AdvancedInteroperableHIE-FOA.pdf

U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology

American Recovery and Reinvestment Act of 2009:

Advance Interoperable Health Information Technology Services to Support Health Information Exchange

Program Guidance Funding Opportunity Announcement

Fiscal Year 2015 Application Due Date: April 6, 2015

Anticipated Award Date: June 12, 2015

Legislative Authority: American Recovery and Reinvestment Act of 2009, Subtitle B—Incentives for the Use of Health Information Technology, Section 3013, State Grants to Promote Health Information Technology

Table of Contents

Opportunity Overview

Executive Summary

I. Funding Opportunity Description A. Background and Purpose B. Purpose C. Scope of Services D. Program Structure and Approach E. Program Milestones

II. Award Information A. Summary of Funding B. Performance Evaluation C. Award Type

III. Eligibility Information A. Eligible Applicants B. Cost-Sharing or Matching

IV. Application and Submission Information A. Address to Request Application Package B. Content and Form of Application Submission B.1. Project Abstract:

B.2. Project Narrative:

B.3. Problem Statement:

B.4. Targeted Population Areas:

B.5. Proposed Approach:

B.6. Collaborator Involvement:

B.7. Project Management:

B.8. Work Plan:

B.9. Process for Dissemination of Learning Resources:

B.10. Budget Forms:

B.11. Budget Narrative/Justification:

B.12. Letters of Commitment/Support:

C. Submission Dates and Times D. Application Responsiveness and Completeness Criteria E. Notice of Intent to Apply

V. How to Apply Information A. Application procedures B. Grants.gov Registration B.1. Intergovernmental Review B.2. Funding Restrictions

VI. Application Review Information A. Criteria B. Merit Review Criteria C. Review and Selection Process D. Discussions and Award E. Anticipated Announcement and Award Dates

VII. Award Administration Information A. Award Notices B. Public Material Use C. Intellectual Property/Copyrights D. Reporting E. Non-Disclosure Requirements F. Potential for Organizational and Personal Conflicts of Interest (COI)

VIII. Agency Contacts

IX. Other Information A. Restrictions A.1. HHS Grants Policy Statement:

A.2. Records Retention:

B. Milestone Documentation C. Standard Terms and Conditions - ONC Grants D. Cooperative Agreement Terms and Conditions of Award E. Cooperative Agreement Roles and Responsibilities E.1. Office of the National Coordinator for Health Information Technology:

E.2. Grantees:

F. Other Terms and Conditions G. Administrative and National Policy Requirements G.1. Audit Requirements

X. Appendices and Other Information

Appendix A. Budget Detail

Appendix B. Suggested Format for Letter from State Designating Official (Governor or Equivalent, for Territories)

Appendix C. Suggested Format for Letter of Support from Critical Stakeholders, Vendors, or supporting entities who support efforts of applicant to achieve programmatic goals of this FOA

Appendix D. Logic Model Example

Appendix E. Sample Table to Establish Baseline

Appendix F. Example Certification Criteria That Support Interoperability

Opportunity Overview Funding Opportunity Announcement Title: Advance Interoperable Health Information Technology (Health IT) Services to Support Health Information Exchange (HIE)

Federal Funding Agency: Office of the National Coordinator for Health Information Technology (ONC), U.S. Department of Health and Human Services (HHS)

Announcement Type: New Award

Funding Opportunity Number: IX-IX-15-001

Catalog of Federal Domestic Assistance (CFDA) Number: 93.719

Statutory Authority: American Recovery and Reinvestment Act of 2009 (ARRA or Recovery Act), Subtitle B—Incentives for the Use of Health Information Technology, Section 3013, State Grants to Promote Health Information Technology

Approximate amount of funding available: $28,000,000

Anticipated number of awards: Ten (10) – Twelve (12) awards

Approximate Range of funding per award: $1,000,000 - $ 3,000,000

Period of Performance: Two (2) years or 24 months

Important Dates: The table below sets out the required submission and other useful target dates related to the Funding Opportunity Announcement (FOA).

Item Date Public FOA release February 3, 2015 Notice of Intent to Apply Due March 2, 2015 at 11:59 p.m.

Applications Due April 6, 2015 at 11:59 p.m.

Estimated Award Announcements June 12, 2015 Anticipated Project Start Date June 12, 2015

Executive Summary This Funding Opportunity Announcement (FOA) uses funds remaining from the State Health Information Exchange Program (State HIE Program) to increase the adoption and use of interoperable health IT tools and services to support the interoperable exchange of health information and enable send, receive, find, and use capabilities in a manner that is appropriate, secure, timely, and reliable for both senders and receivers 1.

This FOA will be a full and open competition. Ten (10) to twelve (12) new awards will be made in the form of cooperative agreements to states2 territories, or state designated entities (SDE)3 to continue under the same intent as the original State HIE Program of enabling nationwide health information exchange across the care continuum and improving care coordination and transitions of care. This new FOA will allow grantees to leverage the existing operational HIE infrastructure to expand the use of interoperable exchange tools and services to improve transitions of care and care coordination, thus furthering federal, state, and/or community health reform efforts. Information exchange is both critical to enabling care coordination and other improvements to health care quality and efficiency). This opportunity is authorized under section 3013 of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Total federal funding available under this FOA is approximately $28,000,000. Under this program, the applicant’s match requirement is $1 for every $3 Federal dollars. In other words, for every three (3) dollars received in Federal funding, the applicant must contribute at least one (1) dollar in non-Federal resources toward the project’s total cost. This “three to one” ratio is reflected as a formula in the Appendix A.

Budget Detail section of this FOA which applicants may use to calculate the minimum required match. In preparing the application budget, applicants should consider these cost-sharing requirements and account for a match on their best estimate of expenditures for each period. Demonstration of this match must be shown in quarterly financial reports.

Award decisions will be made according to the following thresholds: 15% for programmatic planning, requirements, and reporting; 20% for the adoption of health information exchange technology, tools, or services; 30% for send, receive, find, and use of a common clinical data set that complies with national content and format standards; and 35% for interoperability and integration of data from external sources.

States, territories and/or SDEs may apply as designated by the state. Applicants are encouraged, but not required, to enter into multi-state agreements or engage in regional partnerships; however one state or SDE must act as the responsible fiscal agent and submit the application on behalf of all the partners. Per the HHS

1 Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, 2 For the purposes of the FOA, “state” shall be understood to mean any of the 50 United States, the District of Columbia, Puerto Rico, US Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

3 For purposes of this program, to be a qualified State-designated entity, with respect to a State, an entity shall— ‘‘(1) be designated by the State as eligible to receive awards under this section;

‘‘(2) Be a not-for-profit entity with broad stakeholder representation on its governing board;

‘‘(3) Demonstrate that one of its principal goals is to use information technology to improve health care quality and efficiency through the authorized and secure electronic exchange and use of health information;

‘‘(4) adopt nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscrimina-tory participation by stakeholders; and ‘‘(5) conform to such other requirements as the Secretary may establish.

http://www.healthit.gov/policy-researchers-implementers/state-health-information-exchange http://www.healthit.gov/policy-researchers-implementers/health-it-adoption-programs http://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf

Grants Policy Statement4, the prime recipient or awardee must enter into a formal written agreement with each sub-recipient that addresses the arrangements for meeting the programmatic, administrative, financial, and reporting requirements of the grant, including those necessary to ensure compliance with all applicable Federal regulations and policies.

4 http://www.hhs.gov/asfr/ogapa/aboutog/hhsgps107.pdf http://www.hhs.gov/asfr/ogapa/aboutog/hhsgps107.pdf

I. Funding Opportunity Description

A. Background and Purpose On February 17, 2009, the President signed the American Recovery and Reinvestment Act of 2009 (ARRA or Recovery Act). This statute includes the HITECH Act that, among other things, sets forth a plan for advancing the meaningful use (MU) of health information technology (health IT) to improve the quality and efficiency of care. HITECH also codified the Office of the National Coordinator for Health Information Technology (ONC) within the Department of Health and Human Services (HHS). ONC serves as the principal federal entity charged with coordinating the overall effort to implement a nationwide health information technology infrastructure that allows for the electronic use and exchange of health information.

The Recovery Act included an estimated $167 billion over ten years for programs at HHS. The Recovery Act activities support efforts to increase access to health care, protect those in greatest need, expand educational opportunities, and modernize the Nation’s health IT infrastructure. A strong, flexible health IT ecosystem will support achievement of this goal and will help transform care into a model that enhances access and addresses health beyond the confines of the health care system. The Advance Interoperable Health IT Services to Support Health Information Exchange FOA will build on previous efforts to rapidly build capacity for exchanging health information across the health care system both within and across states while moving toward nationwide interoperability. Grantees will be responsible for increasing connectivity of disparate data sources and systems to enable send, receive, find, and use capability to improve care coordination and transitions of care.

Through this funding opportunity, grantees will leverage the investments and lessons learned from the original State HIE Program to advance the standardized, secure, and interoperable movement of health information across organization, vendor, and geographic boundaries. Through the expansion and use of operational health information exchange infrastructure, grantees will seek to address workflow challenges and technical issues and improve the meaningful use of clinical data from external sources. In addition, this funding announcement will promote the use of health information exchange through interoperable health IT to move towards a robust learning health system where data may be leveraged securely and effectively to improve care coordination. Our ultimate goal is to have a learning health system where accurate and evidence-based information helps ensure the right individual receives the right care at the right time to increase health care quality, lower health care costs, and improve population health5. Grantees will be expected to engage care providers from across the entire care continuum, including those who are not eligible for the EHR Incentive Programs, to enable the send, receive, find, and use capabilities of health IT both within and outside their care delivery system.

B. Purpose ONC’s ARRA-funded programs invested in a standardized, nationwide health IT infrastructure, and prepared the workforce to enable care providers to improve health care. Five years since ARRA’s passage, ONC’s critical work continues as new care delivery and payment programs seek to improve health outcomes, enhance patient satisfaction, and generate cost savings. Health IT also allows for innovations in

5 http://www.healthit.gov/buzz-blog/from-the-onc-desk/developing-shared-nationwide-roadmap-interoperability/ http://www.healthit.gov/policy-researchers-implementers/health-it-adoption-programs http://www.healthit.gov/policy-researchers-implementers/state-health-information-exchange http://www.healthit.gov/buzz-blog/from-the-onc-desk/developing-shared-nationwide-roadmap-interoperability/ care delivery to improve the efficiency and experience of care across the entire care continuum. As health care delivery and payment shifts from volume-to-value-based care, interoperable health IT is integral to effective care coordination and achieving the three-part aim of better healthcare, better health, and reduced costs.

There are many potential opportunities for the use of electronic health information within interoperable health IT to improve the delivery of care, particularly related to transitions between settings and across healthcare providers.

Transitions between care settings commonly occur, and the need for enhanced information exchange to facilitate seamless care coordination is acute. In 2010, there were 35.1 million hospital discharges.6 Opportunities for medical errors increase during hand-offs between settings. Approximately 1 in 5 discharged patients suffer an adverse event and approximately half of patients experience a medical error post-discharge.7 Electronic sharing of health information during transitions has the potential to promote greater continuity of care by addressing information gaps. Yet, as of 2012, less than half of physicians reported they received discharge summaries (whether in paper or electronic format).8

There is a similar need for greater care coordination within ambulatory settings. In 2010, over 90 million ambulatory care patients were referred to another health care provider.9 Furthermore, the typical primary care physician has to coordinate care with 229 other physicians working in 117 practices.10 Care providers need to know how they will be able to work with other care providers, care givers, patients, and organizations across the entire care continuum to facilitate health information exchange and integrate information from external sources into their workflow. In many cases, transitions or referral to another provider or care setting are poorly coordinated, disrupting continuity of care. Communication between primary care providers and specialists during the referral process is often inadequate both in terms of quality and timing. Physicians are dissatisfied with the process and have identified several important barriers to communication.11

All levels of health professionals, such as physicians, nurses, pharmacists, health care managers, front desk staff, and other allied health professionals, will continue to require some level of training, education, and hands-on technical assistance with incorporating health information exchange tools and services into their clinical workflows in order for practice transformation to occur.

6 National Hospital Discharge Survey, 2010

7 Kriplani et. al. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians, JAMA, 2007.

8 ONC-NCHS analysis of 2012 NAMCS EMR Supplement survey.

9 2010 NAMCS summary table. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

10 Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009; 150:236-42

11 Gandhi, T. K., Sittig, D. F., Franklin, M., Sussman, A. J., Fairchild, D. G. and Bates, D. W. (2000), Communication Breakdown in the Outpatient Referral Process. Journal of General Internal Medicine, 15: 626–631. doi: 10.1046/j.1525-1497.2000.91119.x http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

Grantees will seek to improve care coordination and enhance communication among care providers across the care continuum by: (1) expanding the adoption of health information exchange technology, tools, services, and policies that enable interoperable exchange; (2) facilitating and enabling send, receive, find, and use capabilities to access health information from external sources to incorporate into the care provider’s clinical and non-clinical workflows and interactions with patients; and (3) increasing the integration of health information in interoperable health IT to support care processes and decision-making (e.g. filtering, subscription, alerting) that will improve health and health care (e.g. population management, patient engagement, care coordination, and data analytics).

Through the use of interstate and intrastate funding grantees will engage both clinical and non-clinical care providers (e.g., long-term and post-acute care providers, behavioral health, care support services, social service case workers, emergency medical services) and individuals12in health information exchange by providing technical assistance, training, education, exchange services, and resources to enable care providers to send, receive, find, and use health information in a manner that is appropriate, secure, timely, and reliable for both senders and receivers

This funding is intended to focus programmatic efforts on the following populations and care settings:

including rural, underserved and other communities where health IT adoption and use lags behind national trends. This project is utilizing categories of eligibility defined in the EHR Incentive programs to identify, in part, providers and hospitals with whom grantees will work. For the purposes of this FOA, however, the general term “care providers” is broadly inclusive of the care continuum, reflecting primary care providers, specialists, nurses, pharmacists, physical therapists and other allied care providers, hospitals, mental health and substance abuse services, long- term and post-acute care facilities, home and community-based services, other support service providers, care managers, and other authorized individuals and institutions.

Grantees must select at least one (1) eligible care provider and at least two (2) non eligible care providers for their target population from the list below in order to meet the funding requirements.

Eligible Care Providers Non-eligible Care Providers

• Eligible Professionals (EPs) (as defined by the EHR Incentive Programs)

• Critical Access Hospital (CAHs) (as defined by the EHR Incentive Programs)

• Long-Term and Post-Acute Care (LTPAC)

• Behavioral Health (BH)

• Individuals

• Other care settings and care providers (e.g. safety net providers, public health, social services, emergency medical services) are recognized stakeholders that grantees are encouraged to engage. This provides flexibility for grantees to work with other clinical and non-clinical care providers across the entire care continuum.

12 For the purposes of this FOA, the term “individual” includes care providers and others including family members authorized to act on the patient’s behalf.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eligibility.html http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eligibility.html

Grantees will also be encouraged to engage communities that have been successful and can serve as scalable models to advance other replicable health IT efforts across the country.

Grants awarded under this funding opportunity will have a period of performance of two years. Grantees will support continued widespread adoption of interoperable health information exchange tools and services to increase the number of new exchange participants by conducting outreach efforts around recruitment, education, enrollment, training, technical assistance provision, and workflow redesign. Grantees will engage new exchange participants and as applicable continue to support existing exchange participants with ongoing hands-on technical assistance and workflow redesign support to incorporate the use of data from external sources into daily workflows and interactions with patients.

In addition, grantees will support both eligible and non-eligible care providers and care settings with their adoption and use of health information exchange technology and services. At the end of the program, grantees will have reporting mechanisms in place to demonstrate improvements in clinical and/or process outcomes measures (both qualitative and quantitative) and reduced costs.

C. Scope of Services This funding opportunity announcement will leverage the investments and lessons learned from the original State HIE Program and accelerate the widespread adoption and use of health information exchange infrastructure, including the following transport mechanisms, Direct secure messaging, query-based exchange, and/or consumer mediated exchange. The awards will fund efforts to provide training, education, and technical assistance services to minimize barriers and support care providers with incorporating health information exchange into their existing workflows to improve care coordination, population management, and measurement reporting. Grantees will utilize interstate and intrastate partnerships to enable care providers to send, receive, find, and use a common clinical data set across unaffiliated organizations to improve care coordination and promote a learning environment. Grantees working with individuals will similarly leverage interstate and intrastate partnerships to offer secure access to an individual’s online health information where they live/work and plan to support self-management and the ability to view, download, and/or transmit to a destination of their choice. ONC is strongly encouraging applications that provide individuals standards-based exchange tools and services to easily and securely access, download, and transport their health information. To support this objective, ONC is interested in understanding consumer outreach and engagement strategies, consumer mediated exchange technology capabilities, and how these efforts support View, Download, & Transmit (VDT) capabilities of health IT in health information exchange.

Applicants applying for funding to leverage Direct secure messaging transport protocols and query-based exchange to support transitions of care and care coordination, must clearly describe their current and future plans to address workflow challenges and the integration of health information from external sources.

ONC is interested in organizations supporting notification, alerting, data segmentation, filtering, and/or subscription services that route, filter, and highlight information in increasingly meaningful ways.

Supporting clinical and non-clinical workflow changes that may be required to maintain increased health information exchange activity and use of data within interoperable health IT will be critical. Another important component that grantees should focus on is increasing the utility of data itself so that health care providers and individuals find value in and can easily use the information to support their decision-making and care processes. Through guidance issued for care providers that are ineligible for the Medicare and http://www.healthit.gov/policy-researchers-implementers/state-health-information-exchange

Medicaid EHR Incentive Programs,13 ONC suggests that health IT can support other types of functions that would promote interoperability, including but not limited to clinical decision support, transmission of data to public health agencies, and clinical quality measurement in addition to capabilities required by the EHR Incentive Programs.

13 http://www.healthit.gov/sites/default/files/generalcertexchangeguidance_final_9-9-13.pdf

All grantees are expected to participate in communities of practices, workgroups, and/or other peer learning health collaborations to identify best practices, address challenges in executing program requirements, and support critical building blocks (e.g., privacy, security, governance, standards) to enabling exchange.

Grantees will partner with ONC to synthesize learnings, solutions, and best practices to ensure that they are scalable and replicable across the country.

The table below provides additional details on the care providers, individuals, and care settings that applicants are expected to focus on as well as additional details on the scope of services to be addressed by applicants under this program. As previously mentioned, grantees must select at least two non-eligible care providers for their target population and at least one eligible care provider from the list below in order to meet the funding requirements.14

14 The basic set of essential health information that builds from the common meaningful use (MU) data set incorporated into ONC’s HIT Certification Program as part of the 2014 Edition EHR Certification Criteria and currently used to support three MU objectives included in the Medicare and Medicaid EHR Incentive Programs.

Target Population and Care Settings

Scope of Services

Eligible Care Providers Eligible Professionals

(EP)

Grantees will provide technical assistance services to help educate and train EPs and administrative staff on how to send, receive, find, and use a common clinical data set that aligns with national standards. This will enable an EP to incorporate relevant data from external sources into their existing workflows and their day-to-day interactions with patients to improve care transitions. Where not yet achieved, grantees must assist EPs with meeting the Stage 2 MU TOC Measure 2 criteria and improve the ability of EPs to report on this measure.

To accomplish programmatic goals, grantees must work collaboratively with federal partners, care providers, vendors, and other health IT community stakeholders to ensure alignment with national format, content, and transport standards. For example, providing technical assistance support to a health information exchange entity to increase the ability to accept, parse, and integrate consolidated clinical document architecture (C-CDA).

Grantees will also support sharing of essential14 health information such as clinical summaries, care plans, or medication lists with the entire care team to improve care coordination.

http://www.cms.gov/regulations-and-guidance/legislation/EHRincentiveprograms/downloads/Stage2_EPCore_15_SummaryCare.pdf http://www.healthit.gov/policy-researchers-implementers/consolidated-cda-overview http://www.healthit.gov/sites/default/files/generalcertexchangeguidance_final_9-9-13.pdf

Target Population and Care Settings

Scope of Services

Eligible Care Providers, continued Critical Access (CAH)/Rural Hospitals (RH)

Grantees will provide technical assistance services to help train and educate CAH/RHs and their clinical and administrative staff on how to send, receive, find, and use, a common clinical data that aligns with national standards.

To accomplish programmatic goals, grantees must work collaboratively with federal partners, care providers, vendors, and other health IT community stakeholders to ensure alignment with national format, content, and transport standards. For example, providing technical assistance support to a health information exchange entity to accept, parse, and integrate a C-CDA.

Non-Eligible Care Providers Long Term and Post- Acute Care (LTPAC)

Support the adoption and use of technology and services that enable interoperable health information exchange. Such support would provide technical assistance, training, education, workflow redesign, and other supports to increase adoption and use of technology, tools, services, and policies that enable exchange.

Grantees will support sharing of essential health information such as clinical summaries, care plans, and medication lists with the entire care team to improve care coordination.

Behavioral Health

(BH)

Support the adoption and use of technology, tools, and services that enable interoperable health information exchange. Such support would provide technical assistance, training, education, workflow redesign, and other supports to enable exchange and increase the availability of health information from primary care providers to behavioral health providers.

Grantees will also support the use of health IT to integrate behavioral health information into primary care settings so that primary care physicians may holistically understand and more effectively coordinate patient care.

• Grantees will utilize methods of electronically capturing and persisting patient consent during integration and exchange of information from primary care and behavioral health providers as described above using technical methods that are built on Data Segmentation 4 Privacy (DS4P) work [in 2013- 2014]. Data Segmentation 4 Privacy (DS4P) work [in 2013-2014]. ONC is particularly interested in solutions to electronically obtain an individual’s consent to disclose mental health or substance abuse information per 42 CFR Part 2 and the technical specifications for persisting an individual’s choice in sharing such information. 42 CFR Part 2 information applies to data that would identify a patient as an alcohol or drug abuser either directly, by reference to other publicly available information, or through verification of such identification by another person. For more information about the 42 CFR Part 2 Substance Abuse and Mental Health Services Administration’s (SAMHSA) federal substance abuse (alcohol and drug) confidentiality regulation and how it relates to health information exchange please see http://www.integration.samhsa.gov/operations-administration/confidentiality http://www.healthit.gov/providers-professionals/ds4p-initiative http://www.samhsa.gov/about-us/who-we-are/laws/confidentiality-regulations-faqs http://www.samhsa.gov/about-us/who-we-are/laws/confidentiality-regulations-faqs http://www.integration.samhsa.gov/operations-administration/confidentiality

Target Population and Care Settings

Scope of Services

Non-Eligible Care Providers, continued Individuals Increase consumer demand for consumer-mediated exchange tools and services and the proportion of individuals offered, registered, educated, trained, and enrolled in access to individual-facing technology such as patient health records (PHRs), patient portals, or mobile health applications that operate with a provider’s certified EHR.

Grantees will seek to increase view, download, and transmit MU levels, particularly download and transmit, and will train patients on how to upload and share their data with their provider to increase patient-provider data exchange.

Grantees will also support provider efforts to share a summary of care record with patients per episode of care or care transition.

Note: “Individuals” include care providers and others including family members authorized to act on the patient’s behalf.

Other Settings and Care providers

Care providers and settings (e.g. safety net providers, public health, social services, emergency medical services, learners, researchers) in this category are recognized stakeholders that grantees are encouraged to engage. This provides flexibility for grantees to work with other clinical and non-clinical care providers across the care continuum to support a more comprehensive, integrated patient record or care plan.

Grantees will help facilitate exchange to improve care coordination and will support sharing of essential health information such as clinical summaries, care plans, or medication lists with the entire care team.

D. Program Structure and Approach This program will fund efforts to address all of the eligible and non-eligible care settings described in the scope of services section, with particular focus on integrating non-eligible care providers into health information exchange to improve care transitions and the closure of referral loops. Grantees will work with participating clinical and administrative staff and individuals to integrate a set of common clinical data from external sources into their clinical workflows to improve care coordination, transitions of care, population health management, and quality measurement reporting.

ONC will award up to twelve (12) cooperative agreements to states, territories, or state designated entities (SDEs), however intrastate, interstate, and regional partnerships are encouraged. Applicants must select at least one (1) eligible care provider and at least two (2) non eligible care providers for their target population from the list provided in the Scope of Services in Section I.C. in order to meet the funding requirements and accomplish an adequate spread/distribution of the defined target populations.

E. Program Milestones The milestones described below identify the performance-based payment structure and describes the technical assistance services that grantees will perform in order for milestone-based payments to occur. Based on this payment structure and program focus, grantees will (1) increase adoption of health information exchange technology, tools, and services; (2) increase the movement of electronic, secure, and standardized patient health information to improve care transitions, and; (3) increase the interoperability of health information exchange from external data sources used by individuals and care providers from unaffiliated organizations. Payments will be directly tied to these three milestones and they need not be sequential; however grantees must establish a current baseline and set a target goal for each milestone. For example, an applicant may have robust adoption across the EP population, and therefore elects to focus primarily on advancing exchange and interoperability to enable more effective care transitions. This applicant may elect to only focus on the exchange and interoperability milestones due to successful adoption efforts. Once awarded, the grantee will work with ONC to establish an appropriate process for validating each core programmatic milestone achievement.

Grantees will work with clinical and non-clinical care providers and individuals to establish reporting mechanisms, set goals, and track progress on the health information exchange milestones, including tracking the rates of send, receive, find, and use of available health information and the interoperable uses of this data downstream to improve health and health care. This system of reporting on health information exchange and interoperability may be created to generate individual level reports for internal use and aggregated reports for ONC. This will also allow for piloting and testing of measures on health information exchange and interoperability that can be used at the national level for reporting on progress related to these measures.

Grantees will partner with ONC to establish reporting mechanisms to track and monitor individual exchange participant and aggregate progress towards process outcomes (qualitative and quantitative data).

Grantees will work with ONC to set process outcome improvement goals throughout the program.

A brief description of the three milestones is listed below:

• Adoption – This milestone promotes widespread adoption and recruitment efforts for using health information exchange, technology and services that enable exchange of common clinical data.

Transport mechanisms include Direct secure messaging, query-based exchange, and/or consumer-mediated exchange. Grantees must describe in detail current adoption baselines and the supporting exchange infrastructure, approaches, and processes that exist to meet programmatic goals. This may include, but is not limited to, education, outreach, on-boarding activities, vendor engagement and management, and the administrative or legal aspects related to participation agreements. This means each applicant will identify their current adoption and exchange participation baseline by transport mechanism where applicable, and set a goal for the net new number of participants across the selected care provider groups that they will target over the program. Grantees will need to attest that each new exchange participant is subscribed or enrolled in services and has at least logged in once. Applicants should plan to conduct widespread adoption and recruitment efforts for care providers above their determined baseline.

• Exchange of Health Information – This milestone ensures that after a care provider or individual has subscribed or enrolled for services under this program, actual exchange of health information is enabled and actively used. Grantees will ensure that the care provider or individual is receiving the appropriate level of support to increase the % of care transitions (e.g. transfers, discharges, referrals) that include an electronic summary of care record and the common clinical data set that complies with national content and format standards. For example, a grantee may set a threshold for exchange participants that for 50% of all their care transitions (e.g. transfers, discharges, and referrals), a summary of care record is included. Another example would be that for 50% of all episodes of care for exchange participants, a signed note automatically triggers the summary of care record to be sent to an end point that the individual designates. This would become an automated process that would facilitate the exchange of information that is consumable for individual- based applications, and contributes to a software ecosystem in which care providers, hospitals, and individuals may access and exchange data regardless of their EHR vendor.

• Interoperability of data systems – This milestone addresses the need for electronic health information exchange from outside care providers and individuals to be integrated and incorporated into health IT systems for population management, measurement reporting, and improvements in clinical care. Grantees must describe in detail the necessary changes or updates to existing, operational exchange infrastructure to ensure the ability of patient information to securely move between interoperable health information technology tools and services and how the applicant will work with exchange participants to digest relevant information to support quality improvement efforts. Examples of measures might include rates of sending and receiving electronic health information from outside sources (e.g. proportion of direct messages received that contain electronic health information; proportion of messages sent that contain electronic health information); rates of integrating electronically received information from outside sources within EHRs (e.g. proportion of TOC summary of care records received that were integrated within an EHR); and characterizing the downstream usage of data that is integrated from outside sources.

The table below provides additional details on each of these milestones and the payment-based structure.

Proposed Milestone

Milestone Achievements To Be Met by Grantees15

Adopt technology and services that enable health information exchange

• Grantees will engage new clinical and non-clinical care provider prospects through marketing, outreach, education, and digital health literacy resources and work with them to enroll or subscribe to health information exchange technology, tools, and services. In addition to onboarding new exchange participants, grantees will provide technical assistance services to establish new user accounts and provide training on health information exchange technology.

• Milestone achievement and payment occurs when each individual participant adopts an exchange mechanism (Direct secure messaging, query-based exchange, or consumer mediated exchange). Grantees will need to attest that each new exchange participant is subscribed or enrolled in services and has at least logged in once.

• Grantee will work with ONC to establish an audit-appropriate process for validating adoption achievement with ONC.

• Each applicant will identify their current adoption and exchange participation baseline by transport mechanism where applicable, and set a goal for the net new number of participants across the selected care provider groups that they will support during the program. As part of the application review process, reviewers will need to examine how ambitious and realistic the applicant’s targets are. If the targets are too modest, the applicant is at risk of not receiving the grant. If the targets are too ambitious, the applicant is at risk of not getting paid during the period of performance.

15 Other examples of instances where milestone achievement and payment will occur may be found in the Advancing Interop-erable Health Information Technology Services to Support Health Information Exchange Frequently Asked Questions (FAQ) document located at http://healthit.gov/newsroom/advance-interoperable-health-information-technology-services-sup-port-health-information#faqs

Other examples of instances where milestone achievement and payment will occur may be found in the Advancing Interoperable Health Information Technology Services to Support Health Information Exchange Frequently Asked Questions (FAQ) document located at http://healthit.gov/newsroom/advance-interoperable-health-information-technology-services-support-health-information#faqs Other examples of instances where milestone achievement and payment will occur may be found in the Advancing Interoperable Health Information Technology Services to Support Health Information Exchange Frequently Asked Questions (FAQ) document located at http://healthit.gov/newsroom/advance-interoperable-health-information-technology-services-support-health-information#faqs

Proposed Milestone

Milestone Achievements To Be Met by Grantees

Exchange of Health Information

• Grantees will work with new and existing clinical or non-clinical care providers to demonstrate electronic send, receive, find, and use of essential health information capabilities across unaffiliated organizations to improve care coordination. Where not yet achieved, grantees will work with MU eligibles to increase rates of access and exchange transactions in order to meet the Stage 2 MU TOC Measure 2 criteria.

• Grantees will provide hands-on technical assistance services, trainings, resources, and educational opportunities, and will support workflow redesign efforts.

• Grantees are strongly encouraged to use filtering, subscription, and notification tools to increase the use of health information exchange technology, tools, and services.

• Grantees engaging individuals (or the designated caregiver or family member) to support use of online information to enable individuals to better manage their healthcare, will need to support their preferences to share health information with the designee of their choice

• For example, grantee could identify a 50% threshold that for 50% of all care transitions (e.g. discharges, referral), technical assistance support will promote the sharing of a summary of care record with the patient.

• For example, a grantee could identify a threshold that for 50% of all episodes of care for exchange participants, a signed note automatically triggers the summary of care record to be sent to an end point that the individual designates.

• Grantee will work with ONC to establish an audit-appropriate process for validating exchange achievement with ONC.

Interoperability of health IT

• Grantees demonstrate that provider organizations are integrating the information they have received from external sources into their EHRs and using it for clinical care, population management, or measurement reporting.

• Grantees will provide hands-on technical assistance and support workflow redesign and the use of applications that leverage data that is exchanged (e.g., summary of care record) so that the information is useful and is used by care providers.

• For example, grantee may set a threshold that for 50% of all transitions of care, an electronic summary of care record exchange occurs that complies with the common MU clinical data set and national standardized data formats.

• Grantee will work with ONC to establish an audit-appropriate process for validating interoperability achievement of its provider organizations’ health IT with ONC.

The payment structure will vary based upon the population and varying starting points or baselines. For example, given that LTPAC and BH providers were largely not eligible for the EHR Incentive programs, adoption and exchange of health information milestones may be the focus. In contrast, the focus for EPs and CAHs will be weighted towards exchange of health information and interoperability of health IT. As mentioned previously, milestone payments for these three categories need not be sequential.

II. Award Information

A. Summary of Funding

Type of Award: Cooperative Agreement

Total Amount of Funding Available: $28,000,000

Number of Awards: Ten (10) – Twelve (12) awards

Period of Performance: Two (2) years or 24 months

Estimated Start Date: June 12, 2015

ONC reserves the right to make additional awards under this announcement, consistent with Agency policy, if additional funding becomes available after the original selections are made. Any additional selections for awards are expected to be made no later than 12 months after the original selection decisions.

Funding Description:

The two-year cooperative agreements will be awarded to states, territories, and/or SDEs the beginning of June. For the purposes of this FOA, “state” shall be understood to mean any of the 50 United States, the District of Columbia, Puerto Rico, US Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. While applicants are encouraged to enter into multi-state agreements or engage in regional partnerships, ONC does not anticipate awarding any HIE cooperative agreement for a geographic service area that overlaps with another HIE cooperative agreement. Each award will be made for a defined geographic area that does not overlap or otherwise duplicate any other award under this FOA.

For the two-year cooperative agreement, grantees will use federal funding across two categories:

I. Program Support and Engagement Funding: (approximately 15% of total award) this funding may be used to meet initial programmatic needs; ; travel to and from ONC meetings; peer learning and collaboration efforts (participation in CoPs); documentation of initial challenges and bright spots; tweaking existing infrastructure; establishing evaluation processes; ; establishing financial and programmatic reporting requirements; and developing resources to conduct initial outreach, education, and/or implementation. Funding will be released pursuant to milestones established by each award.

II. Direct Technical Assistance Funding: Grantees will increase the adoption and use of interoperable health IT tools and services to support the interoperable exchange of health information and enable send, receive, find, and use capabilities in a productive manner for both senders and receivers. Awards will be made according to the following key milestone thresholds:

a. Milestone 1 – Adoption of health information exchange technology or services (20%): For example, the adoption of transport mechanisms such as Direct secure messaging, query-based exchange, and/or consumer mediated exchange. Education, outreach, recruitment, training, enrollment, and subscription to program services.

b. Milestone 2 - Exchange (30%): This milestone ensures that the care provider or individual is receiving the appropriate level of support to demonstrate send, receive, find and use of a common clinical data set that complies with national content and format standards.

Grantees will provide technical assistance to increase the % of care transitions (e.g. transfers, discharges, referrals) that include an electronic summary of care record.

c. Milestone 3 – Interoperability of health IT and integration of data from external sources (35%): This milestone addresses the need for electronic health information from outside care providers and individuals to be integrated and incorporated into health IT systems for population management, measurement reporting, and improvements in clinical care.

While this is a cost-based reimbursable award, it is important to note that progress must be made towards achieving the milestone as outlined in grantee’s approved budget and project narrative/work plan.

Materials developed through this funding will be made publicly available at the end of the project period.

B. Performance Evaluation The grantee’s performance will be evaluated on a quarterly basis by ONC to ensure that the project is meeting program objectives (milestones vs. projections), criteria described within the Scope of Services, including the gap analysis and convening of subject matter experts. The grantee shall submit semi-annual progress reports related to its projects and overall project performance. A specific Performance Report format will be finalized by ONC following the award date.

C. Award Type The funding instrument used for this program will be the cooperative agreement, an award type in which substantial ONC programmatic involvement with the grantee is anticipated during the performance of the activities. Under the cooperative agreement, ONC’s purpose is to support and stimulate each grantee’s activities by involvement in and otherwise working jointly with the awarded grantees in a partnership role;

it is not to assume direction, prime responsibility, or a…