Attachment F Federal Register Notice

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Federal Register / Vol. 78, No. 74 / Wednesday, April 17, 2013 / Notices

First National Bank of Menahga &
Sebeka, Menahga, Minnesota.
Board of Governors of the Federal Reserve
System, April 12, 2013.
Margaret McCloskey Shanks,
Deputy Secretary of the Board.

By order of the Federal Open Market
Committee, April 10, 2013.
William B. English,
Secretary, Federal Open Market Committee.
[FR Doc. 2013–08952 Filed 4–16–13; 8:45 am]
BILLING CODE 6210–01–P

[FR Doc. 2013–09031 Filed 4–16–13; 8:45 am]
BILLING CODE 6210–01–P

FEDERAL RETIREMENT THRIFT
INVESTMENT BOARD

FEDERAL RESERVE SYSTEM

Sunshine Act; Notice of Meeting

Federal Open Market Committee;
Domestic Policy Directive of March 19–
20, 2013

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In accordance with Section 271.25 of
its rules regarding availability of
information (12 CFR part 271), there is
set forth below the domestic policy
directive issued by the Federal Open
Market Committee at its meeting held
on March 19–20, 2013.1
Consistent with its statutory mandate,
the Federal Open Market Committee
seeks monetary and financial conditions
that will foster maximum employment
and price stability. In particular, the
Committee seeks conditions in reserve
markets consistent with federal funds
trading in a range from 0 to 1⁄4 percent.
The Committee directs the Desk to
undertake open market operations as
necessary to maintain such conditions.
The Desk is directed to continue
purchasing longer-term Treasury
securities at a pace of about $45 billion
per month and to continue purchasing
agency mortgage-backed securities at a
pace of about $40 billion per month.
The Committee also directs the Desk to
engage in dollar roll and coupon swap
transactions as necessary to facilitate
settlement of the Federal Reserve’s
agency mortgage-backed securities
transactions. The Committee directs the
Desk to maintain its policy of rolling
over maturing Treasury securities into
new issues and its policy of reinvesting
principal payments on all agency debt
and agency mortgage-backed securities
in agency mortgage-backed securities.
The System Open Market Account
Manager and the Secretary will keep the
Committee informed of ongoing
developments regarding the System’s
balance sheet that could affect the
attainment over time of the Committee’s
objectives of maximum employment
and price stability.

9:00 a.m. (Eastern Time)
April 22, 2013.
PLACE: 10th Floor Training Room, 77 K
Street NE., Washington, DC 20002.
STATUS: Parts will be open to the public
and parts closed to the public.
MATTERS TO BE CONSIDERED:
TIME AND DATE:

Parts Open to the Public
1. Approval of the Minutes of the March
25, 2013 Board Member Meeting
2. Approval of the Minutes of the
October 9, 2012 ETAC Meeting
3. Thrift Savings Plan Activity Reports
by the Executive Director
a. Monthly Participant Activity Report
b. Quarterly Investment Policy Report
c. Legislative Report
4. Quarterly Vendor Financials
5. Annual Financial Audit—Clifton
Larson Allen (CLA)
6. Office of Enterprise Planning Report
7. Default Investment Fund Option
8. Communications Update
9. Sequestration and the TSP
Parts Closed to the Public
1. Procurement
CONTACT PERSON FOR MORE INFORMATION:

Kimberly Weaver, Director, Office of
External Affairs, (202) 942–1640.
Dated: April 15, 2013.
James B. Petrick,
Secretary, Federal Retirement Thrift
Investment Board.
[FR Doc. 2013–09117 Filed 4–15–13; 11:15 am]
BILLING CODE 6760–01–P

GENERAL SERVICES
ADMINISTRATION
[Notice–CIB–2013–03; Docket No. 2013–
0002; Sequence 11]

Privacy Act of 1974; Notice of
cancellation of System of Record
Notice (SORN)
General Services
Administration (GSA).
ACTION: Withdrawal of GSA/GOV–8
Excluded Parties List System (EPLS)
System of Record Notice (SORN).
AGENCY:

1 Copies

of the Minutes of the Federal Open
Market Committee at its meeting held on March 19–
20, 2013, which includes the domestic policy
directive issued at the meeting, are available upon
request to the Board of Governors of the Federal
Reserve System, Washington, DC 20551. The
minutes are published in the Federal Reserve
Bulletin and in the Board’s Annual Report.

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Pursuant to the Privacy Act of
1974 (5 U.S.C. 552a), notice is given that

SUMMARY:

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the General Services Administration
(GSA), is canceling the following system
of record notice: GSA/GOV–8 Excluded
Parties List System (EPLS).
DATES: Effective Date: April 17, 2013.
FOR FURTHER INFORMATION CONTACT: Call
or email the GSA Privacy Act Officer:
telephone 202–208–1317; email
[email protected].
GSA Privacy Act Officer
(CIB), General Services Administration,
1800 F Street NW., Washington, DC
20405.

ADDRESSES:

SUPPLEMENTARY INFORMATION:

The GSA/GOV–8 Excluded Parties
List System (EPLS) is being cancelled
because the information in the system is
now part of the (GSA/GOVT–9) System
of Award Management (SAM). The
(SORN) was published in the Federal
Register at 73 FR 22374 on Friday, April
25, 2008.
Dated: April 11, 2013.
James Atwater,
Acting Director, Office of Information
Management.
[FR Doc. 2013–09004 Filed 4–16–13; 8:45 am]
BILLING CODE 6820–34–P

DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Agency for Healthcare Research and
Quality
Agency Information Collection
Activities; Proposed Collection;
Comment Request
Agency for Healthcare Research
and Quality, HHS.
ACTION: Notice.
AGENCY:

This notice announces the
intention of the Agency for Healthcare
Research and Quality (AHRQ) to request
that the Office of Management and
Budget (OMB) approve the proposed
information collection project:
‘‘Applying Novel Methods to Better
Understand the Relationship between
Health IT and Ambulatory Care
Workflow Redesign.’’ In accordance
with the Paperwork Reduction Act, 44
U.S.C. 3501–3521, AHRQ invites the
public to comment on this proposed
information collection.
This proposed information collection
was previously published in the Federal
Register on January 28th, 2013 and
allowed 60 days for public comment. No
comments were received. The purpose
of this notice is to allow an additional
30 days for public comment.
DATES: Comments on this notice must be
received by May 17, 2013.
SUMMARY:

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Federal Register / Vol. 78, No. 74 / Wednesday, April 17, 2013 / Notices
Written comments should
be submitted to: AHRQ’s OMB Desk
Officer by fax at (202) 395–6974
(attention: AHRQ’s desk officer) or by
email at
[email protected]
(attention: AHRQ’s desk officer).
Copies of the proposed collection
plans, data collection instruments, and
specific details on the estimated burden
can be obtained from the AHRQ Reports
Clearance Officer.
FOR FURTHER INFORMATION CONTACT:
Doris Lefkowitz, AHRQ Reports
Clearance Officer, (301) 427–1477, or by
email at [email protected].
SUPPLEMENTARY INFORMATION:

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ADDRESSES:

Proposed Project
Applying Novel Methods to Better
Understand the Relationship between
Health IT and Ambulatory Care
Workflow Redesign.
The Agency for Healthcare Research
and Quality (AHRQ) requests that the
Office of Management and Budget
(OMB) approve, under the Paperwork
Reduction Act of 1995, AHRQ’s
collection of information for the project
‘‘Applying Novel Methods to Better
Understand the Relationship between
Health IT and Ambulatory Care
Workflow Redesign.’’ The data to be
collected consists of interviews and
focus groups with clinical, non-clinical,
and management staff about their
experiences with new health
information technology (IT) in an
ambulatory care facility. The overall
goal of this study is to characterize the
relationship between health IT
implementation and health care
workflow in six (6) small and mediumsized ambulatory care practices
implementing patient-centered medical
homes (PCMH), with a focus on the
influence of behavioral and
organizational factors and the effects of
disruptive events.
AHRQ is a lead Federal agency in
developing and disseminating evidence
and evidence-based tools on how health
IT can improve health care quality,
safety, efficiency, and effectiveness.
Health IT has been widely viewed as
holding great promise to improve the
quality of health care in the U.S. Health
IT can improve access to information for
both patients and providers,
empowering patients to become
involved in their own self-care.
Increased patient safety can result from
health IT when records are shared,
medications are reconciled, and adverse
event alerts are in place. When health IT
improves efficiency, providers can
spend more time directly caring for
patients, ultimately improving the
quality of care patients receive.

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In redesigning an ambulatory office
practice as a patient-centered medical
home (PCMH), health IT is intended to
allow for a seamless and organized flow
of information among providers. The
health IT system is critical, because
under the PCMH model, a team of
clinicians aims to provide continuous
and coordinated care throughout a
patient’s lifetime.
Unfortunately, health IT systems can
fail to generate anticipated results and
even carry unintended consequences
which undermine usability and
usefulness. Directly or indirectly, health
IT may create more work, new work,
excessive system demands, or
inefficient workflow (the sequence of
clinical tasks). Electronic reminders and
alerts may be timed poorly. Software
may require excessive switching
between screens, leading to cognitive
distractions for end users. Providers
may spend more time on health IT
system-related tasks than on direct
patient care.
The literature also suggests that the
ambulatory health care environment is
full of unpredictable yet frequently
occurring events requiring actions that
deviate from normal practice.
Unpredictable events such as
interruptions requiring a provider’s
immediate attention, or disruptions in
the normal functioning of the health IT
system (exceptions) divert health care
workers from the usual course of
workflow. The inability of health IT to
properly accommodate these events
could cause compromises to clinical
work.
Because of adverse, unintended and
disruptive consequences, developing an
understanding of how health IT
implementation alters clinical work
processes and workflow is crucial.
Unfortunately, research is scarce, and
methods of investigation vary widely.
Empirical evidence of health IT’s impact
on clinical workflow has been
‘‘anecdotal, insufficiently supported, or
otherwise deficient in terms of scientific
rigor’’ (Carayon and Karsh, 2010).
This study aims to examine more
systematically the impact of health IT
on workflow in six (6) small and
medium-sized ambulatory care practices
varying in their characteristics but all
implementing PCMH. All of the
practices will be in the process of
implementing a new health IT system
during the course of the study, but some
may have an existing, baseline system
such as an electronic health record
system. The focus of the study will be
on the new systems being implemented.
It will employ the complementary
quantitative and qualitative methods of
previous research. The combination of

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methods produces quantitative results
and allows validation through
observation and solicitation of
qualitative participant opinions.
The specific goals of this study are to
identify 1) the relationship between
health IT implementation and
ambulatory care workflow; 2) the
behavioral and organizational factors
and the role they play in mitigating or
augmenting the impact of health IT on
workflow; and 3) how the impacts of
health IT are magnified through
disruptive events such as interruptions
and exceptions.
This study is being conducted by
AHRQ through its contractor, Billings
Clinic, pursuant to AHRQ’s statutory
authority to conduct and support
research on healthcare and on systems
for the delivery of such care, including
activities with respect to the quality,
effectiveness, efficiency,
appropriateness and value of healthcare
services and with respect to clinical
practice, including primary care and
practice-oriented research. 42 U.S.C.
299a(a)(1) and (4).
Method of Collection
To achieve the goals of this project the
following data collection will be
implemented:
(1) Mapping of Study Practices. This
activity will detect any changes made to
the physical layout as a result of
implementing PCMH and health IT.
Practices will be mapped at the
beginning of the study and maps will be
updated as needed. Recording this
information will not burden the clinic
staff and is not included in the burden
estimates.
(2) Staff Observation. Clinicians
(physicians, nurse practitioners,
physician assistants, nurses, medical
assistants, pharmacists, and case
managers) and non-clinical office
personnel will be observed to delineate
the overall characteristics of clinical
workflow before, during, and after
health IT implementation. Particular
attention will be paid to interruptions
and exceptions. If necessary and if the
situation allows, observers will as
unobtrusively as possible ask clinic staff
to clarify certain observed actions.
Recording this information will not
burden the clinic staff and is not
included in the burden estimates.
(3) Before—After Time and Motion
Study. This activity quantifies staffs
time expenditures on different clinical
activities and delineates the sequence of
task execution. It will be conducted
before and after health IT
implementation. This data will be
collected by observation only.
Recording this information will not

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Federal Register / Vol. 78, No. 74 / Wednesday, April 17, 2013 / Notices

burden the clinic staff and is not
included in the burden estimates.
(4) Extraction of Clinical Data. Logs,
audits trails, and time-stamped clinical
data will be extracted from the health IT
system to reconstruct clinical workflow
related to the health IT system. This
information validates and supplements
the data recorded by human observers.
Extracting this data will not burden the
clinic staff and is not included in the
burden estimates.
(5) Semi-Structured Interviews. This
data collection will be conducted posthealth IT implementation to solicit
attitudes and perceptions by health IT
end users including clinical staff, nonclinical personnel, and management
regarding how health IT has changed
their workflow. Particular attention will
be paid to behavioral and organizational
factors.
(6) Focus Group. A focus group will
be conducted post-health IT
implementation with the clinical staff,
non-clinical personnel, and

management team to ensure the research
findings, as well as the interpretation of
the findings, accurately reflect their
experiences using health IT.
On-site data collection will be
conducted over a 5-day period during
each of three phases. Preimplementation data collection
activities will be conducted prior to user
training. During-implementation data
collection will begin when staff are
instructed to start using the health IT
system. Post-implementation data
collection will be conducted
approximately 3 months after
implementation at each study practice.
The qualitative study components of
this project, namely staff observations,
semi-structured interviews, and focus
groups, will generate qualitative data in
the form of observation notes and
interview transcripts. The time-andmotion study and the electronic clinical
data will produce quantitative
information in the form of sequences of
clinical activities and information about

the duration, location, and performer of
each action. Mapping will create
annotated floor plans delineating the
physical layout of each study clinic,
which will be incorporated in the
collection and analysis of the data of the
other study components.
Estimated Annual Respondent Burden
Exhibit 1 shows the estimated annual
burden hours for participation in this
study. The semi-structured interview
will be completed by 60 respondents
across the 6 clinics (10 per practice) and
requires one hour. Sixty (60) clinic staff
members will be asked to participate in
the focus group across all 6 clinics (10
per practice). The focus group requires
no more than 45 minutes. The total
annual burden is estimated to be 105
hours.
Exhibit 2 shows the estimated annual
cost burden associated with the
respondents’ time to participate in this
research. The total annual burden is
estimated to be $5,505.

EXHIBIT 1—ESTIMATED ANNUALIZED BURDEN HOURS
Number of
respondents

Form name
Semi-Structured Interview ...............................................................................
Focus Group ....................................................................................................
Total ..........................................................................................................

Number of
responses per
respondent

60
60
120

Hours per
response

1
1
na

Total burden
hours

1
45/60
na

60
45
105

EXHIBIT 2—ESTIMATED ANNUALIZED COST BURDEN
Number of
respondents

Form name
Semi-Structured Interview ...............................................................................
Focus Group ....................................................................................................
Total ..........................................................................................................

Total burden
hours

60
60
120

Average
hourly wage
rate*

60
45
105

Total cost
burden

$55
49
na

$3,300
2,205
5,505

*Based upon the mean of the average wages, National Compensation Survey: wages in the United States July 2010, U.S. Department of
Labor, Bureau of Labor Statistics, http://www.bls.gov/ncs/ocs/sp/nctb1477.pdf. For the semi-structured interviews, hourly wage is an average including 2 physicians or surgeons ($85.67), 1 registered nurse ($32.42), 2 non-physician providers (measured here as physician assistants,
$43.44), and 1 senior administrator (measured here as ‘‘Medical and health services managers,’’ $42.28). For focus groups, 3.34 physicians or
surgeons ($85.67), 1.66 non-physician providers (measured here as physician assistants, $43.44), 3.34 registered nurses ($32.42), and 1.66
medical assistants ($14.46).

Estimated Annual Costs to the Federal
Government
The total cost of this study is
$799,014 over a 36-month time period

from June 1, 2012 through May 31, 2015
for an annualized cost of $266,338.
(Because the project entails gathering
data before, during, and after health IT
implementation, a period of 21 months

is planned for data collection.) Exhibit
3 provides a breakdown of the estimated
total and average annual costs by
category.

EXHIBIT 3—ESTIMATED TOTAL AND ANNUALIZED COST
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Cost component

Total cost

Project Development ...............................................................................................................................
Data Collection Activities .........................................................................................................................
Data Processing and Analysis .................................................................................................................
Publication of Results ..............................................................................................................................
Project Management ................................................................................................................................
Overhead .................................................................................................................................................

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$135,759
177,460
239,426
51,779
67,729
126,861

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Annualized cost
$45,253
59,153
79,809
17,260
22,576
42,287

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Federal Register / Vol. 78, No. 74 / Wednesday, April 17, 2013 / Notices
EXHIBIT 3—ESTIMATED TOTAL AND ANNUALIZED COST—Continued
Cost component

Total cost

Total ..................................................................................................................................................

Request for Comments
In accordance with the Paperwork
Reduction Act, comments on AHRQ’s
information collection are requested
with regard to any of the following: (a)
Whether the proposed collection of
information is necessary for the proper
performance of AHRQ healthcare
research and healthcare information
dissemination functions, including
whether the information will have
practical utility; (b) the accuracy of
AHRQ’s estimate of burden (including
hours and costs) of the proposed
collection(s) of information; (c) ways to
enhance the quality, utility, and clarity
of the information to be collected; and
(d) ways to minimize the burden of the
collection of information upon the
respondents, including the use of
automated collection techniques or
other forms of information technology.
Comments submitted in response to
this notice will be summarized and
included in the Agency’s subsequent
request for OMB approval of the
proposed information collection. All
comments will become a matter of
public record.
Dated: April 4, 2013.
Carolyn M. Clancy,
Director.
[FR Doc. 2013–08833 Filed 4–16–13; 8:45 am]
BILLING CODE 4160–90–M

DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Agency for Healthcare Research and
Quality
AHRQ Standing Workgroup for Quality
Indicator Measure Specification
Agency for Healthcare Research
and Quality (AHRQ), HHS.
ACTION: Notice of request for
nominations.
AGENCY:

The Agency for Healthcare
Research and Quality (AHRQ) is seeking
nominations for both a time-limited
workgroup and a standing workgroup to
be convened by an AHRQ contractor.
The workgroups shall be comprised of
individuals with knowledge of the
AHRQ Quality Indicators (QIs), their
technical specifications, and associated
methodological issues. The overarching
goals of each group are to provide
feedback to AHRQ regarding

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SUMMARY:

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refinements to the QIs. The time-limited
workgroup is more restricted to specific
clinical or methodological issues, while
the standing workgroup addresses
broader issues related to the
measurement cycle.
Because AHRQ did not get a set of
candidates with anticipated breadth of
diversity of experience as required in
response to our notice (https://
www.federalregister.gov/articles/2013/
01/28/2013-01348/ahrq-standingworkgroup-for-quality-indicatormeasure-specification) published on
January 28, 2013, Volume 78, No. 18,
page numbers: 5810 & 5811, AHRQ
resubmits the same notice to give
opportunity to those interested in this
objective.
DATES: Please submit nominations on or
before May 3, 2013. Self-nominations
are welcome. Third-party nominations
must indicate that the individual has
been contacted and is willing to serve
on the workgroup. Selected candidates
will be contacted by AHRQ no later than
May 17, 2013. Please include the
workgroup of interest. Candidates may
apply for both workgroups.
ADDRESSES: Nominations can be sent in
the form of a letter or email, preferably
as an electronic file with an email
attachment, and should specifically
address the submission criteria as noted
below. Electronic submissions are
strongly encouraged. Responses should
be submitted to: Pamela Owens, Ph.D.,
Senior Research Scientist, Agency for
Healthcare Research and Quality, Center
for Delivery, Organization and Markets,
540 Gaither Road, Rockville, MD 20850,
Email: [email protected],
Phone: (301) 427–1412, Fax: (301) 427–
1430.
FOR FURTHER INFORMATION CONTACT:
Please contact Pamela Owens, see her
information above.
Background
The AHRQ Quality Indicators (AHRQ
QIs) are a unique set of measures of
health care quality that make use of
readily available hospital inpatient
administrative data. The QIs have been
used for various purposes. Some of
these include tracking, hospital selfassessment, reporting of hospitalspecific quality or pay for performance.
The AHRQ QIs are provider- and arealevel quality indicators and currently
consist of four modules: the Prevention

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Annualized cost

799,014

266,338

Quality Indicators (PQIs), the Inpatient
Quality Indicators (IQIs), the Patient
Safety Indicators (PSIs), and the
Pediatric Quality Indicators (PQIs). In
response to feedback from the AHRQ QI
user community and guidance from
NQF, AHRQ is committed to the
ongoing improvement and refinement of
the QIs in an accurate and transparent
manner. For additional information
about the AHRQ QIs, please visit the
AHRQ Web site at http://
www.qualityindicators.AHRQ.gov.
These
workgroups are being administered by
AHRQ’s contractor as part of a
structured approach to formally and
broadly engage stakeholders, and to
enhance and expand transparency about
the scientific development of the AHRQ
QIs.

SUPPLEMENTARY INFORMATION:

Time-Limited Workgroup
Time-limited workgroups are
formative in nature, providing feedback
on significant measure improvement
issues and representing a broad range of
stakeholders. The focus for this
upcoming year will be the Prevention
Quality Indicators (PQI). The role of
time-limited group members is to: (1)
Provide technical guidance on the PQI
specifications and rationales, risk
adjustment strategies, and other quality
measurement issues; (2) provide input
on critical information gaps, as well as
research methods to address them; (3)
provide guidance on draft
recommendations for the PQI measure
refinements; (4) offer scientifically
rigorous recommendations for the
evaluation and validation efforts
required to ensure the accuracy of the
PQIs; and, (5) provide input on and
review of the contractor’s technical
report resulting from the workgroup’s
discussions.
The time-limited workgroup will
consist of 8–12 members consisting of:
• One or more statisticians
specialized in the relevant statistical
methods and applications
• One or more individuals with
expertise in population health,
community health care and prevention,
and access to and quality of care
• One or more individuals with
experience using AHRQ PQI measures
for assessing health system performance
and public reporting

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