CMS-10165 Electronic Health Record (EHR) Demonstration Application

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part I: Information Collection Request

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.

Instructions for filling out the form are available at www.paperworkreduction.gov.

1. Agency/Subagency originating request: Centers for Medicare & Medicaid Services

2. Title: Electronic Health Record Demonstration

3. Type of information collection (check one)

(See instructions)

_New collection (Request for a new OMB Control Number)

Extension without change of a currently approved collection

Revision of a currently approved collection

Reinstatement without change of a previously approved collection

Reinstatement with change of a previously approved collection

XNonmaterial or nonsubstantive change to a currently approved collection (formerly 83C)

Existing collection in use without and OMB Control Number

4. OCN: 0938-0965 ____________

5. Type of review requested (check one)

a. X Regular

b. Emergency - Approval requested by: / /

c. Delegated

If Emergency, please attach justification.( 4000 characters maximum)

6. Requested expiration date (check one)

a. X Three years from approval date

b. Six Months from approval date (Maximum for Emergency reviews)

3. Other
   

Specify: / (mm/yy)
or Number of Months from Approval Date:

7. Abstract (4000 characters maximum, attach additional sheets as necessary)

The Centers for Medicare & Medicaid Services (CMS) requests clearance for the application utilized to identify and enroll practices into the Electronic Health Record demonstration. This demonstration is a high-priority Administration of this initiative. The purpose of this demonstration project is to reward the delivery of high-quality care supported by the adoption and use of electronic health records in small to medium-sized primary care physician practices. While this initiative is separate and distinct from the Medicare Care Management Performance (MCMP) Demonstration, it expands upon the foundation created by the MCMP Demonstration, which was mandated by Section 649 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The electronic health record demonstration will be operational for a 5-year period and will be operated under section 402 demonstration waiver authority.

The information to be obtained as part of the application form is necessary to document basic information for physician practices that intend to participate in this demonstration initiative. This information will be used to establish that the practices meet basic eligibility requirements for participation in this initiative. The application form requests basic physician office information (e.g., number of physicians in the practice, specialties, organizational structure, Medicare Provider Identification Number, tax identification number, contact information, etc. Practices that apply will be expected to sign a data sharing consent form that will accompany the form. It is expected that up to 2,400 application forms will be submitted by physician practices in 12 states for subsequent randomization to treatment and control groups.

8. Authorizing Statute(s)

Public Law:

Congress Number	Sequence Number	Section	Name

US Code:

Title	Section	Name

Executive Order:

Number	Name

Statute:

Title	Subtitle

9. Associated Rulemaking Information Stage of Rulemaking (check one) Federal Register Citation

RIN: - a. Proposed Rule Volume Page number ____________
Publication Date / /____

b. Interim Final or Final Rule

For a Proposed Rule, OMB will not consider an ICR complete until the Notice of Proposed Rulemaking has been published.

For a Final Rule, please put the ICR reference number for the ICR reviewed at the proposed rule stage in Box 4.

For ICRs associated with Interim Final or Final rules that are not significant under EO

10. Federal Register Notices & Comments

Federal Register Citation

60-day Notice: Volume Page number Publication Date / /

30-day Notice: Volume Page number Publication Date / /

Did the Agency receive public comments on this ICR? _Yes _No

Unless submitted as an Emergency or Associated with Rulemaking, OMB will not consider an ICR complete until the 30-day notice has been published.
12866, please attach a draft of the Federal Register document.

11. Annual Cost to Federal Gov:

$ approximately 312,000 (one-time only cost)

14. Agency contact:

Name: Debbie Van Hoven

Phone: 410-786-6625

E-mail: [email protected]

12. Does this ICR contain surveys, censuses, or employ statistical methods?

Yes (Attach Part B of Supporting Statement) X No

confirms

13. Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?

Yes X No

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part I: Information Collection Request (continued)

Information Collection Budget (ICB)

If a change in burden is due to a Program Change Due to New Statute, identify the Citations for New Statutory Requirements:

Public Law:

Congress Number	Sequence Number	Section	Name

US Code:

Title	Section	Name

Executive Order:

Number	Name

Statute:

Title	Subtitle

If Program Change is due to Agency Discretion, please categorize the reduction. Burden reduction from (select one):

a. Cutting Redundancy
b. Using Information Technology
c. Changing Regulations
d. Changing Forms
e. X Miscellaneous Actions

If Program Change is due to Agency Discretion, please categorize the increase in burden. Burden increase caused by (select one):
a. Changing Regulations
b. X Miscellaneous Actions

Explain the reasons for any program changes or adjustments reported; that is, provide a short statement how the reduction in burden was achieved or why the increase in burden occurred. (If you need more space, please provide a short summary here and elaborate in the Supporting Statement.)

This demonstration is a high-priority Administration initiative conducted under section 402 demonstration waiver authority. Only physician practices that respond and express interest in participating will complete the application. The burden associated with the proposed collection of information is completely voluntary; however, it should be noted that physician practices that voluntarily respond may ultimately be eligible to earn substantial financial rewards as part of their subsequent participation in this demonstration initiative.