Form 1 Attachment 1

Attachment 1

Form Approved

OMB No. 0990-XXXX

Exp. Date xx/xx/xxxx

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. It is entered on the SF 424. 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, though applicants should allow a minimum of five days to complete the CCR registration.

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. Applicants should prepare a clear, accurate, concise abstract that can be understood without reference to other parts of the application and which gives a description of the proposed project, including: the project’s goal(s), objectives, overall approach (including target population and significant partnerships), anticipated outcomes, products, and duration. Detailed instructions for completing the summary/abstract are included in Appendix L of this document.

The Project Abstract must be double-spaced with a font size of not less than 11 point.

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

• Project Title

• States/territories included in the application

• Applicant Name

• Address

• Contact Name

• Contact Phone Numbers (Voice, Fax)

• E-Mail Address

• Web Site Address, if applicable

• Congressional districts within your service area

• Brief explanation of where the state is in achieving statewide HIE among healthcare providers

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.

The Project Abstract must include a brief description of the proposed cooperative agreement, how the activities support and will enhance HIE services across all health care and public health stakeholders, the current status of the state’s efforts, the need(s) to be met with the funds, the design and scope of the state’s plan.

Project Narrative

The Project Narrative is the most important part of the application, since it will be used as the primary basis to determine whether or not the application meets the minimum requirements for funding. The Project Narrative must provide a detailed picture of the current state of HIE in the state (and at the multi-state level, if applicable) and must describe the needs of specific geographic areas of the state to achieve greater availability and use of electronic health information exchange. The Project Narrative is in addition to the outlined State Plan (Strategic and Operational). The narrative must provide the reader with an understanding of the state’s current efforts and what activities are planned through the State HIE Program to implement health information exchange across the state or region. As appropriate, applicants should reference the pathway to HIE and the five critical domains discussed above.

The Project Narrative must be double-spaced, on 8 ½” x 11” papers with 1” margins on both sides, and a font size of not less than 11. Smaller font sizes may be used to fill in the Standard Forms and Sample Formats. The suggested length for the Project Narrative is 25 to 40 pages; 40 pages is the maximum length allowed. ONC will not accept applications with a Project Narrative that exceeds 40 pages. The State Plans (Strategic and Operational Plans), Governor’s Designation Letter, Project Abstract, Letters of Commitment, and Resumes of Key Personnel are not counted as part of the Project Narrative for purposes of the 40-page limit, but all of the other sections noted below are included in the limit.

The components of the Project Narrative counted as part of the 40 page limit include:

• Current State

• Proposed Project Strategy

• Required Performance Measures

• Project Management

• Evaluation

• Organizational Capability Statement

The Project Narrative is a critical part of the application as it will be used as the primary basis to determine whether or not the application meets the minimum requirements for funding under the HITECH Act. The Project Narrative should provide a clear and concise description of the project. ONC recommends that the project narrative include the following components:

Current State

In this section applicants shall:

• Discuss and determine the current status of the state’s progress in achieving statewide HIE among healthcare providers, including:

  • Electronic eligibility and claims transactions

  • Electronic prescribing and refill requests

  • Electronic clinical laboratory ordering and results delivery

  • Electronic public health reporting (immunizations, notifiable laboratory results)

  • Quality reporting capabilities

  • Prescription fill status and/or medication fill history

  • Clinical summary exchange for care coordination and patient engagement.

• Describe the progress and status of the state in its project planning and implementation as described in Section I.E.1., Self-Assessment of the State’s Current Status.

Proposed Project Summary

This section should provide a clear and concise description of activities funded by the cooperative agreement to develop, finalize and maintain Strategic and Operational plans to increase the extent of electronic information exchange for the HIE program objectives. It is not expected to be a summary of a state’s existing state plans. Applicants must articulate the rationale for the overall approach to the project. Also note any major barriers anticipated to be encountered and how the project will be able to overcome those barriers. The project summary should include all portions required but applicants may frame their answers according to their current status (whether the state has an existing plan or intends to develop or finalize one using federal funds). It is expected that those applicants with plans will have more fully developed and final responses while those without applications may address intended approaches to be used. The proposed summary shall include:

• For states without existing state plans at the time of application, a description of the approach the applicant proposes to develop and finalize such a plan.

• For states with existing state plans at time of application, a description of the approach the applicant proposes to implement the plan including the mechanisms to overcome obstacles and a realistic and achievable high-level project plan and timeline.

• A discussion of approach to be employed to ensure compliance with the Privacy and Security requirements for Health IT as outlined in Section I.F.2., Privacy and Security.

• A description of the proposed communications strategy with key stakeholders and the health community.

• A description of how the applicant plans to involve community-based organizations in a meaningful way in the planning and implementation of the proposal project. This section should also describe how the proposed intervention will target medically underserved populations, and the needs of special populations including newborns, children, youth, including those in foster care, the elderly, persons with disabilities, Limited English Proficiency (LEP) persons, persons with mental and substance use disorders, and those in long term care.

• A discussion of how the interests of the stakeholders below will be considered and incorporated into planning and implementation activities.

  • Health care providers, including providers that provide services to low income and underserved populations

  • Health plans

  • Patient or consumer organizations that represent the population to be served

  • Health information technology vendors

  • Health care purchasers and employers

  • Public health agencies

  • Health professions schools, universities and colleges

  • Clinical researchers

  • Other users of health information technology such as the support and clerical staff of providers and others involved in the care coordination of patients

• Additionally, for those submitting collaborative applications (multi-state/territory), a discussion that:

  • Demonstrates that the application represents the best interest of each state or territory involved in the consortium.

  • Documents how financial accountability will be assured, so that risks and challenges faced by one member of the collaborative do not impede the progress of another member and develop a reporting mechanism that tracks expenditures and activities by state.

  • Describes how governance standards will be met, to include governance structures at the state/territory level that is represented within a collaborative governance structure.

  • Documents how financial accountability will be assured, so that risks and challenges faced by one member of the collaborative do not impede the progress of another member.

  • Ensures that sufficient funds will be available to each state/territory for planning at the state level.

Required Performance Measures and Reporting

Reporting and Performance Measures are required for applicants requesting funding for planning or implementation activities. Reporting Requirements must be submitted by applicants requesting funding for planning and/or implementation activities. Once a recipient has entered into implementation activities, the Performance Measures become ongoing requirements.

The applicant shall provide detailed information in the application about the methodologies, tools, and strategies they intend to use to collect all data, including the reporting requirements and performance measures, for the project to satisfy the reporting requirements of this program and the Government Performance Reporting Act of 2003. Other performance measures specific to ARRA reporting are required and provided in Appendix G. ARRA reporting requirements will also be included in the Notice of Award. The performance measures will be used as part of the state and/or national program evaluation. As the program evolves, additional requirements may be provided through program guidance.

Specific reporting requirements, performance and evaluation measures and methods to collect data and evaluate project performance will be provided at a later date in program guidance and through technical assistance, prior to award of cooperative agreements. These measures will include those related to the following domains: governance, finance, technical infrastructure, business and technical operations, and legal/policy. The core set of reporting requirements and performance measures enables states to monitor their own progress, and when aggregated across recipients, provides ONC with a national view of progress across the program. The core set of reporting requirements and performance measures includes but are not limited to:

Reporting Requirements

(Required for those requesting funding for planning and/or implementation activities)

• Governance

  • What proportion of the governing organization is represented by public stakeholders?

  • What proportion of the governing organization is represented by private sector stakeholders?

  • Does the governing organization represent government, public health, hospitals, employers, providers, payers and consumers?

  • Does the state Medicaid agency have a designated governance role in the organization?

  • Has the governing organization adopted a strategic plan for statewide HIT?

  • Has the governing organization approved and started implementation of an operational plan for statewide HIT?

  • Are governing organization meetings posted and open to the public?

  • Do regional HIE initiatives have a designated governance role in the organization?

• Finance

  • Has the organization developed and implemented financial policies and procedures consistent with state and federal requirements?

  • Does organization receive revenue from both public and private organizations?

  • What proportion of the sources of funding to advance statewide HIE are obtained from federal assistance, state assistance, other charitable contributions, and revenue from HIE services?

  • Of other charitable contributions listed above, what proportion of funding comes from health care providers, employers, health plans, and others (please specify)?

  • Has the organization developed a business plan that includes a financial sustainability plan?

  • Does the governance organization review the budget with the oversight board on a quarterly basis?

  • Does the recipient comply with the Single Audit requirements of OMB?

  • Is there a secure revenue stream to support sustainable business operations throughout and beyond the performance period?

• Technical Infrastructure

  • Is the statewide technical architecture for HIE developed and ready for implementation according to HIE model(s) chosen by the governance organization?

  • Does statewide technical infrastructure integrate state-specific Medicaid management information systems?

  • Does statewide technical infrastructure integrate regional HIE?

  • What proportion of healthcare providers in the state are able to send electronic health information using components of the statewide HIE Technical infrastructure?

  • What proportion of healthcare providers in the state are able to receive electronic health information using components of the statewide HIE Technical infrastructure?

• Business and Technical Operations

• Is technical assistance available to those developing HIE services?

• Is the statewide governance organization monitoring and planning for remediation of HIE as necessary throughout the state?

• What percent of health care providers have access to broadband?

• What statewide shared services or other statewide technical resources are developed and implemented to address business and technical operations?

• Legal/Policy

  • Has the governance organization developed and implemented privacy policies and procedures consistent with state and federal requirements?

  • How many trust agreements have been signed?

  • Do privacy policies, procedures and trust agreements incorporate provisions allowing for public health data use?

Performance Measures

The following measures are applicable to the implementation phase of the cooperative agreement. They are an initial set of measures intended to give a state specific and national perspective on the degree of provider participation in HIE enabled state level technical services and the degree to which pharmacies and clinical laboratories are active trading partners in HIE. E-prescribing and laboratory results reporting are two of the most common types of HIE within and across states.

• Percent of providers participating in HIE services enabled by statewide directories or shared services.¹

• Percent of pharmacies serving people within the state that are actively supporting electronic prescribing and refill requests.

• Percent of clinical laboratories serving people within the state that are actively supporting electronic ordering and results reporting.

Recipients will also be required to report on additional measures that will indicate the degree of provider participation in different types of HIE particularly those required for meaningful use.

Future areas for performance measures that will be specified in program guidance will include but are not limited to: providers’ use of electronic prescribing, exchange of clinical summaries among treating providers, immunization, quality and other public health reporting and eligibility checking.

Project Management

This section should include a clear delineation of the roles and responsibilities of project staff, consultants and partner organizations, and how they will contribute to achieving the project’s objectives and outcomes. It should specify who would have day-to-day responsibility for key tasks such as: leadership of project; monitoring the project’s on-going progress, preparation of reports, and communications with other partners and ONC. It should also describe the approach that will be used to monitor and track progress on the project’s tasks and objectives.

Evaluation

This section should describe the method(s), techniques and tools that will be used to track and maintain project information expected to be required for the state to conduct a self-evaluation of the project and to inform a national program-level evaluation.

Organizational Capability Statement

Each application shall include an organizational capability statement. The organizational capability statement should describe how the applicant agency (or the particular division of a larger agency that will have responsibility for this project) is organized, the nature and scope of its work and/or the capabilities it possesses. It should also include the organization’s capability to sustain some or all project activities after federal financial assistance has ended. It must define who is considered key staff and the applicant must provide resumes for each key staff member in the attachments to the application, which are not included in the page limitation.

This description should cover capabilities of the applicant agency, such as any current or previous relevant experience and/or the record of the project team in preparing cogent and useful reports, publications, and other products. If appropriate, include in the attachments an organization chart showing the relationship of the project to the current organization, which will not count toward the page will limit. Also include information about any contractual organization(s) that will have a significant role(s) in implementing project and achieving project goals.

Required Plans

If, at the time of application, the applicant has a state plan (Strategic or Operational) that is either consistent or not consistent with planning guidance in this document, it should be included with this application.

Applicants that have plans that are not consistent with the planning guidance may take the time during application period to revise their Strategic and Operational Plans to be consistent with planning guidance, if they choose. The applicant should indicate if the State Plan submitted with this application is submitted for official approval by the National Coordinator.

Collaborations and Letters of Commitment from Key Participating Organizations and Agencies

The applicant shall fully describe the current relationships established to meet the State’s HIE goals. If there are relationships that have yet to be formalized, provide a plan for engaging these groups. The applicant must also include, in an attachment to the application, a copy of the interagency agreement (or similar document) that outlines the parameters of such relationships. At a minimum this section must explain the demonstrated commitment on the part of the state government and how the state and project coordinate with critical stakeholders.

Include confirmation of the financial or in-kind commitments to the project (should it be funded) made by key collaborating organizations and agencies in this part of the application. Any organization that is specifically named to have a significant role in carrying out the project should be considered an key collaborating organization and a letter of support should be included for each. For applications submitted electronically via grants.gov, signed letters of commitment should be scanned and included as attachments. These letters should not be considered as part of the 25 page limit. A template for these letters can be found in Appendix E.

Budget Narrative/Justification

All applicants are required to outline proposed costs that support all project activities in the Budget Narrative/Justification. The application must include the allowable activities that will take place during the funding period and outline the estimated costs that will be used specifically in support of the program. Costs are not allowed to be expended until the start date listed in the Notice of Grant Award. All costs must be allowable, allocable, reasonable and necessary under the applicable OMB Cost Circular: www.whitehouse.gov/omb/circulars (Circular A-87 for States and Circular A-122 for SDEs) and based on the programmatic requirements for administering the program as outlined in ARRA.

Prior to the application due date, and after submission of the required letter of intent, eligible applicants will be provided an allocation amount for the proposed project period. This figure will be determined as described in Section G.2 – Other Funding Information, below. This amount plus required match should be the total of all allowable project costs for the four year project period. Applicants are required to submit a one year budget for each of the four years of the project period.

Applicants are suggested to use the format included as Appendix K of this Funding Opportunity Announcement. Applicants are also encouraged to pay particular attention to Appendix J, which provides an example of the level of detail sought. A combined multi-year Budget Narrative/Justification, as well as a detailed Budget Narrative/Justification for each year of potential grant funding is required. Instructions are also included in Appendix I as they pertain to completing the SF 424.

Attachment 2

Budget Narrative/Justification ––Template

Object Class Category	Federal Funds	Non-Federal Cash	Non-Federal In-Kind	TOTAL	Justification
Personnel
Fringe Benefits
Travel
Equipment
Supplies
Contractual
Other
Indirect Charges
TOTAL

Attachment 3

Survey instructions on Ensuring Equal Opportunity for Applicants

Applicant Organization’s Name: _________________________________________________

Applicant’s DUNS Number: ___________________

Grant Name: ____________________________________________CFDA Number: _____________

1. Does the applicant have 501(c)(3) status? Yes No	4. Is the applicant a faith-based/religious organization? Yes No
2. How many full-time equivalent employees does the applicant have? (Check only one box). 3 or Fewer 15-50 4-5 51-100 6-14 over 100	5. Is the applicant a non-religious community-based organization? Yes No
3. What is the size of the applicant’s annual budget? (Check only one box.) Less Than $150,000 $150,000 - $299,999 $300,000 - $499,999 $500,000 - $999,999 $1,000,000 - $4,999,999 $5,000,000 or more	6. Is the applicant an intermediary that will manage the grant on behalf of other organizations? Yes No
	7. Has the applicant ever received a government grant or contract (federal, State, or local)? Yes No
	8. Is the applicant a local affiliate of a national organization? Yes No

1 ONC will negotiate with each state to determine best way to further specify this measure based on the statewide directories and shared services pursued within each state under this program.