Form 1 PIMS

DRAFT OMB Number:

Expiration Date:

Office of Rural Health Policy: Rural Health

Community-Based Grant Programs

Performance Improvement and Measurement System (PIMS) Database

Public Burden Statement: 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 OMB control number for this project is 0915-0319. Public reporting burden for this collection of information is estimated to be 3.77 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room Rockville, Maryland, 20857.

Rural Health Information Technology Network Development Grant Program (RHITND)

The purpose of the RHITND Program is to improve health care and support the adoption of Health Information Technology (HIT) in rural America by providing targeted HIT support to rural health networks. HIT plays a significant role in the advancement of Health and Human Services’ (HHS) priority policies to improve health care delivery. Some of these priorities include:

• improving health care quality, safety, efficiency and reducing disparities,

• engaging patients and families in managing their health,

• enhancing care coordination,

• improving population and public health and

• ensuring adequate privacy and security of health information.

Table 1: ACCESS TO CARE

Instructions:

Information collected in this table provides an aggregate count of the number of counties within the service area which may or may not be the total population residing within the service area. Please indicate a numerical figure or DK for do not know, if applicable.

Number of counties

• End of the budget year number is the number of counties served at the end of the budget year.

• Denotes the number of counties served through the program. Please include entire, as well as partial counties served through the grant program. If your project is serving only a fraction of a county, please count that as one (1) county.

1	Number of counties: (If you serve a sub-county area please count this as 1)	End of budget year number
	Number of counties served in program

Table 2: POPULATION DEMOGRAPHICS

Instructions:

The Baseline Number 9/1/2011 column is the initial number when the grant was awarded and only applies to #2.

Number of people in service population

Denotes the total number of people in your service population (not necessarily the number of people who availed your services). For example, the number of persons impacted by the services rendered by network partners.

Please provide the number of people in your service population by race, ethnicity, and age. The service population may or may not be the total population residing within the service area. If the number of people is zero (0), please put zero (0)_in the appropriate section; do not leave any sections blank.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino). Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)

Network Service Population		Baseline Number (prior to 9/1/2011)	End of budget year number
2	Number of people in the service population (as defined in your grant application)

Population Demographics		End of budget year number
3	Number in service population by ethnicity:
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
4	Number in service population by race:
	American Indian/Alaska Native
	Asian
	Black or African American
	Native Hawaiian/Other Pacific Islander
	White
	More than one race
	Unknown

Table 3: STAFFING/WORKFORCE

Instructions:

Please provide the number of Full-Time Equivalents (FTEs) for clinical and non-clinical staff recruited in the project and the total number of staff FTEs that are shared between two or more Network partners.  Please provide the staff FTE at the end of the grant award (2011), the number of new HIT FTE staff recruited, and the total number of staff FTEs. 

5	Number of new clinical staff recruited to work on the project:	End of budget year number
	Clinician/Practitioner Consultants
	Physician
	Dentist
	Podiatrist
	Optometrist
	Chiropractor
	Nurse Practitioner
	Physician Assistant
	Certified nurse midwife
	Other-Specify Type
	None
	TOTAL
6	Number of new non-clinical staff recruited to work on the project:
	Technical/Software Support
	Project Manager
	Trainers
	Health IT Specialist
	Other – Specify Type and Title
	None
	TOTAL
7	Number of staff positions shared between two or more Network Partners. (Please indicate if they are FTEs or part-time positions.)
8	Number of staff with HIT-training obtained through HRSA grant funds. (HIT training is defined as courses specifically related to planning, selecting, implementing, and managing electronic health records and other health information technology.)
9	Type of HIT Training (check all that apply):
	Seminars
	College-level courses
	Self-taught
	Webinar
	Federally-sponsored training
	Association meeting
	Other- Specify Type and Sponsor

Table 4: NETWORK

Instructions:

Please identify the total number of formal member organizations in the consortium or network, as well as the types of member organizations by non-profit and for-profit status and organization type. Please indicate a number for each category. The Baseline Number 9/1/2011 column is the initial number when the grant was awarded and only applies to #10-12.

Then, of the total, please provide the number of new member organizations that joined within the budget year. Please refer to the detailed definitions for consortium/networks in the program guidance. Please also indicate the number of health care providers, professionals and critical access hospitals that are eligible for the Medicare and Medicaid EHR Incentive Program.

Network Size		Baseline Number 9/1/2011	Number joined this budget year number
10	Number of non-profit member organizations in the consortium or network
11	Number of for-profit member organizations in the consortium or network
12	Number of member organizations in the Consortium/Network
	Area Health Education Center (AHEC)
	Community College
	Community Health Center
	Critical Access Hospital
	Faith-Based Organization
	Federally Qualified Health Center (FQHC)
	Health Center Controlled Network (HCCN)
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University/College
	Other – Specify Type:

Network Characteristics		Number joined this budget year
13	Total number of health care providers in the network that are eligible for the Medicare and Medicaid EHR Incentive Program
14	Number of eligible professionals
15	Number of critical access hospitals
16	Number of hospitals

Table 5: SUSTAINABILITY

Instructions:

Please provide the following funding/revenue amounts:

• The annual program award based on box 12a of your Notice of Grant Award (NGA) or Notice of Award (NoA).

• The amount of annual revenue (if any) for the Network.

• The amount of additional funding secured to sustain the program.

• Please provide the estimated amount of savings due to participation in a network/consortium (Consider shared staff, training, equipment, etc.)

• Please indicate if you have a sustainability plan and select your sustainability activities.

If the total amount of additional funding secured is zero (0), please put zero in the appropriate section. Do not leave any sections blank.

Please identify the source(s) of revenue for sustainability and indicate whether you have developed a sustainability plan. Please identify the types of sustainability activities that the network/consortium engaged in during the respective budget year; please check all that apply.

Please indicate if you used HRSA’s Economic Impact Analysis Tool (www.raconline.org,

go to “Find Resources” at the bottom of the page, Click “Tools for Success”). If so, please provide the ratio for Economic Impact vs. HRSA Program Funding.

17	Funding/Revenue:	Dollar Amount
	Annual program award
	Annual network revenue
	Additional funding secured to assist in sustaining the project
	Does the network have a sustainability plan that has been approved by the network’s membership?	Y/N
	Does the network have alternate sources of revenue, other than grants, as a part of the sustainability plan? If yes, what is the dollar amount?	Y/N
	Estimated amount of cost-savings due to participation in the network
18	Sources of Network Revenue: (Check all that apply)	Selection list
	Network Business Revenue
	In-Kind Contributions
	Project Member Dues
	Fundraising
	Contractual Services
	Other – Specify Type:
	None
19	HIT Sustainability Activities (Partnerships):	Selection list
	The number of network members that participate in a state-designated Health Information Exchange (HIE)?	Number
	Local, State and/or Federal program collaboration (i.e.: Regional Extension Centers (REC), Health Center Controlled Networks (HCCN), Office of the National Coordinator, Regional Health Information Organization(RHIO),Federally Qualified Health Center (FQHC), Federal Communication Commission (FCC), etc.)	Specify program type & name
20	HIT Sustainability Activities:	Check all that apply
	Media campaigns
	Consolidation of activities, services and purchases (with Network partners)
	Communication plan development
	Economic impact analysis
	Return on investment analysis
	Marketing plan development
	Community engagement activities
	Business plan development
	Incorporation
	Organization bylaws
	SWOT analysis
	Sustainability plan
	Other – Specify activity:
21	Did you use the HRSA Economic Impact tool?	Y/N
22	If yes, what was the ratio for Economic Impact vs. HRSA Program Funding	Number
23	Will the Network/Consortium sustain beyond the Federal funding period?	Y/N
24	What activities of the Network/Consortium will sustain?	Y/N
25	Will Network sponsored-HIT training continue after HRSA/ORHP funding ends?	Y/N
26	If HRSA/ORHP supported the maintenance of the EHR system, will maintenance of the EHR system continue after HRSA/ORHP funding ends?	Y/N

Table 6: HEALTH INFORMATION TECHNOLOGY

Instructions:

Please select all types of technology implemented, expanded or strengthened through this program. If your grant program did not fund these activities, please select “Not Applicable.” Please select all of the Meaningful Use Stage 1 criteria achieved through this program for each partner, and indicate the number of partners in the space provided.

Please specify the Health Information Technology (HIT) Meaningful Use Stage 1 criteria that the network/consortium organization as a whole has attained. If the network/consortium has been funded to complete these activities, but has not acquired HIT, please mark “None”.

Please refer to the detailed definition for consortium/networks, as defined by program guidance and please refer to the detailed definition for HIT Meaningful Use Stage.

27	Type(s) of technology implemented, expanded or strengthened through this program:	Selection list. Choose the appropriate number:
	Computerized laboratory functions
	e-prescribing
	Inpatient pharmacy
	Outpatient pharmacy
	CPOE (computerized Physician Order Entry)
	Practice Management System
	Email
	Electronic clinical applications
	Certified Electronic Medical Records
	Health Information Exchange
	Patient/Disease Registry
	Other – Please specify criteria
28	Are the EHR systems ONC certified?	Y/N
29	How many of your members have attested to Meaningful Use?	Number
30	How many of your network members have received Medicare or Medicaid incentive payments?	Number
	Of the network members receiving Medicare or Medicaid incentive payments, how much have each of them received?	Amount (for each partner)
31	Indicate the number of members that have achieved each HIT Meaningful Use Stage 1 implementation criteria listed.	Selection list
	A. Eligible Professionals –10 Menu Objectives
	Drug-formulary checks
	Incorporate clinical lab test results as structured data
	Generate lists of patients by specific conditions
	Send reminders to patients per patient preference for preventive/follow up care
	Provide patients with timely electronic access to their health information
	Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate
	Medication reconciliation
	Summary of care record for each transition of care/referrals
	Capability to submit electronic data to immunization registries/systems
	Capability to provide electronic syndromic surveillance data to public health agencies
	B. Hospitals–10 Menu Objectives
	Drug-formulary checks
	Record advanced directives for patients 65 years or older
	Incorporate clinical lab test results as structured data
	Generate lists of patients by specific conditions
	Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate
	Medication reconciliation
	Summary of care record for each transition of care/referrals
	Capability to submit electronic data to immunization registries/systems
	Capability to provide electronic submission of reportable lab results to public health agencies
	Capability to provide electronic syndromic surveillance data to public health agencies

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