infrastructure goes well beyond information technology. Mitchell Thornbrugh: At all of our organizations. I think we would all agree that this infrastructure is really the operating system for healthcare delivery systems. Mitchell Thornbrugh: And you know we we want to make sure that that we've got adequate support and partnerships to address those organizational change challenges, recognizing that this project is going to impact everybody in healthcare. Mitchell Thornbrugh: And in the healthcare delivery model. So thank you for that question.

Jennifer Gillissen: So any additional questions, you can put into the chat box, or you can unmute your long and questions. We do have time Thomas Bonina: Quick question, I take the fuel and this is a company on with Kodiak Thomas Bonina: Curious on the stabilization of the RPM s Thomas Bonina: You know, and the other activities of the renew and you know the other options, how long Thomas Bonina: How long do you think you'll go out and, you know, uh, when will the stabilization opportunity be coming out. And is that like a year long effort to do stabilization while you know, while you getting ready to do the other picture means Mitchell Thornbrugh: Yeah, so I don't think we were we view that stabilization as a single procurement, but as a as a body of planning and work to make sure that we're addressing ongoing needs of our PMS. Mitchell Thornbrugh: So I don't think that there's a clear starter finish because you know we're continuing to do that.

Mitchell Thornbrugh: But it does formalize our commitment to make sure that we're we're sending clear messages that we are going to continue to support the RPS users and the patients that rely on it and so Mitchell Thornbrugh: You know, it's a body of activity over the life of the project to make sure that we're keeping up with those standards and so I mentioned earlier the 2015 certified edition, you know, that's Mitchell Thornbrugh: You know, I think we were in arrears of reaching that but it really represented a milestone in our commitment to support quality recording Mitchell Thornbrugh: Because there was not a financial return on investment for that work. Mitchell Thornbrugh: But it ensures that we and our partners can continue to report to CMS quality outcomes in their communities as they need for various programs and again to support quality outcomes across the country. Mitchell Thornbrugh: You know, but recognizing that we've completed that milestone. We're preparing for the next iteration and advancement of that that


2021-02-08 12:28

Show Video

Other news