PARTICIPATING HEALTH CENTER
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Participating Health Center Name
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Grant/Look alike Number
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PATIENT DETAILS
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Total Patients (UDS Definition)
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Number of Sites (Baseline)
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Number of Sites (Current)
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ENHANCE THE PATIENT AND PROVIDER EXPERIENCE
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What percentage of patients at this PHC accessed their
patient portal within the last 12 months?
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What patient portal features are currently
available to patients?
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[ ] medical history [ ] lab/test results [ ] shared care
plans [ ] education/self-management tools [ ] appointment
scheduling [ ] appointment reminders [ ] medication refill
[ ] remote monitoring devices
[ ] other (explain)
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What percentage of patients have used a
digital tool (e.g., electronic messages sent through the patient
portal to providers, remote monitoring) between visits to
communicate health information with the PHC in the last 12
months?
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What percentage of providers reported
increased satisfaction post implementation of at least one health
IT-facilitated intervention?
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What health IT-facilitated intervention has
this PHC used within the last 12 months to improve provider
satisfaction?
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[ ] improved CDS [ ] EHR template customization/optimization
[ ] telehealth [ ] eConsults
[ ] mobile health [ ] dashboards [ ]
other reporting tools (please explain)
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ADVANCE INTEROPERABILITY
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In the last 12 months, did this PHC complete a security
risk analysis?
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[_] Yes [_] No [_] Previously completed within project period
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In the last 12 months, did this PHC implement
a breach mitigation and response plan based upon the completion
of a security risk analysis?
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[_] Yes [_] No [_] Previously completed within project period
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In the last 12 months, did this PHC
experience a data breach or ransomware event?
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[_] Yes [_] No
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In the last 12 months, did this PHC transmit
a summary of care record to at least 3 external health care
providers and/or health systems using certified EHR technology
through platforms that align with HL7 or national standards
specified in the ONC Interoperability Standards Advisory?
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[_] Yes [_] No
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If you answered yes to Question 4 above,
please provide details about the platform you are using to
transmit a summary of care record.
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In the last 12 months, did this PHC integrate
data into structured EHR fields (i.e., not free text or
attachments) from at least 3 external clinical and/or
non-clinical sources?
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[_] Yes [_] No
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USE DATA TO ENHANCE VALUE
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What other health IT tools and solutions did this PHC
use in the last 12 months to analyze data in support of
value-based care activities?
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[ ] Business Intelligence Software [ ] Data
Analytics [ ] Predictive Analytics [ ] SMART Apps [ ]
Patient-Centered Tools [ ] other (please explain)
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In the last 12 months, did this PHC use a
dashboard and/or standard reports to present useful data to
inform value-based care activities (e.g., improve clinical
quality, achieve efficiencies, reduce costs)?
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[_] Yes [_] No
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In the last 12 months, did this PHC use
health IT to collect or share social risk factor data with care
teams and use this data to inform care plan development on at
least 50 percent of patients identified as having a risk factor?
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[_] Yes [_] No
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Describe progress to date on the applicant
choice objective
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THE HEALTH CENTER CONTROLLED NETWORK WILL COMPLETE THIS SECTION AT
THE END OF THE 3-YEAR PROJECT PERIOD FOR THE ONE-TIME FINAL REPORT
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CUSTOMER SATISFACTION
CHALLENGES AND BARRIERS
LESSONS LEARNED
CONTINGENCY PLANNING
PROMISING PRACTICES
KEY CONTACT
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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 currently valid OMB control number. The OMB
control number for this project is 0915-0285. Public reporting
burden for this collection of information is estimated to average
1 hour 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 14N-39,
Rockville, Maryland, 20857.
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