Medical Society of the State of New York

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					   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 rpucherelli@mssny.org



                                   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.




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                                       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
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