Regional Extenion Center

Regional Extension Center Cooperative Agreement Program (CRM Tool)

0990- REC Operation Plan Template RECs.xls

Regional Extenion Center

OMB: 0990-0369

Document [xlsx]
Download: xlsx | pdf

Overview

Cover Page
Front page
Instructions
Contacts
Mission & Vision
Service Area
Providers & Patients
Baseline
Budget & Milestones
Org chart
Staff
Sub-Recipients
Stakeholders
Key activities
Gantt chart
Risk mitigation

Sheet 1: Cover Page
Form Approved
OMB No. 0990-NEW
Exp. Date 06/30/2010


According to the Paperwork Reduction Act of 1995, no persons are 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- . The time required to complete this information collection is estimated to average 1 hour, 30 minutes to complete, 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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Sheet 2: Front page
Jump to:







Instructions
ONC Regional Extension Center Operations Plan





Contacts







Mission & vision
This operations plan template is a guide for each REC to describe their plan for contributing to the REC Program's shared goal of bringing 100,000 primary care clinicians to meaningful use of electronic health records in 2010 and 2011.

Please click on Instructions for abbreviated instructions on using this Operations Plan tool. Please see the accompanying "Guidelines for REC Operations Planning" for detailed instructions and guidance on completing this plan.


Service area



Providers & patients



Baseline



Org chart



Staff







Sub-recipients







Stakeholders







Key activities







Gantt chart
Version history





Risk mitigation
REC Update Version REC Point of contact REC Signature REC approval date ONC Point of Contact ONC Signature ONC Approval Date









Data entry field







Reference field







Calculated field



































































































e.g., XXXXXX name of primary author e.g., mm/dd/yy e.g., mm/dd/yy name of ONC approver





















Budget and Milestone Reimbursement Rates







Original Request $-
Comments




ONC approved $-



Core Funding (years 1 + 2)* $-


Total Direct Assistance $-


Provider Target $-


Blended Rmbs Rate #DIV/0!












MILESTONE RATES



Milestone 1 #DIV/0!






Milestone 2 #DIV/0!






Milestone 3 #DIV/0!




Sheet 3: Instructions
Jump to Front Page






Legend


Data entry field


Reference field


Calculated field
ONC Regional Extension Center Operations Plan -- Description and Abbreviated Instructions


Please see the "REC Operations Planning Guidelines" for more detailed information on the Operational Plan


General instructions
The Operations Plan is the principle planning document for the REC. Like a business plan, it describes the goals & objectives of the REC and how the REC proposes to achieve these goals & objectives.



This Operations Plan template is provided to each REC as an aid to creating a realistic plan for meeting the REC's goals, and to standardize basic data collection and terminology to allow tracking and information-sharing across RECs.



This template is designed to capture structured data consistently across the entire REC program. Please do not alter the templates outside of the data input fields shaded in orange, as indicated in the legend to the left.


All worksheets have a "Comments" box at the bottom of the sheet where any comments or supporting detail may be entered.



In addition to the brief instructions provided here, more detailed guidance can be found in the "REC Operational Planning Guideline" document.


Contacts Please enter contact information for the REC and its Sub-Recipients as appropriate. (Note: Sub-recipients are those organizations or contractors that will receive Federal money for performing REC activities.) This will be the main input to ONC's REC contact list so please keep it updated as often as necessary.


Mission & vision The Mission & Vision section is designed to capture the RECs high-level statement about why it's activities are important, what it would like to accomplish, and how the REC's activities will affect health care delivery. Ideally, the mission and vision should define the RECs ambitions in a way that is meaningful to the RECs employees and stakeholders. Key questions that the mission statement should address are: what does the REC want to accomplish? what about the REC will make it well-positioned to accomplish its objectives? Key question that the vision statement should address include: what will the service area be like after the REC has accomplished its goals and fulfilled its mission? how will health care delivery in the service area be different than it is today? (note: the mission and vision statements are specific to the REC program and may be different than the mission and vision statements of the organization operating the REC)


Service area Geographic service area defines the state/territory, counties, and zip codes in which the REC will operate. For multi-state RECs, please enter state, county, and zip codes for each state separately in the columns provided. County and zip code information may be pasted into the worksheet from sources such as www.downloadzipcode.com or the US Postal Service.


Providers & patients This section describes key characteristics of the provider landscape and patient population in the REC's service area. Information in this section should match that of your REC's FOA response. US census data may be used for patient data. Data sources such as the AMA or Kaiser Family Foundation may be used for provider data.


Baseline The milestone and budget baselines are key elements of operational planning. Once established, the milestone and budget baselines are what the program will be tracked against for the remainder of the program. Baselines may be periodically adjusted to reflect new factors, however, such changes must be approved by ONC and recorded in this document. All of the succeeding sections of the Operations Plan should be geared to the goals reflected in the baseline.


Org chart The Org Chart section captures both the REC's relationships with stakeholders, partners, sub-recipients, and sub-contractors, and the internal organization structure of the REC itself.


Staff As described in the Funding Opportunity Announcement, the REC is required to provide a number of key functions that have been determined to be critical to success of the REC program. It is not necessary that the REC structure their organization with these position titles, and it is anticipated that individuals will perform more than one function. In order to ensure that all of the functions are being covered, and to allow knowledge-sharing and comparability across RECs, please map your current and anticipated employees and job titles with the prescribed functions.


Sub-recipients Sub-recipients are organizations identified in the Cooperative Agreement as recipients of award dollars. As such, they are key partners of the REC and contributors to its success.


Stakeholders Each REC will have a wide variety of stakeholders with whom it will have formal as well as informal relationships that taken together will form the RECs approach to achieving its objectives. Identifying stakeholder roles, responsibilites, and expectations are critical inputs to the development of an meaningful Operations Plan. Making this information available to ONC and other RECs will greatly facilitate the development of learning communities and channels for knowledge-sharing across RECs. Please categories the "level of commitment for each stakeholder using the following scale: Level 1 – Stakeholder is involved with REC; Level 2 – Stakeholder intends to make financial contribution to REC; Level 3 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC; Level 4 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC -and- intends to make financial contribution to REC.


Key activities The Key Activities are the high-level activity areas that the REC will conduct to fulfill the required functions articulated in the FOA. It is expected that the REC will itself have highly detailed project plans tracking day-to-day tasks and activities at the ground-level -- the REC Operational Plan does not require this level of detail and should only include the high-level "rollup" activities. (Note, the expectation is that 5-10 activities will be listed under each service area.)


Gantt chart The Gantt chart is simply a timeline of the Key activities defined above. The template is designed to provide a simple depiction of the activities and high-level timelines associated with each function. Please enter a "1" into the chart cells to change the color and illustrate the activity timeline. (Note: the months are calculated based on the project start date in the Baseline section)


Risk mitigation Each REC will face a number of challenges to achieving its goals. Some of these challenges will be common to all RECs, while others will be unique to the particular REC's organization characteristics and service area environment. It is important that each REC have as clear an understanding as possible of the risks that it faces and puts into place a proactive strategy for mitigating such risks to the greatest extent that is practical.

Sheet 4: Contacts
Jump to Front Page
















Legend
Primary contact information - (Main REC Office)





Data entry field
REC information





Reference field
Organization name
enter name



Calculated field
Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.myrecname.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number














Primary contacts







REC primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














REC secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














ONC GMO name
enter first and last name of ONC Grant Management Officer





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














ONC PO name
enter first and last name of ONC Project Officer





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Additional contact information - (REC Sub-Recipient Office)







Sub-Recipient information







Organization name
enter name





Street address
e.g., 12 Main Street





City
e.g., Springfield





State
pick from drop-down list





Zip code
e.g., 01234-0000





Website
e.g., www.organization.org





DUNS number
9 digit Dun and Bradstreet Data Universal Numbering System number





Primary contacts







Sub-Recipient primary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]














Sub-Recipient secondary contact name
enter first and last name





telephone number
enter 10 digit phone number





email address
e.g., [email protected]









































Comments

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sheet 5: Mission & Vision
Jump to Front Page






Legend
Mission statement for the REC Program
Data entry field
Double-click on box to type directly into it; use alt-enter to start new paragraph
Reference field


Calculated field













































Vision statement for the REC program


Double-click on box to type directly into it; use alt-enter to start new paragraph



























































Comments

















Sheet 6: Service Area
Jump to Front Page


















Legend
Geographic Service Area






Data entry field
For in counties in top of sheet; scroll down to fill in zip codes






Reference field








Calculated field
State or territory #1
State or territory #2
State or territory #3









Pick from drop-down list












Full names of counties (Boroughs for Alaska, Parishes for Louisiana)
Full names of counties (Boroughs for Alaska, Parishes for Louisiana)
Full names of counties (Boroughs for Alaska, Parishes for Louisiana)










Fill in full-name of county








County lists may be downloaded from external sources such as:








http://www.naco.org/Template.cfm?Section=Find_a_County


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Zip Codes Represented
Zip Codes Represented
Zip Codes Represented










Please enter 5 digit zip code








Zip code lists may be downloaded from external sources such as:








http://www.downloadzipcode.com/




























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Comments

































































































































































































































































































































































































































































































































Sheet 7: Providers & Patients
Jump to Front Page














Legend
General patient and provider landscape




Data entry field

Number



Reference field
Providers in service area




Calculated field
Total Providers (all specialties)






Primary Care Providers






Priority Primary Care Providers (PPCPs)






PPCPs Participating in REC and committed to attaining Meaningful Use (projected)
Note: This should match estimate provided in your FOA response




Non-PPCP Providers participating in REC projected)














Number of patients in REC Service Area by Age
Note: This is the number for all patients in service area, not just the patients the REC will serve




Age Under 19
Patient information may be found at




Age 19 to 64
http://www.communityhealth.hhs.gov/homepage.aspx?j=1




Age 65 to 84






Age 85+






Total -





Insurance coverage in REC Service Area






Number of patients on Medicare






Number of patients on Medicaid






Number of uninsured patients






















Provider baseline (list number of providers for each)







REC PPCP participants non-PPCP REC participants Non-participants Total Providers


Small Practice (fewer than 10 providers)


-


Public Hospital


-


Critical Access Hospital


-


Community Health Center


-


Rural Health Center


-


Other setting (please define):


-


Total - - - - These totals should correspond with Provider numbers above



Number of providers Number of providers Number of providers















Other health setting (mental health, dental, etc):














Comments













































Sheet 8: Baseline
Jump to Front Page


























































Legend




























Data entry field
Baseline summary


























Reference field




























Calculated field

Baseline version (last approved milestone baseline)




























Baseline document name Date

























































enter document name here mm/dd/yy

























































REC starting month Apr-10 Note: this date drives baseline months



























Month 2010

























































Baseline summary PPCPs




























Measures Year 1 Year 2 Total

























Milestone baseline




























M1: New Providers enrolled in program - - -

























M2: New Providers implemented on HER - - -

























M3: New Providers achieving meaningful use - - -























































Baseline summary Non-PPCPs




























Measures Year 1 Year 2 Total

























Milestone baseline




























M1: New Providers enrolled in program - - -

























M2: New Providers implemented on EHR - - -

























M3: New Providers achieving meaningful use - - -

















































































































Implementation goal PPCPs (baseline)



























































Implementation goal -- PPCPs without EHRs




























Please enter number of new providers projected to hit milestone each month and not the cumulative total




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month























-



M2: New Providers implemented on EHR each month























-



M3: New Providers achieving meaningful use each month























-



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -


































Implementation goal -- PPCPs with EHRs




























Please enter number of new providers projected to hit milestone each month and not the cumulative total




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month























-



M3: New Providers achieving meaningful use each month























-



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -


































Implementation goal -- total




























Calculated table




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month - - - - - - - - - - - - - - - - - - - - - - - - -



M2: New Providers implemented on EHR each month - - - - - - - - - - - - - - - - - - - - - - - - -



M3: New Providers achieving meaningful use each month - - - - - - - - - - - - - - - - - - - - - - - - -



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -































































Implementation goal Non-PPCPs (baseline)



























































Implementation goal -- Non-PPCPs without EHRs




























Please enter number of new providers projected to hit milestone each month and not the cumulative total




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month























-



M2: New Providers implemented on EHR each month























-



M3: New Providers achieving meaningful use each month























-



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -


































Implementation goal -- Non-PPCPs with EHRs




























Please enter number of new providers projected to hit milestone each month and not the cumulative total




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month























-



M3: New Providers achieving meaningful use each month























-



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -


































Implementation goal -- total




























Calculated table




























Implementation milestone Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Total




Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12




M1: New Providers enrolled in program each month - - - - - - - - - - - - - - - - - - - - - - - - -



M2: New Providers implemented on EHR each month - - - - - - - - - - - - - - - - - - - - - - - - -



M3: New Providers achieving meaningful use each month - - - - - - - - - - - - - - - - - - - - - - - - -



Monthly total - - - - - - - - - - - - - - - - - - - - - - - - -



Cumulative total - - - - - - - - - - - - - - - - - - - - - - - -



























































































































Comments



















































































































































































































































Sheet 9: Budget & Milestones
REC name here


Original Request


ONC approved


Core Funding (years 1 + 2)*
*this number is for planning purposes and does not denote ONC approval of any pending core funds change requests.
Total Direct Assistance $-
Provider Target
Blended Provider Reimbursement Rate #DIV/0!


































Milestone Reimbursement Rates

Blended Rate Broken Out Rate


Providers on Paper Providers on EHR
Provider Target 0 0 0
Blended Reimbursement Rate #DIV/0! $- #DIV/0!
Total Direct Assistance #DIV/0! $- #DIV/0!


#DIV/0!
Milestone 1 #DIV/0! $- #DIV/0!
Milestone 2 #DIV/0! $- #DIV/0!
Milestone 3 #DIV/0! $- #DIV/0!






*The broken-out rate calculation tool is OPTIONAL.


*These cells are flexible and unprotected.

















Comments










Sheet 10: Org chart
Jump to Front Page






















Legend










Data entry field










Reference field










Calculated field
REC relationships with sub-recipients, partners, and stakeholders










Please modify the diagram as appropriate to show how your REC connects with other stakeholders and partners

































































































































































































































































































































































































































































REC organization chart










Please modify the diagram as appropriate to show the organization of your REC and its Sub-Recipients




This should include only staff for organizations that will receive funding through the REC













































































































































































Comments


























Sheet 11: Staff
Jump to Front Page
















Legend
Staff list





Data entry field
REC functional role Organization Name Title Newly Hired? (Y/N) Phone number Email
Reference field
Authorized Representative





Calculated field
Project Director







Finance Lead







Clinical Lead







Education and Outreach Coordinator







Vendor Selection Coordinator







Practice and Workflow Design Coordinator







Interoperability and HIE Coodinator







Implementation Project Management Coordinator







Privacy and Security Coordinator







Meaningful Use Coordinator







Workforce Coordinator







CRM Coordinator







Other (please specify)







Other (please specify)







Other (please specify)







Other (please specify)







Other (please specify)







Role as defined in FOA
First name last name Position title Y or N e.g., xxx-xxx-xxxx






































Comments

















































































































































































Y







N

Sheet 12: Sub-Recipients
Jump to Front Page






















Legend
Sub-recipient list








Data entry field
Sub Recipient Name Description of Role in REC DUNS number Street Address City State Congressional District Amount of Award Amount of Award Distributioned Sub Award Date
Reference field










Calculated field
























































































































































































































































































































































































































































































































Comments

















































































Sheet 13: Stakeholders
Jump to Front Page




















Legend









Data entry field









Reference field









Calculated field











Stakeholders









Organization type Organization name Contact Name Phone Email Role Level of Stakeholder Support (levels below) Affliated National Organization


Independent Provider Organizations









Health Professional Societies









State Primary Care Assocations









Health Center Controlled Networks (HCCNs)









Federally Qualified Health Centers









Rural Health Centers









Other Community Health Centers









State/Local/Tribal Government (Public health, health care, or other partnering institution)









State Health Information Exchange Coordinator









State Medicaid Director









Health Plans









Hospital Systems









Public Hospital









Critical Access Hospitals









Laboratories









Community colleges









Local workforce programs









Medicare Quality Improvement Organizations









Federal Stakeholders (HHS regional office, VA, IHS, etc.)









Other (please specify)









Other (please specify)









Other (please specify)









Other (please specify)









Other (please specify)









Other (please specify)















Level 1 – Stakeholder is involved with REC









Level 2 – Stakeholder intends to make financial contribution to REC









Level 3 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC









Level 4 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC -and- intends to make financial contribution to REC














Comments








































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Sheet 14: Key activities
Jump to Front Page
















Legend







Data entry field







Reference field
Key activities





Calculated field
Insert rows as necessary below







Service area Description of Service Area and each activity Goal of each activity REC Staff Subcontractors/Partners Activities/Dates/Outcomes Challenges Requiring Support and/or Assistance


Outreach & education







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Vendor selection







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Practice & workflow design







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Interoperability and HIE







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Implementation support







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Privacy & security







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Meaningful use







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







Workforce







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)







CRM







activity 1 (please specify)







activity 2 (please specify)







activity 3 (please specify)







activity 4 (please specify)







activity 5 (please specify)


































Comments






















































Sheet 15: Gantt chart
Jump to Front Page




















































Legend
Gantt chart























Data entry field
Please type a "1" in the cell indicating activity/month as per your plan























Reference field
Insert rows as necessary below























Calculated field
Service area Apr-2010 May-2010 Jun-2010 Jul-2010 Aug-2010 Sep-2010 Oct-2010 Nov-2010 Dec-2010 Jan-2011 Feb-2011 Mar-2011 Apr-2011 May-2011 Jun-2011 Jul-2011 Aug-2011 Sep-2011 Oct-2011 Nov-2011 Dec-2011 Jan-2012 Feb-2012 Mar-2012


Outreach & education

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Vendor selection

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Practice & workflow design

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Interoperability and HIE

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Implementation support

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Privacy & security

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Meaningful use

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Workforce

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































CRM

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Organizational development

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)




















































Other (please specify)

























activity 1 (please specify)

























activity 2 (please specify)

























activity 3 (please specify)

























activity 4 (please specify)

























activity 5 (please specify)





































































































































Comments








































































































































































Sheet 16: Risk mitigation
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Legend
Key risks and mitigation steps




Data entry field
Insert rows as necessary below; please indicate "none" as applicable; double-click on cell to see entire cell




Reference field
Category Detailed description Risk/restriction mitigation steps Risk Likelihood [1=least likely, 10=most likely] Risk Impact [1=least impact, 10=most impact]
Calculated field
Grant restrictions






restriction 1 (please specify)






restriction 2 (please specify)






Outreach & education






risk 1 (please specify)






risk 2 (please specify)














Vendor selection






risk 1 (please specify)






risk 2 (please specify)














Practice & workflow design






risk 1 (please specify)






risk 2 (please specify)














Interoperability and HIE






risk 1 (please specify)






risk 2 (please specify)














Implementation support






risk 1 (please specify)






risk 2 (please specify)














Privacy & security






risk 1 (please specify)






risk 2 (please specify)














Meaningful use






risk 1 (please specify)






risk 2 (please specify)














Workforce






risk 1 (please specify)






risk 2 (please specify)














CRM






risk 1 (please specify)






risk 2 (please specify)













Organization






risk 1 (please specify)






risk 2 (please specify)














Sustainability






risk 1 (please specify)






risk 2 (please specify)














Other (please specify)






risk 1 (please specify)






risk 2 (please specify)














































Comments





































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File Modified2010-10-21
File Created2010-01-13
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