Capital Improvement Program HRSA-09-244

1. Electronic Health Record Projects and Readiness May 7, 2009 Capital Improvement ProgramHRSA-09-244

2. CIP Funding • $850M one-time, 2-year project/budget period FY 2009 grants to support • Construction • Renovation and equipment • Acquisition of health information technology • Grantees must • Demonstrate improvements in access to health services for the underserved populations • Create health center and construction-related jobs • 2-Year project/budget period (July 1, 2009 – June 30, 2011) • Maximum funding based on CY 2008 UDS Data Formula • All section 330 grantees eligible for $250K base amount • Plus $35 per patient served based on 2008 UDS as of 04/24/2009 • New Start grantees without 2008 UDS data will have $250K maximum

3. CIP Funding, part 2 • CIP guidance available: May 1, 2009 • One-time award for 2-year budget/project period • No on-going funding anticipated • Grantees will only be submitting one CIP application • Grantees may propose more than 1 project • Grantees will submit applications/requests through EHB • Applications due no later than: June 2, 2009 8:00PM ET • EHB-generated email • Eligibility code • Maximum eligible budget amount • Sent to all eligible Health Center Program grantees on May 2, 2009 • Electronic application available: May 4, 2009

4. Types of CIP Projects • The eligible project types are: • Alteration/repair/renovation, with or without IT/equipment • Construction (new site or expansion of existing site), with or without IT/equipment • IT/equipment-only purchase • HIT-only purchase (non-EHR equipment) • Certified EHR-related purchase

5. Ineligible CIP Costs • Operating costs (e.g., funding direct services, clinical full-time equivalents, rent, mortgage payments, refinanced credit facilities). • Purchase of EHR systems that are not certified by an organization recognized by the Secretary of HHS. • None of the funds appropriated or otherwise made available under the Recovery Act may be used by any State or local government, or any private entity, for any casino or other gambling establishment, aquarium, zoo, golf course, or swimming pool. • Non-certified EHR systems can not be listed as other equipment. • Costs incurred prior to February 17, 2009.

6. Certified Electronic Health Record (EHR) Computer software that providers use to track all aspects of patient care Health Information Technology (HIT) Includes hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packages solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information. ! For CIP, allowable costs include pre-implementation and readiness, software, infrastructure/clinical facility, data center infrastructure, and implementation staffing. EHR and HIT

7. Health Information Technology (HIT) Telehealth-related equipment Registries Electronic prescribing Enhancements necessary to interface between HIT/EHR and other electronic systems Dental and oral health Allowable use of funds Certified Electronic Health Record (EHR) • Certified EHR software costs: EHR application costs, maintenance, computer-based training • Infrastructure clinical facility costs: wireless LAN infrastructure, LAN switches, tablets, desktop PCs, cameras, printers • Data infrastructure costs: servers, routers, switches, back-up software, fire suppression, cooling/HVAC, physical security, power upgrades • Implementation staff: core team training, vendor project management, data migration, paper chart conversion, CIO, network administration ! HIT–only (non-EHR equipment) and certified EHR-related purchases can be proposed either as site-specific, multi-site, or organization-wide (inclusive of all sites).

8. EHR Considerations • Grantees are encouraged to work with others who have successfully procured, adopted, and used certified EHRs and other HIT systems, and to use up to 2% of the CIP project budget for HIT and certified EHR implementation technical assistance. • In regards to EHR-related purchases, health center grantees within the scope of a current HRSA-funded health center controlled network are encouraged to work with their network to enhance their existing system. • If EHR-related equipment will require significant installation, the grantee should propose an a/r/r or construction project to account for the installation of any fixed equipment. The grantee should also propose a separate EHR project to account for the purchase of all related EHR components.

9. Electronic Health Records All EHRs must: • Be certified by an organization recognized by the Secretary of HHS • Certification Commission for Healthcare Information Technology (CCHIT) • http://www.cchit.org • Any EHR certified by CCHIT is eligible All health centers must: • Demonstrate readiness • Complete the EHR Readiness Checklist in Appendix 5 (pg 33) of the guidance • Certify immediate readiness for certified EHR purchase, OR • Certify purchase of the certified EHR system will occur once readiness is achieved within the 2-year project period

10. Identify goals for the EHR project Create a strategic plan that guides the certified EHR procurement and identifies key milestones to achieving “meaningful use” Include a completed feasibility analysis Include a completed comprehensive organizational readiness assessment Include a completed comprehensive staff skills assessment Assess and inventory current resources (staff, hardware, software, etc.) Outline an implementation strategy for the EHR project that will achieve “meaningful use” Inventory all additional hardware, software, and staff expertise needed to implement the EHR project Identify a multidisciplinary committee to oversee the readiness, due diligence, selection, and implementation of the certified EHR project Identify a plan to address the decrease in productivity during training and implementation Develop a plan to protect patient’s health information ! EHR Planning and Readiness information can be found at http://www.hrsa.gov/healthit/ EHR Planning and Readiness Process

11. CIP funds cannot supplant HRSA funds that have been allocated for certified EHR-related activities (i.e., other HRSA grants that have been awarded to health center controlled networks for certified EHR adoption). Purchase of EHR systems that are not certified by an organization recognized by the Secretary of HHS are not allowed. At this time, CCHIT is the only recognized certifying organization. Grantees may not add a new site as part of certified EHR-only projects, although they may propose that these types of projects occur at a site added previously as part of an alteration/repair/renovation or construction project in the same application. Electronic Health Records Caveats • Grantees must demonstrate readiness to purchase a certified EHR system prior to expanding CIP funds. • If readiness gaps exist, grantees will need to certify that a certified EHR purchase will occur once readiness is achieved within the two-year period. For, applicants that cannot certify readiness to purchase a certified EHR system within the project period, EHR system costs are not eligible uses of CIP funds.

12. EHB Specifics—EHR Readiness Checklist

13. Electronic Health Records Caveats—cont. • For any contract, grantees will need to make sure they follow the standard procurement principles that apply to all HHS grants. • If the project budget obligates money beyond 25% of the combined budget for all projects or $250,000, the change of scope will need to be reviewed and possibly changed. • All procurement must comply with HHS 45 CFR Parts 74.34 and 92.32. • “In order to ensure objective contractor performance and eliminate unfair competitive advantage, contractors that develop or draft grant applications, or contract specifications, requirements, statements of work, invitations for bids and/or requests for proposals shall be excluded from competing for such procurements.” (http://www.access.gpo.gov/nara/cfr/waisidx_07/45cfr74_07.html.)

14. Environmental Information and Documentation (EID) Checklist • Must be completed and submitted with EACH project (applies to all project types) as part of the CIP application.

15. EHR/HIT Specific Form 424C Line Items • Costs in Line 1 (Administrative) • Personnel costs should be explained by listing each staff member who will be supported from funds, name, position title, percent full time equivalency and annual salary • Travel of staff for trainings on EHR/HIT system • Subcontracts and justifications, provide an explanation as to the purpose of each contract and how the costs were estimated • Pre-implementation/Readiness costs—including but not limited to workflow assessment, change management, planning for loss of staff productivity, communication and training for patient involvement. • EHR/HIT support, maintenance • Consultation and technical assistance costs

16. EHR Specific Form 424C Line Items • Costs in Line 10—EHR acquisition/implementation costs: • Software Costs: EHR/HIT Software costs, operating systems, Help desk application, computer based training, EHR/HIT web portal, and other software • Infrastructure Clinical Facility costs may include: Wireless LAN infrastructure, LAN switches (closets), routers, tablets, table docking stations, tablet batteries (spare), tablet keyboards, docking racks, desktop PCs, scanners, patient ID card systems, patient ID card readers, cameras, network printers, cabling-access points, network transport link to data center • Data Center Infrastructure Costs may include: servers, applications, database, reporting, routers, core switches, desktop switches, data replication, AN-applications, database, reporting, SAN-document management, backup library, backup software, firewall anti malware, server racks, space acquisition, power upgrades, UPS, fire suppression, cooling/HVAC, management consoles, back up media, fax server, etc.

17. Project Impact and Reporting • Application projections • Projected number of providers using the certified EHR or enhanced HIT system as a result of this project • Projected number of patients with an electronic health record as a result of this project • Impact of CIP funding • Number of new/improved sites • Number of health center jobs created and retained • Number of construction-related jobs created • Completion status (% complete) • Actual versus projected budget information—uses of CIP grant funds • Other ARRA reporting required by Act

18. Resources for Planning and Implementing Certified EHR Projects

19. HRSA’s HIT Goals • Bring HIT to America’s safety net providers which will • Improve quality of care • Reduce health disparities • Increase efficiency in care delivery systems • Increase patient safety • Decrease medical errors • Eliminate the digital divide 19

20. HIT is….. • Health Information Technology is the use of information and communication technology in health care. Health Information Technology can include: • Electronic health or medical records • Personal health records • E-mail communication • Clinical alerts and reminders • Computerized decision support systems • Hand-held devices • Other technologies that store, protect, retrieve and transfer clinical, administrative, and financial information electronically within health care settings. • HHS/HRSA/Health Information Technology

21. The Cycle of Health IT Implementation

22. How to start? • Planning Phase • Needs assessments and technology selection • Stakeholder buy-in • Funding and sustainability strategy • RFP process • Implementation Phase • Vendor selection process • Implementation team organization • Sites for go-live • Cost issues • Evaluation • Measure outcomes • Change strategies

23. Needs Assessments • Needs Assessments • Document processes that are inefficient • Do not automate a manual process that does not work—change the process • Understand how technology solutions can solve these inefficiencies: • Need for data integration from many sources • Need to deliver data to many locations • Tools • HRSA Readiness Assessment Tool • http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_1248_227915_0_0_18/ehrguidelines.doc • CHCF Needs Assessment Tool • http://www.communityclinics.org/section/library/?topic=2

24. HIT Planning Considerations • Data & Technical Standards • Interoperability • Certification by certification body that is recognized by the Secretary of HHS • Certification body for electronic health records and their networks, and an independent, voluntary, private-sector initiative

25. What EHR should I choose? • Do not start in “product selection mode” • Begin by identifying the practice processes that you wish to improve first; understand your work flow. • Then search for the functions you need: • Problem List • Medications • Clinical Encounters • Lab/X-ray/Pathology • Telephone Calls • Referrals • Preventive Care • Managed care

26. Advancing HIT through Networks • Why Networks? • Collaboration of health centers and other safety net providers • Economies of scale/cost efficiencies/volume • Enhanced efficiencies in business and clinical core areas • Higher performance and value • Sharing of expertise and staff among collaborators

27. Which EHR should I choose? • Anticipate primary and secondary users • Primary • Clinical decision making • Documentation • Support for billing • Quality improvement • Secondary • Provider profiling and service utilization • Quality report cards and outcomes analysis • Regulatory reporting and justification for studies

28. Lessons Learned • Involve clinicians • Identify organization’s need and how HIT adoption will address this need • Integration takes time; move forward but deliberately • Identify roles and responsibilities, expectations, goals, and resources such as technical assistance • Learn from early adopters such as Health Center Controlled Networks or other Health Centers (most are willing to share) and consider partnering with them

29. Lessons Learned (cont’d) • Conduct due diligence with all purchases • Look for small, incremental successes • Set and maintain realistic expectations and goals • Communication must be open, consistent, and include all partners and staff. Establish feedback loops throughout the process.

30. HIT Technical Assistance Center (HITTAC) • Overview—Provide consistent HIT TA to HRSA grantees and staff • One-to-many TA • One-on-one TA

31. HITTAC: One-to-Many TA • HRSA Health IT Community • HIT Toolboxes • HIT Webinars • HIT Workshops

32. HRSA Health IT Community Portal • HRSA Health HIT Community Portal • Developed in collaboration with the AHRQ National Resource Center for Health IT (NRC) • Designed to provide news, tools, and access to research for HRSA's safety net providers interested in health IT. • Includes a searchable internet database that contains literature articles about the costs and/or benefits of health information technology • Request log on password: healthit@hrsa.gov • Log in to the Portal: http://healthit.ahrq.gov/login

33. Introduction to the Health IT Adoption Toolbox • Developed by Health Resources and Services Administration • Compilation of planning, implementation and evaluation resources • Helps community health centers, other safety net and ambulatory providers implement health IT applications • Organized to support needs of stakeholders ranging from senior management to the staff implementing health information systems • Provides information regarding implementing applications such as disease registries, electronic health records, etc. • Various stakeholders in the health IT arena have reviewed and contributed to the toolbox to ensure accurate, relevant, and effective in supporting health IT in health centers • Toolbox made publicly available in November 2008 and can be accessed at: • http://healthit.ahrq.gov/toolbox

34. HIT TA Toolboxes/Modules • Overview on why we create toolboxes • Current Toolbox • Health IT Adoption Toolbox • Upcoming Toolboxes • Rural Health • Telehealth • Children’s Health IT Toolbox • Upcoming Modules • Network Development • Personal Health Records • e-prescribing • Quality through HIT

35. Toolbox Topic-Specific Modules • The toolbox is organized into the following eleven modules: • Introduction to Health IT • Getting Started • Opportunities for Collaboration • Project Management and Oversight • Planning for Technology Implementation • Organizational Change Management and Training • System Implementation • Evaluating, Optimizing, and Sustaining • Advanced Topics • Open Source and Public Domain Software • Privacy and Security

36. HITTAC One-to-Many TA • Webinars • HRSA holds monthly webinars on various HIT-specific topics • Webinars are all archived: http://healthit.ahrq.gov/login • A password and log in is required to access the portal. To obtain this, email the request to healthit@hrsa.gov.

37. HITTAC One-to-Many TA Webinars • Over 3,000 HRSA grantees and staff have participated in a wide range of webinars including: • HIT 101 • Important Factors to Consider When Selecting an EHR System • Collaboration (How do I collaborate with networks, state entities, etc.) • Telehealth 101 • Financing HIT • Readiness Assessments for HIT • HIE 101 • HIT for Special Populations • Using EHRs to Drive Quality Improvement • Personal Health Records

38. HITTAC One-to-Many TA Webinars cont. • Upcoming Webinars: • May 2009 – HIT and Sustainability for Rural Settings • June 2009 – Due Diligence – What is it? Why should I do it? • July 2009 – Disaster Recover Plans for HIT • August 2009 – Public Health Informatics

39. HITTAC One-to-One TAConsultation with OHIT Staff • OHIT encourages HRSA grantees and staff to call or email with any HIT questions • Can you help me identify other grantees using the same software that I am using or looking to implement? • My grantee has a question on HIT I cannot answer—can you assist us? • You may contact us a healthit@hrsa.gov

40. Overview of the CIP Application in the EHB

41. CIP ApplicationProgram Specific Information This diagram shows the structure of a Capital Improvement Program application, using the left side menus from the EHBs. The application has one Program Specific Information section that includes one or more projects. Project forms need to be completed for each proposed project. Multiple projects can be proposed withina single application. Program Specific Information Project #1 Project #2 Project #3

42. Program Specific InformationProposal Cover Page 4 Sections: • Purpose • Sustainability Plan • Green/Sustainable Design Principles • Service Impacts Service Impacts • Projected # additional Provider FTEs • # additional patients served • # of additional visits

43. Program Specific InformationProjects Application Budget Summary Information Update or Delete a Project Add Project button

44. Program Specific InformationAdding a Project • Choose a project type from the list • If you select and confirm the wrong project type, you will not be able to change it. You will have to delete the project from the application and start over. • Enter a project title.

45. Program Specific InformationAdd Project Confirmation Certified EHR-related purchase EHR Project

46. Program Specific InformationProjects—Status Page Each project consists of numerous sections. Each project has its own Status page. Click the “Update” link in the Project Status table to open a section for editing.

47. Project InformationProject Cover Page Standard Sections: • Site Information • Project Management • Contact Information • Need • Implementation • Timeline EHR-specific section: 7. EHR System Readiness

48. Project InformationProject Cover Page—EHR System Readiness EHR Readiness Certification Download and Attach EHR Readiness Checklist Template(see next slide)

49. Project InformationEHR System Readiness Checklist Why are you purchasing a EHR? Do you have staff commitment? Do you have business and clinical goals? Do you have a clinical champion? Did you use HRSA’s EHR Selection Guidelines?

50. Project InformationProject Impact Direct Impacts indicated in terms of: • Square feet improved • Square feet increased • # of providers using the EHR or HIT • # patients with EHR Projected FTEs