Regional Extenion Center

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Overview

Cover Page
Front page
Instructions
Contacts
Mission & Vision
Service Area
Providers & Patients
Baseline
Budget & Milestones
Org chart
Staff
Sub-Recipients
Stakeholders
Key activities
Gantt chart
Risk mitigation

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Sheet 1: Cover Page

Form Approved

OMB No. 0990-NEW

Exp. Date 06/30/2010

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 1 hour, 30 minutes to complete, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

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Sheet 2: Front page

Jump to:
Instructions		ONC Regional Extension Center Operations Plan
Contacts
Mission & vision		This operations plan template is a guide for each REC to describe their plan for contributing to the REC Program's shared goal of bringing 100,000 primary care clinicians to meaningful use of electronic health records in 2010 and 2011. Please click on Instructions for abbreviated instructions on using this Operations Plan tool. Please see the accompanying "Guidelines for REC Operations Planning" for detailed instructions and guidance on completing this plan.
Service area
Providers & patients
Baseline
Org chart
Staff
Sub-recipients
Stakeholders
Key activities
Gantt chart		Version history
Risk mitigation		REC Update Version	REC Point of contact	REC Signature	REC approval date	ONC Point of Contact	ONC Signature	ONC Approval Date
Data entry field
Reference field
Calculated field
		e.g., XXXXXX	name of primary author	e.g., mm/dd/yy	e.g., mm/dd/yy	name of ONC approver
		Budget and Milestone Reimbursement Rates
		Original Request	$-		Comments
		ONC approved	$-
		Core Funding (years 1 + 2)*	$-
		Total Direct Assistance	$-
		Provider Target	$-
		Blended Rmbs Rate	#DIV/0!
		MILESTONE RATES
		Milestone 1	#DIV/0!
		Milestone 2	#DIV/0!
		Milestone 3	#DIV/0!

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Sheet 3: Instructions

Jump to Front Page
Legend
Data entry field
Reference field
Calculated field		ONC Regional Extension Center Operations Plan -- Description and Abbreviated Instructions
		Please see the "REC Operations Planning Guidelines" for more detailed information on the Operational Plan
		General instructions	The Operations Plan is the principle planning document for the REC. Like a business plan, it describes the goals & objectives of the REC and how the REC proposes to achieve these goals & objectives.
			This Operations Plan template is provided to each REC as an aid to creating a realistic plan for meeting the REC's goals, and to standardize basic data collection and terminology to allow tracking and information-sharing across RECs.
			This template is designed to capture structured data consistently across the entire REC program. Please do not alter the templates outside of the data input fields shaded in orange, as indicated in the legend to the left.
			All worksheets have a "Comments" box at the bottom of the sheet where any comments or supporting detail may be entered.
			In addition to the brief instructions provided here, more detailed guidance can be found in the "REC Operational Planning Guideline" document.
		Contacts	Please enter contact information for the REC and its Sub-Recipients as appropriate. (Note: Sub-recipients are those organizations or contractors that will receive Federal money for performing REC activities.) This will be the main input to ONC's REC contact list so please keep it updated as often as necessary.
		Mission & vision	The Mission & Vision section is designed to capture the RECs high-level statement about why it's activities are important, what it would like to accomplish, and how the REC's activities will affect health care delivery. Ideally, the mission and vision should define the RECs ambitions in a way that is meaningful to the RECs employees and stakeholders. Key questions that the mission statement should address are: what does the REC want to accomplish? what about the REC will make it well-positioned to accomplish its objectives? Key question that the vision statement should address include: what will the service area be like after the REC has accomplished its goals and fulfilled its mission? how will health care delivery in the service area be different than it is today? (note: the mission and vision statements are specific to the REC program and may be different than the mission and vision statements of the organization operating the REC)
		Service area	Geographic service area defines the state/territory, counties, and zip codes in which the REC will operate. For multi-state RECs, please enter state, county, and zip codes for each state separately in the columns provided. County and zip code information may be pasted into the worksheet from sources such as www.downloadzipcode.com or the US Postal Service.
		Providers & patients	This section describes key characteristics of the provider landscape and patient population in the REC's service area. Information in this section should match that of your REC's FOA response. US census data may be used for patient data. Data sources such as the AMA or Kaiser Family Foundation may be used for provider data.
		Baseline	The milestone and budget baselines are key elements of operational planning. Once established, the milestone and budget baselines are what the program will be tracked against for the remainder of the program. Baselines may be periodically adjusted to reflect new factors, however, such changes must be approved by ONC and recorded in this document. All of the succeeding sections of the Operations Plan should be geared to the goals reflected in the baseline.
		Org chart	The Org Chart section captures both the REC's relationships with stakeholders, partners, sub-recipients, and sub-contractors, and the internal organization structure of the REC itself.
		Staff	As described in the Funding Opportunity Announcement, the REC is required to provide a number of key functions that have been determined to be critical to success of the REC program. It is not necessary that the REC structure their organization with these position titles, and it is anticipated that individuals will perform more than one function. In order to ensure that all of the functions are being covered, and to allow knowledge-sharing and comparability across RECs, please map your current and anticipated employees and job titles with the prescribed functions.
		Sub-recipients	Sub-recipients are organizations identified in the Cooperative Agreement as recipients of award dollars. As such, they are key partners of the REC and contributors to its success.
		Stakeholders	Each REC will have a wide variety of stakeholders with whom it will have formal as well as informal relationships that taken together will form the RECs approach to achieving its objectives. Identifying stakeholder roles, responsibilites, and expectations are critical inputs to the development of an meaningful Operations Plan. Making this information available to ONC and other RECs will greatly facilitate the development of learning communities and channels for knowledge-sharing across RECs. Please categories the "level of commitment for each stakeholder using the following scale: Level 1 – Stakeholder is involved with REC; Level 2 – Stakeholder intends to make financial contribution to REC; Level 3 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC; Level 4 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC -and- intends to make financial contribution to REC.
		Key activities	The Key Activities are the high-level activity areas that the REC will conduct to fulfill the required functions articulated in the FOA. It is expected that the REC will itself have highly detailed project plans tracking day-to-day tasks and activities at the ground-level -- the REC Operational Plan does not require this level of detail and should only include the high-level "rollup" activities. (Note, the expectation is that 5-10 activities will be listed under each service area.)
		Gantt chart	The Gantt chart is simply a timeline of the Key activities defined above. The template is designed to provide a simple depiction of the activities and high-level timelines associated with each function. Please enter a "1" into the chart cells to change the color and illustrate the activity timeline. (Note: the months are calculated based on the project start date in the Baseline section)
		Risk mitigation	Each REC will face a number of challenges to achieving its goals. Some of these challenges will be common to all RECs, while others will be unique to the particular REC's organization characteristics and service area environment. It is important that each REC have as clear an understanding as possible of the risks that it faces and puts into place a proactive strategy for mitigating such risks to the greatest extent that is practical.

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Sheet 4: Contacts

Jump to Front Page
Legend		Primary contact information - (Main REC Office)
Data entry field		REC information
Reference field		Organization name		enter name
Calculated field		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.myrecname.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		REC primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@myrecname.org
		REC secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@myrecname.org
		ONC GMO name		enter first and last name of ONC Grant Management Officer
		telephone number		enter 10 digit phone number
		email address		e.g., name@hhs.gov
		ONC PO name		enter first and last name of ONC Project Officer
		telephone number		enter 10 digit phone number
		email address		e.g., name@hhs.gov
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Additional contact information - (REC Sub-Recipient Office)
		Sub-Recipient information
		Organization name		enter name
		Street address		e.g., 12 Main Street
		City		e.g., Springfield
		State		pick from drop-down list
		Zip code		e.g., 01234-0000
		Website		e.g., www.organization.org
		DUNS number		9 digit Dun and Bradstreet Data Universal Numbering System number
		Primary contacts
		Sub-Recipient primary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Sub-Recipient secondary contact name		enter first and last name
		telephone number		enter 10 digit phone number
		email address		e.g., myname@organization.org
		Comments

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Sheet 5: Mission & Vision

Jump to Front Page
Legend		Mission statement for the REC Program
Data entry field		Double-click on box to type directly into it; use alt-enter to start new paragraph
Reference field
Calculated field
		Vision statement for the REC program
		Double-click on box to type directly into it; use alt-enter to start new paragraph
		Comments

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Sheet 6: Service Area

Jump to Front Page
Legend		Geographic Service Area
Data entry field		For in counties in top of sheet; scroll down to fill in zip codes
Reference field
Calculated field		State or territory #1		State or territory #2		State or territory #3
								Pick from drop-down list
		Full names of counties (Boroughs for Alaska, Parishes for Louisiana)		Full names of counties (Boroughs for Alaska, Parishes for Louisiana)		Full names of counties (Boroughs for Alaska, Parishes for Louisiana)
								Fill in full-name of county
								County lists may be downloaded from external sources such as:
								http://www.naco.org/Template.cfm?Section=Find_a_County
		Zip Codes Represented		Zip Codes Represented		Zip Codes Represented
								Please enter 5 digit zip code
								Zip code lists may be downloaded from external sources such as:
								http://www.downloadzipcode.com/
		Comments

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Sheet 7: Providers & Patients

Jump to Front Page
Legend		General patient and provider landscape
Data entry field			Number
Reference field		Providers in service area
Calculated field		Total Providers (all specialties)
		Primary Care Providers
		Priority Primary Care Providers (PPCPs)
		PPCPs Participating in REC and committed to attaining Meaningful Use (projected)		Note: This should match estimate provided in your FOA response
		Non-PPCP Providers participating in REC projected)
		Number of patients in REC Service Area by Age		Note: This is the number for all patients in service area, not just the patients the REC will serve
		Age Under 19		Patient information may be found at
		Age 19 to 64		http://www.communityhealth.hhs.gov/homepage.aspx?j=1
		Age 65 to 84
		Age 85+
		Total	-
		Insurance coverage in REC Service Area
		Number of patients on Medicare
		Number of patients on Medicaid
		Number of uninsured patients
		Provider baseline (list number of providers for each)
			REC PPCP participants	non-PPCP REC participants	Non-participants	Total Providers
		Small Practice (fewer than 10 providers)				-
		Public Hospital				-
		Critical Access Hospital				-
		Community Health Center				-
		Rural Health Center				-
		Other setting (please define):				-
		Total	-	-	-	-	These totals should correspond with Provider numbers above
			Number of providers	Number of providers	Number of providers
		Other health setting (mental health, dental, etc):
		Comments

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Sheet 8: Baseline

Jump to Front Page

Legend

Data entry field

Baseline summary

Reference field

Calculated field

Baseline version (last approved milestone baseline)

Baseline document name

Date

enter document name here

mm/dd/yy

REC starting month

Apr-10

Note: this date drives baseline months

Month 2010

Baseline summary PPCPs

Measures

Year 1

Year 2

Total

Milestone baseline

M1: New Providers enrolled in program

-

-

-

M2: New Providers implemented on HER

-

-

-

M3: New Providers achieving meaningful use

-

-

-

Baseline summary Non-PPCPs

Measures

Year 1

Year 2

Total

Milestone baseline

M1: New Providers enrolled in program

-

-

-

M2: New Providers implemented on EHR

-

-

-

M3: New Providers achieving meaningful use

-

-

-

Implementation goal PPCPs (baseline)

Implementation goal -- PPCPs without EHRs

Please enter number of new providers projected to hit milestone each month and not the cumulative total

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

M2: New Providers implemented on EHR each month

-

M3: New Providers achieving meaningful use each month

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Implementation goal -- PPCPs with EHRs

Please enter number of new providers projected to hit milestone each month and not the cumulative total

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

M3: New Providers achieving meaningful use each month

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Implementation goal -- total

Calculated table

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

M2: New Providers implemented on EHR each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

M3: New Providers achieving meaningful use each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Implementation goal Non-PPCPs (baseline)

Implementation goal -- Non-PPCPs without EHRs

Please enter number of new providers projected to hit milestone each month and not the cumulative total

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

M2: New Providers implemented on EHR each month

-

M3: New Providers achieving meaningful use each month

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Implementation goal -- Non-PPCPs with EHRs

Please enter number of new providers projected to hit milestone each month and not the cumulative total

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

M3: New Providers achieving meaningful use each month

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Implementation goal -- total

Calculated table

Implementation milestone

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

Month 13

Month 14

Month 15

Month 16

Month 17

Month 18

Month 19

Month 20

Month 21

Month 22

Month 23

Month 24

Total

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

M1: New Providers enrolled in program each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

M2: New Providers implemented on EHR each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

M3: New Providers achieving meaningful use each month

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Monthly total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Cumulative total

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Comments

---

Sheet 9: Budget & Milestones

REC name here
Original Request
ONC approved
Core Funding (years 1 + 2)*		*this number is for planning purposes and does not denote ONC approval of any pending core funds change requests.
Total Direct Assistance	$-
Provider Target
Blended Provider Reimbursement Rate	#DIV/0!
	Milestone Reimbursement Rates
	Blended Rate	Broken Out Rate
		Providers on Paper	Providers on EHR
Provider Target	0	0	0
Blended Reimbursement Rate	#DIV/0!	$-	#DIV/0!
Total Direct Assistance	#DIV/0!	$-	#DIV/0!
		#DIV/0!
Milestone 1	#DIV/0!	$-	#DIV/0!
Milestone 2	#DIV/0!	$-	#DIV/0!
Milestone 3	#DIV/0!	$-	#DIV/0!
		*The broken-out rate calculation tool is OPTIONAL.
		*These cells are flexible and unprotected.
	Comments

---

Sheet 10: Org chart

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Legend

Data entry field

Reference field

Calculated field

REC relationships with sub-recipients, partners, and stakeholders

Please modify the diagram as appropriate to show how your REC connects with other stakeholders and partners

REC organization chart

Please modify the diagram as appropriate to show the organization of your REC and its Sub-Recipients

This should include only staff for organizations that will receive funding through the REC

Comments

---

Sheet 11: Staff

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Legend		Staff list
Data entry field		REC functional role	Organization	Name	Title	Newly Hired? (Y/N)	Phone number	Email
Reference field		Authorized Representative
Calculated field		Project Director
		Finance Lead
		Clinical Lead
		Education and Outreach Coordinator
		Vendor Selection Coordinator
		Practice and Workflow Design Coordinator
		Interoperability and HIE Coodinator
		Implementation Project Management Coordinator
		Privacy and Security Coordinator
		Meaningful Use Coordinator
		Workforce Coordinator
		CRM Coordinator
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Role as defined in FOA		First name last name	Position title	Y or N	e.g., xxx-xxx-xxxx
		Comments
						Y
						N

---

Sheet 12: Sub-Recipients

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Legend		Sub-recipient list
Data entry field		Sub Recipient Name	Description of Role in REC	DUNS number	Street Address	City	State	Congressional District	Amount of Award	Amount of Award Distributioned	Sub Award Date
Reference field
Calculated field
		Comments

---

Sheet 13: Stakeholders

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Legend
Data entry field
Reference field
Calculated field
		Stakeholders
		Organization type	Organization name	Contact Name	Phone	Email	Role	Level of Stakeholder Support (levels below)	Affliated National Organization
		Independent Provider Organizations
		Health Professional Societies
		State Primary Care Assocations
		Health Center Controlled Networks (HCCNs)
		Federally Qualified Health Centers
		Rural Health Centers
		Other Community Health Centers
		State/Local/Tribal Government (Public health, health care, or other partnering institution)
		State Health Information Exchange Coordinator
		State Medicaid Director
		Health Plans
		Hospital Systems
		Public Hospital
		Critical Access Hospitals
		Laboratories
		Community colleges
		Local workforce programs
		Medicare Quality Improvement Organizations
		Federal Stakeholders (HHS regional office, VA, IHS, etc.)
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Other (please specify)
		Other (please specify)
								Level 1 – Stakeholder is involved with REC
								Level 2 – Stakeholder intends to make financial contribution to REC
								Level 3 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC
								Level 4 – Stakeholders has committed Senior Level Executive(s) and/or Board Members to REC -and- intends to make financial contribution to REC
		Comments

---

Sheet 14: Key activities

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Legend
Data entry field
Reference field		Key activities
Calculated field		Insert rows as necessary below
		Service area	Description of Service Area and each activity	Goal of each activity	REC Staff	Subcontractors/Partners	Activities/Dates/Outcomes	Challenges Requiring Support and/or Assistance
		Outreach & education
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Vendor selection
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Practice & workflow design
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Interoperability and HIE
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Implementation support
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Privacy & security
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Meaningful use
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Workforce
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		CRM
		activity 1 (please specify)
		activity 2 (please specify)
		activity 3 (please specify)
		activity 4 (please specify)
		activity 5 (please specify)
		Comments

---

Sheet 15: Gantt chart

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Legend

Gantt chart

Data entry field

Please type a "1" in the cell indicating activity/month as per your plan

Reference field

Insert rows as necessary below

Calculated field

Service area

Apr-2010

May-2010

Jun-2010

Jul-2010

Aug-2010

Sep-2010

Oct-2010

Nov-2010

Dec-2010

Jan-2011

Feb-2011

Mar-2011

Apr-2011

May-2011

Jun-2011

Jul-2011

Aug-2011

Sep-2011

Oct-2011

Nov-2011

Dec-2011

Jan-2012

Feb-2012

Mar-2012

Outreach & education

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Vendor selection

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Practice & workflow design

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Interoperability and HIE

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Implementation support

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Privacy & security

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Meaningful use

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Workforce

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

CRM

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Organizational development

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Other (please specify)

activity 1 (please specify)

activity 2 (please specify)

activity 3 (please specify)

activity 4 (please specify)

activity 5 (please specify)

Comments

---

Sheet 16: Risk mitigation

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Legend		Key risks and mitigation steps
Data entry field		Insert rows as necessary below; please indicate "none" as applicable; double-click on cell to see entire cell
Reference field		Category	Detailed description	Risk/restriction mitigation steps	Risk Likelihood [1=least likely, 10=most likely]	Risk Impact [1=least impact, 10=most impact]
Calculated field		Grant restrictions
		restriction 1 (please specify)
		restriction 2 (please specify)
		Outreach & education
		risk 1 (please specify)
		risk 2 (please specify)
		Vendor selection
		risk 1 (please specify)
		risk 2 (please specify)
		Practice & workflow design
		risk 1 (please specify)
		risk 2 (please specify)
		Interoperability and HIE
		risk 1 (please specify)
		risk 2 (please specify)
		Implementation support
		risk 1 (please specify)
		risk 2 (please specify)
		Privacy & security
		risk 1 (please specify)
		risk 2 (please specify)
		Meaningful use
		risk 1 (please specify)
		risk 2 (please specify)
		Workforce
		risk 1 (please specify)
		risk 2 (please specify)
		CRM
		risk 1 (please specify)
		risk 2 (please specify)
		Organization
		risk 1 (please specify)
		risk 2 (please specify)
		Sustainability
		risk 1 (please specify)
		risk 2 (please specify)
		Other (please specify)
		risk 1 (please specify)
		risk 2 (please specify)
		Comments