Form 1 Attachment 1

Section 3012 Health Information Technology Extension Program: Full Application

3012 PRA Full Ap Attachment 1 8.26.2009

Full Application Required Data Elements

OMB: 0990-0343

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Form Approved OMB No. 0990-XXXX

Exp. Date xx/xx/xxxx

Reporting Requirements Identified in the FOA for the Full Application



Address to Submit Full Applications

Full applications for all announcements must be submitted electronically through http://www.grants.gov. The grants.gov registration process can take several days.  If your organization is not currently registered with http://www.grants.gov, please begin this process immediately. For assistance with http://www.grants.gov, please contact them at [email protected] or 1-800-518-4726 between 7 a.m. and 9 p.m. Eastern Time.  At http://www.grants.gov, you will be able to download a copy of the application packet, complete it off-line, and then upload and submit the application via the grants.gov website. 

Applications submitted via http://www.grants.gov :

  • You may access the electronic application for this program on http://www.grants.gov.  You must search the downloadable application page by the Funding Opportunity Number (EP-HIT-09-002-010535) or CFDA number (93.718).

  • At the http://www.grants.gov website, you will find information about submitting an application electronically through the site, including the hours of operation.  ONC strongly recommends that you do not wait until the application due date to begin the application process through http://www.grants.gov because of the time delay.

  • All applicants must have a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number and register in the Central Contractor Registry (CCR).  You should allow a minimum of five days to complete the CCR registration.

  • You must submit all documents electronically, including all information included on the SF424 and all necessary assurances and certifications.



According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 280 hours per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201 Attention: PRA Reports Clearance Officer.


  • Prior to application submission, Microsoft Vista and Office 2007 users should review the Grants.gov compatibility information and submission instructions provided at http://www.grants.gov (click on “Vista and Microsoft Office 2007 Compatibility Information”).

  • Your application must comply with any page limitation requirements described in this Program Announcement.

  • After you electronically submit your application, you will receive an automatic acknowledgement from http://www.grants.gov that contains a grants.gov tracking number.  ONC will retrieve your application form from grants.gov.

  • After ONC retrieves your application form from grants.gov, a return receipt will be emailed to the applicant contact.  This will be in addition to the validation number provided by Grants.gov.

  • Each year organizations registered to apply for Federal grants through http://www.grants.gov will need to renew their registration with the Central Contractor Registry (CCR). You can register with the CCR online and it will take about 30 minutes (http://www.ccr.gov).

FULL APPLICATIONS CANNOT BE ACCEPTED THROUGH ANY EMAIL ADDRESS. FULL APPLICATIONS CANNOT BE ACCEPTED THROUGH ANYWEBSITE OTHER THAN http://www.grants.gov . FULL APPLICATIONS CANNOT BE RECEIVED VIA PAPER MAIL, COURIER, OR DELIVERY SERVICE.

APPLICANTS WHO ARE INVITED TO SUBMIT FULL APPLICATIONS ARE STRONGLY ENCOURAGED TO COMPLETE AND SUBMIT APPLICATIONS AS FAR IN ADVANCE OF THE SUBMISSION DEADLINE AS POSSIBLE. THE APPLICATION INCLUDING ALL REQUIRED ATTACHMENTS AND INCLUDED FILES FOR POTENTIAL CONSIDERATION IN THE REVIEW PROCESS MUST BE RECEIVED BY 11:59 PM EASTERN TIME ON THE DATE SPECIFIED IN SECTION IV E, BELOW.



Key Contact for all Preliminary Application:

Inquiries should be addressed to:

U.S. Department of Health and Human Services

Office of the National Coordinator for Health Information Technology

Email: [email protected]



Full Application Content Requirements

Applicants whose preliminary applications are approved will be notified by ONC according to the dates indicated in section IV D. This notification will include an invitation for the applicant to submit a full application for a competitive process. ONC will provide further guidance on the following areas:

DUNS Number

The Office of Management and Budget (OMB) requires applicants to provide a Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number when applying for federal grants or cooperative agreements on or after October 1, 2003. As part of the full application process, applicants will complete the SF 424. The DUNS number is entered on the SF 424 (For more information about completing the SF 424, see Appendix C). It is a unique, nine-digit identification number, which provides unique identifiers of single business entities. The DUNS number is free and easy to obtain.

Organizations can receive a DUNS number at no cost by calling the dedicated toll-free DUNS Number request line at 1-866-705-5711 or by using this link to access a guide: https://www.whitehouse.gov/omb/grants/duns_num_guide.pdf .

Project Abstract

Applicants shall include a one-page abstract (no more than 500 words) of the application. This abstract is often distributed to provide information to the public and Congress and represents a high-level summary of the project. As a result, applicants should prepare a clear, accurate, concise abstract that can be understood without reference to other parts of the application and that provides a description of the proposed project, including: the project’s goal(s), objectives, overall approach (including target priority primary-care providers and significant partnerships), anticipated outcomes, products, and duration.

The project abstract must be double-spaced, formatted to 8 ½” x 11” (letter-size) pages with 1” or larger margins on top, bottom, and both sides, and a font size of not less than 12 point.

The applicant shall place the following information at the top of the narrative abstract (this information is not included in the 500 word maximum):

  • Project Title

  • Service area included in the application, described via USPS zip codes: zip-three code(s) for one or more entire counties, zip-five codes for any partial-county areas included in the proposed service area.

  • Applicant Name

  • Address

  • Contact Name

  • Contact Phone Numbers (Voice, Fax)

  • E-Mail Address

  • Web Site Address, if applicable

Project Narrative

The Project Narrative must be double-spaced, formatted to 8 ½” x 11” (letter-size) pages with 1” or larger margins on top, bottom, and both sides, and a font size of not less than 12 point. The suggested length for the Project Narrative is ten to twenty pages; twenty pages is the maximum length allowed. A full application with a Project Narrative that exceeds 30 pages will not be accepted. The Sustainability Plan (see IV C 4), Letters of Support and resumes of Key Personnel are not counted as part of the Project Narrative for purposes of the 30-page limit, but all of the other sections listed below are included in the limit.

The Project Narrative is the part of the application that will offer the most substantive information about the proposed project, and it will be used as the primary basis to determine whether or not the project meets the minimum requirements for grants under ARRA. The Project Narrative should provide a clear and concise description of your project.

(Note: a concise resource offering tips for writing proposals for HHS grants can be accessed via the Web at: http://www.hhs.gov/grantsnet/AppTips.htm)

Current State and Gap Analysis

Applicants are expected to complete a current analysis of the state of EHR adoption and meaningful use and determine gaps within their service areas. The applicant should propose a detailed geographic service area and the distribution of priority primary-care providers (by practice/facility type and size) to whom they will provide direct assistance. The service area will be finalized as part of the cooperative process between HHS and applicants. Considerations for HHS will include the desire for geographic diversity, as well as the:

  • Number of priority primary-care providers targeted for direct assistance, and the proportions this number represents of the total priority primary-care and total primary-care providers in the proposed service area.

  • Uninsured, underinsured, and medically underserved individuals as a proportion of the service area’s total population.

  • Number of Federally Qualified Health Centers (FQHC) and public and non-profit Critical Access Hospitals (CAH) in service area at which primary-care professionals with prescriptive privileges furnish outpatient primary-care services, and the proportion of these facilities participating.

  • Partnership or collaboration with a community college or other institution of higher education offering a certificate or associates degree program(s) in health information technology or related field (please specify).

  • Presence within or in close proximity to the service area of a VA hospital, DOD medical facility, IHS or other Tribal health facility.

  • Presence of organization(s) to provide for and/or infrastructure(s) providing the secure electronic exchange of health information within the geographic service area (please specify and briefly describe).

Provider Commitments

This section includes a list of priority primary-care providers from or for whom the applicant has signed commitment letters to use the Regional Center’s direct technical assistance resources according to the terms laid out in the proposed budget. Letters may be from solo practitioners, individual practitioners within small-group practices or other prioritized settings, or authorized representatives of practices, FQHCs, or public hospitals or nonprofit CAHs. Letters must include the names and National Provider Identifier numbers of the priority primary-care providers thereby committed to use the Regional Center’s services.

Goals and Objectives

This section includes the mission statement of the applicant’s non-profit organization, and the vision, short term/long term goals and objectives that the Regional Center is using to guide its operations.

Proposed Strategy

This section will describe how the Regional Center plans to provide services to the priority primary-care providers as described in the section I C Scope of Services with particular attention to clarifying their understanding of the barriers faced by small practices in achieving meaningful use of certified EHR products and their approach to mitigating or eliminating these barriers through the broad support offered to all providers in the region, as well as the intensive direct assistance. This includes the following:

  • Education and Training for All Providers in Service Area

  • National Learning Consortium

  • Vendor Selection & Group Purchasing

  • Implementation and Project Management

  • Practice and Workflow Redesign

  • Functional Interoperability and Health Information Exchange

  • Privacy and Security Best Practices

  • Progress Towards Meaningful Use

  • Local Workforce Support

Populations with Specific Needs

The Regional Center will also state how the unique needs of providers serving American Indian and Alaska Native, non-English speaking and other historically underserved populations as well as those that serve patients with maternal child, long term care, and behavioral health needs, will be met.

Project Management

This describes how the Regional Center plans to govern and manage the execution of its overall program. It will include the Regional Center’s governance structure, roles/responsibilities, operating procedures, composition of committees, workgroups, teams and associated leaders, and communications plans that will provide adequate planning, monitoring, and control to the overall project. The project management activities should provide details on how plans and decisions are developed and documented, issues/risks managed, and meetings facilitated.

If the applicant proposes to serve one or more entire states and/or territories, the applicant organization must demonstrate how it will effectively and efficiently provide prompt, responsive, individualized support to small practices across the entire proposed service area.

Core Performance Measures

This section describes how the Regional Center will achieve program outcomes assessed by quantitative performance measures, such as:

  • Signed contracts with financial commitments by priority primary-care providers.

  • Number of priority primary-care providers that are actively using an EHR, including active use of electronic prescribing.

  • Utilization of EHRs and promoting features essential for meaningful use.

  • Helping priority primary-care providers to understand, and implement technology and process changes needed to attain, and demonstrate attainment of, meaningful use requirements defined by the Secretary in applicable regulations and guidelines.

Evaluation

Recipients will be required to maintain information relevant to achieving the milestones specified in sections II A 2 and 4. ONC will provide for project management software for all Regional Centers to use in capturing information needed to monitor and evaluate performance. More information on the provided software and the biennial evaluation will be in program guidance by December 31, 2009.

Coordination and Continual Improvement

This section describes how Regional Centers will coordinate with the HITRC. This includes describing their plans for participation in regional and national network meetings, sharing experiences with barriers and solutions, use of the client management, tracking, reporting application to provide ongoing data for contract and program monitoring and evaluation purposes, and sharing of locally developed materials or tools.

This section also describes how Regional Centers will rapidly promote and disseminate knowledge about the effective strategies and practices to implement and effectively use health IT through outreach, training programs, and marketing.

Organizational Capability Statement

This section describes the current capability possessed by the Regional Center to organize and operate effectively and efficiently. This includes:

  • 2009 Annual budget and sources of income.

  • Number and roles of FTE staff in different functional areas (outreach/ communications, health IT implementation, interfaces and information exchange, hardware and network infrastructure, quality improvement, privacy and security, other).

  • Identify key staff who will provide substantive work for each area covered in the Scope of Services section I C, and provide 1 page resumes for these individuals (please submit these resumes as attachments to the application).

  • Previous experience with EHR implementation (number of existing vendor contracts, practices, practice sites, and providers served).

  • Previous experience with workflow redesign and clinical quality improvement (number of practices, practice sites, and professional providers served).

  • Previous experience with outreach, education and particularly on-site direct technical assistance in EHR adoption, implementation and appropriate use.

  • Any other relevant experience that aligns with the program goals and objectives.

Sustainability Plan

This section describes how the Regional Center plans to maintain its services and continue to operate by the end of year two, through the remainder of the cooperative agreement period and beyond the end of the funding period. This will include local cost sharing contributions/additional funding streams, methods for achieving independent sustainability, such as payments for technical assistance and ongoing maintenance from certain non-prioritized providers who can afford services, potential assignment of payment from Medicaid providers (in the instances when the Regional Center is designated by the state as eligible to receive such assignment as an adoption entity pursuant to Section 1903(t) (1) of the Social Security Act as added by ARRA) and other potential income, such as revenue from facilitation of community-based participatory research networks.

As one aspect of achieving sustainability, applicants are encouraged to include in contracts between the Regional Center and providers a commitment of payment to the Regional Center contingent upon achievement of meaningful use criteria.

Collaborations and Letters of Commitment from Key Participating Organizations and Agencies

Coordination with other federal programs, and with related ARRA funded activities – This section describes how the Regional Centers will utilize, where locally available, the expertise and capabilities of practice networks supported by other federal agencies, such as IHS, HRSA, VA, CMS, and DOD.

Multi-Stakeholder Community and Provider Support – This section describes the various types of support that the Regional Center plans to obtain/has already received from state primary care associations, health professional societies, HCCNs, state/local/tribal public health agencies, State Medicaid Director(s), health plans, hospital systems, community colleges, Medicare Quality Improvement Organization(s), and others relevant stakeholders.

Nondiscrimination and conflict of interest policies – This section describes the potential for any perceived conflict(s) of interest of the applicant(s), and the steps taken to demonstrate a commitment to transparent, fair, nondiscriminatory, and unbiased service to all primary care providers in the geographic service area.

Budget Detail

All applicants are required to outline proposed costs that support all project activities in the Budget Detail. The application must include the allowable activities with estimated costs that will take place during the funding period that will be used specifically in support of the purpose of this cooperative agreement. Costs are not allowed to be incurred until the start date listed in the Notice of Grant Award. Whether direct or indirect, these costs must be allowable, allocable, reasonable and necessary under the applicable OMB Cost Circulars: http://www.whitehouse.gov/omb/circulars and based on the programmatic requirements for administering the program as outlined in ARRA. See Appendix C for detailed information on completing the budget forms.

Awards will be made for a four-year project period with two separate two-year budget periods. In preparing the project budget, applicants should prepare these two budgets, each for two years taking into consideration the requirements of sections II A 2 and 3. For purposes of preparing the budgets, applicants should assume the following:

Core Funding

  • Allocate sufficient funding specifically for core activities, based on the size of the proposed geographic service area for the Regional Center, the need for additional capital and other costs of capacity building, and variations in locality costs, for each year of the initial two-year budget period.

Direct Assistance Funding

  • Allocate approximately one-third of the applicant’s estimated total per priority primary-care provider technical assistance cost upon signed technical assistance contracts;

  • Allocate approximately one-third of the applicant’s estimated total per priority primary-care provider technical assistance cost upon documentation of provider’s Go-Live status on a certified EHR, with active quality reporting and electronic prescribing; and

  • Allocate approximately one-third of the applicant’s estimated total per priority primary-care provider technical assistance cost upon provider achieving meaningful use requirements as defined by the Secretary.

Please note the following funding requirements:

  • Any fees received from providers are program income to be used as specified in section III B.

  • Regional Centers may be directed to use any unexpended direct assistance funds originally awarded for years one and two and unobligated at the end of year two for support of primary-care providers who are not eligible for health IT incentive payments (e.g., pediatricians with fewer than 20 percent Medicaid patients), or to expand the service area of Regional Centers.

  • Additionally, the proposed budget for the first two years should reflect a recipient cost share of at least one dollar for every nine dollars in federal assistance. In preparing the budget for years three and four, the amount of recipient cost share must be nine dollars for every one dollar of federal assistance provided under the cooperative agreement.

  • If proposing to serve professional providers within a single incorporated practice or other organizational provider (e.g. hospital or health system) including more than 10 professional providers with prescriptive privileges, regardless of their practice specialties, the amount of federally supported assistance to allocated to that practice shall not exceed the amount of assistance funding that would be allocated for 10 individual priority primary-care providers.




File Typeapplication/msword
File TitleReporting Requirements Identified in the FOA for the Full Application
AuthorDHHS
Last Modified BySeleda.Perryman
File Modified2009-08-26
File Created2009-08-26

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