VIEWS: 7 PAGES: 8 POSTED ON: 3/11/2010
Medical Society of the State of New York Program: Health Information Technology Pilot Program FAU Control Number: 0607061007 Request for Application Technical Submission Packet Health Information Technology Pilot Program Application Number: ________________ (Please leave blank - To be entered by MSSNY) Lead Applicant Name: Questions Due: March 7, 2007 Applications Due: April 20, 2007 Contact Name & Address: Medical Society of the State of New York One Commerce Plaza, Suite 1103 Albany, NY 12210 c/o Ron Pucherelli, HIT Project Administrator Tel: 518-465-8085 E-mail email@example.com 1 ATTACHMENT 1: Lead Applicant Information This must be completed by the lead applicant who will represent all partner applicants in the RFA process. If the lead applicant is a multi-physician practice, then the practice must designate an individual to assume the lead role. Application #: ___________________(Applicants should leave this space blank.) Project Name: _________________________________________ Region: ____________________ (See RFA section IV.G) Lead Applicant Organization Name: _________________________________________ Address: _________________________________________ _________________________________________ City/State/Zip: _________________________________________ Main Phone Number: __(_____)_________________________________ Cell Phone Number: __(_____)_________________________________ Fax Phone Number: __(_____)_________________________________ Website URL, if any: _________________________________________ Tax Status: Please check one : ____ For Profit ____Not-for Profit ____Public Employer Identification Number (EIN): _____________________________ Parent Organization, If Any: ___________________________________ Relationship to Parent Organization: ___________________________________ CONTACT INFORMATION FOR THIS LEAD APPLICANT Contact Person Name: ___________________________________ Contact Person Title: ___________________________________ Contact Person Phone Number: __(______)__________________________ Contact Person Fax Number: __(______)__________________________ Contact Person e-Mail Address: ___________________________________ Lead Applicant Authorized Signature: ______________________________ Date: ___________ Print Name: _________________________________ Title: _______________________________ 2 ATTACHMENT 2: Project and Applicant Criteria Checklist Must be completed by the lead applicant. Note: Total Project Budget information must match the aggregate total of lead and partner applicants’ Project Budget Detail totals. PROJECT NAME: REGION: Lead Applicant Name: Partner Applicant Names (List below or on additional sheet, if necessary): Total Grant Funding Requested: Total Project Budget: Geographic area covered by project: Project implementation timeframe (Start & End Dates): Please check off which one or more of the following HIT Pilot Program Objectives this project meets (see RFA Section III): ___ interconnect physicians through regional collaborations ___ promote personalized health and consumer choice through technology ___ enhance health care outcomes and health status through interoperable public health surveillance systems and streamlined quality monitoring Please check off which one or more of the following Project Expectations this project meets (see RFA Section III for full description of Expectations): ___ Affirmation of willingness on the part of project-related physicians affiliated or associated with lead or partner applicants to become health information “champions” and share their experiences with other physicians, promote the use of electronic health record systems, educate the physician community and encourage the collaboration to exchange electronic patient health information. ___ Grant applicant awardees will demonstrate projects utilizing electronic health record systems to exchange health information of patients and/or submit electronic prescriptions, order tests, retrieve lab results, etc. ___ Potential for joining a Regional Health Information Organization (RHIO) or expanding inclusion of hospitals, labs, IPAs, etc. ___ Potential for outcomes measurement and evaluation to reflect improvements in patient health care delivery and results. ___ Potential for expansion or interoperability. 3 Please check off each Minimum Applicant Eligibility Requirement to confirm that this project these requirements. Failure to meet one of these requirements will result in the application being ineligible. (See RFA Section II): ___ Community-based initiative ___ Independent primary care participants are central participants ___ Solo and/or small-sized practices are key participants ___ Multiple community-based, independent, health care “partner applicants” ___ Entities are inclusive in their physician membership, with open membership Please check off which one or more of the following Preferred Applicant Target Efforts and Project Characteristics this project meets (see RFA Section II): Preferred Applicant Target Efforts: ___ Demonstrated education in health information technology or initial implementation steps ___ At least one applicant with background in HIT capabilities ___ Lead applicant with capacity and experience for successful project completion IV. Project Characteristics: ___ Local or regional physician-focused projects demonstrating patient-centered care. ___ Likelihood for successful project implementation within designated timeframe and grant funds. ___ Potential for outcomes measurement in order to evaluate impact of project implementation. ___ High degree of interoperability to be achieved among project participants and others involved in the local care or public health system, on a non-exclusive basis. ___ Potential for project expansion locally, or for replicability in other areas. ___ Affirmation of willingness to become health information “champions” e.g. share their experiences with others and educate other physicians. ___ Projects will utilize electronic health record systems to exchange health information between physicians, consultants, laboratories, pharmacies and patients and/or engage in the use of Ambulatory Order Entry (AOE) and/or electronic prescriptions (ePrescribing). ___ Applicant members, who intend to utilize funding to support an ambulatory EHR, indicate that their EHR vendor(s) of choice is/are certified or has/have applied for certification by the Certification Committee for Health Information Technology (CCHIT). If the vendor has applied for certification, applicant will submit documentary proof from said vendor with the application. Applicant members, who intend to utilize funding to support a standalone ePrescribing component, indicate that their eRx vendor(s) of choice is/are certified or has/have applied for certification by SureScripts. If the vendor has applied for certification, applicant will submit documentary proof from said vendor with the application 4 ATTACHMENT 3: Project Narrative PROJECT NAME: REGION: Lead Applicant Name: Please describe the proposed project in narrative form in 5 – 8 pages; these pages are in addition to the information required in the RFA Attachments 1,2, and 4. In writing your narrative, please address the following areas and questions, and number these responses accordingly in the narrative. You may add other relevant attachments, beyond the narrative 5 – 8 pages, provided the required extra copies are submitted along with the original application. I. Project Overview: 1. Describe the project mission: what it will do, how it will do it, and the makeup of the project team’s organization including the roles of the various applicants. 2. What are the goals of this project? 3. How does this project meet: A. HIT Pilot Program Objectives indicated in Attachment 2: Project and Applicant Criteria Checklist? B. Minimum Applicant Eligibility Requirements indicated in Attachment 2: Project and Applicant Criteria Checklist? C. Preferred Applicant Target Efforts and Project Characteristics indicated in Attachment 2: Project and Applicant Criteria Checklist? 4. How will the proposed project meet the Project Expectations that the HIT Pilot Program has for projects to be awarded grants, as described in Section III of the RFA? 5. What are the concrete outcomes expected of this proposed project (include relevant and demonstrated instances to support how the capabilities of the implemented system would achieve the expected outcomes)? How will you evaluate whether the intended outcomes were achieved? 6. Explain how progress towards meeting proposed project outcomes will be monitored. 5 7. Who will be responsible for coordinating the applicants and managing implementation of the project, and describe how will this be done? II. Statement of Need: 1. Describe the need for grant funding to meet the HIT Pilot Program Objectives indicated in Attachment 2: Project and Applicant Criteria Checklist. 2. How will this grant help overcome existing barriers to adoption of HIT? Explain any anticipated problems to providing proposed services and the strategies for overcoming these barriers. III. System Implementation: 1. If partner applicants are implementing full EHR systems, are these systems certified by CCHIT? 2. If any EHR system involved with this application has not achieved CCHIT certification as of the date of application, but the vendor has applied for certification, applicant must secure documentary proof from said vendor and submit it with this application. 3. If any standalone ePrescribing component involved with this application has not achieved SureScripts certification as of the date of application, but the vendor has applied for certification, applicant must secure documentary proof from said vendor and submit it with this application. 4. If the project intends to/will participate in Regional Networks, task forces, coalitions and/or other planning bodies, describe the applicants’ roles and activities in these organizations. 5. Describe how the proposed program activities will be integrated within the community or regionally based organization. 6. Describe the group’s experience working collaboratively with other physician practices and other healthcare stakeholders in the community. 7. Describe the background and experience level in HIT capabilities of the applicant who will be providing the primary HIT expertise for the project. 6 8. Describe the efforts taken or planned by the lead and partner applicants to educate themselves about HIT. IV. Quality Improvement 1. Describe how the project will use its expanded capability to conduct quality improvement efforts in clinical performance. 2. Clinical Measures: Discuss how you will track generally accepted ambulatory clinical performance measures, such as those approved by the National Quality Forum or Physicians’ Consortium for Performance Improvement. Describe how you would use the clinical measures' data to change the office practice. 3. Care management: Describe the use of your EHRs or other planned technical enhancements to develop registries in at least two clinical categories (such as coronary artery disease, diabetes, heart failure, hypertension or clinical preventive services). Discuss how you would use these registries to produce prompts and reminders for the clinicians and patients and also to develop patient-specific care plans. 7 ATTACHMENT 4: Applicant Characteristics PROJECT NAME: REGION: Lead Applicant: Please complete the following for EACH entity involved in the project, including the lead applicant and ALL partner applicants, regardless of whether that partner applicant would receive funding, directly or indirectly, from this project. Copy this sheet for additional applicants, as needed. Applicant Organiz- Parent Tax If Medical If Medical If Medical Annual Name ation Organization, Status(2) Practice, Practice, Practice, # Budget (3) Type (1) If Any Specialties Specialties of Annual & # Of & # PAs, Patient Doctors NPs Visits Lead Applicant: Partner App: Partner App: Partner App: Partner App: 1 Examples of organization types are: Independent Physician Practice (IPP), County Medical Society (CMS), Local Pharmacy (LP), Laboratory (L), Hospital (H), Health Care Payer (HPA), FQHC, RHIO… 2 For-Profit, (FP), Not-For-Profit (NFP), Or Public Status (PS) 3 For Independent Physician Practices, the annual budget is not required if the # of annual visits is provided 8
"Medical Society of the State of New York"