[Federal Register Volume 73, Number 17 (Friday, January 25, 2008)]
[Notices]
[Pages 4584-4592]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-1301]



[[Page 4584]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Strategy To Support Health Information Technology Among HRSA's 
Safety Net Providers

AGENCY: Health Resources and Services Administration (HRSA), HHS.

ACTION: Response to Federal Register notice (71 FR 54829) published on 
September 19, 2006, regarding strategies to support health information 
technology (HIT) among Health Resources and Services Administration's 
(HRSA) safety net providers--Solicitation of Comments.

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SUMMARY: The following represents a series of respondents' comments and 
the Health Resources and Services Administration's (HRSA) responses to 
the comments regarding the Federal Register notice (FRN): September 19, 
2006 (71 FR 54829). The FRN proposed strategies to support health 
information technology (HIT) among safety net providers, and requested 
comments on HIT topic areas addressing quality improvement, 
collaboration, general network-related issues, specific health center 
controlled network (HCCN) related issues, sustainability and building 
HIT capacity. HRSA received a total of 53 comments from a broad range 
of stakeholders, including State health departments, non-profit 
organizations, individual healthcare providers and the health 
information technology industry. HRSA's responses reflect activities 
within the Office of Health Information Technology (OHIT) that include, 
but are not limited to, the development of an HRSA HIT strategic plan, 
technical assistance resources including the establishment of the HRSA 
HIT virtual community, the development of HIT online toolboxes tailored 
to the needs of various HRSA programs, a TA resource center, and the 
development of funding opportunities. The comments have helped, in 
part, to shape the direction and activities of OHIT.

FOR FURTHER INFORMATION CONTACT: Susan Lumsden, Division of Health 
Information Technology State and Community Assistance, Office of Health 
Information Technology, Health Resources and Services Administration, 
5600 Fishers Lane, 7C-26, Rockville, Maryland 20857, [email protected].

SUPPLEMENTARY INFORMATION: In accordance with Public Health Service 
Act, Title III, section 330(e) (1) (C), and 330(c)(1)(B) and 
330(c)(1)(C).

I. General Comments

    The general comments focused on the areas of HIT resources and 
funding eligibility, sustainability and stability, standardization, 
population health, and technical assistance.
    Comment(s): On the issue of HIT resources, comments indicated a 
need for competent staff at safety net provider organizations that have 
a solid knowledge of HIT infrastructure, readiness assessment and 
maintenance. Several comments also noted that successful applicants 
need to demonstrate that they will be able to foster partnerships to 
fully implement electronic health records (EHR) across a network. In 
addition, comments indicated that other entities, in addition to 330 
grantees, should be eligible to apply for the Health Center Controlled 
Network (HCCN) grants, including Federally Qualified Health Centers 
(FQHC) Look-Alikes and non-330 funded clinics.
    Response: HRSA included the importance of competent staff as well 
as the strength of the partnerships into its HIT application guidances. 
In terms of funding eligibility, since the authority for the funding is 
in accordance with section 330(e)(1)(C) of the Public Health Service 
(PHS) Act (42 U.S.C. 254b), as amended and/or with section 330(c)(1)(C) 
and 330(c)(1)(B), 42 U.S.C. 254b (as amended), 330 grantees must be the 
lead organization and maintain 51% control of the network. However, 
other entities are encouraged to join in any networks that are created.
    Comment(s): Several comments noted that health centers cannot 
replace decreased funding to Networks which have historically supported 
clinical initiatives, quality initiatives and market based efforts. 
Comments expressed concerns that there is currently no incentive or 
directive for FQHCs to ``transfer'' funding from 330 grants to a 
Network to underwrite services. Comments noted that fiscal improvements 
and cost efficiencies obtained through collaborative work are plowed 
back into the HCCN member health centers' bottom lines and not as 
readily into the HCCN infrastructure, notably because the mission of 
health centers does not include building for-profit or other non-profit 
organizations. Comments noted that HCCNs need to develop business plans 
to prove their value to community stakeholders (including local 
businesses) in order to structure their requests to large corporations 
and foundations. As a corollary to the business plan, a comprehensive 
marketing plan will be needed to attract new members.
    Response: HRSA plans to use the HCCN model for HIT adoption because 
of their business model in terms of cost efficiencies, the ability to 
attract competent staff, and most of all, their mission and ability to 
strengthen the health centers' operations in the marketplace. HRSA 
believes that no one source of funding will be sufficient to pay for 
EHRs and other HIT initiatives and that sustainability after Federal 
funding will be expected. The program expectation for HIT funding is 
for grantees to move to self-sufficiency within the project period. 
Short-term funding will allow organizations to deal with high initial 
cost and to implement the HIT while adopting new business models, 
identifying cost efficiencies and partnerships. This will lead to 
enhanced care management and health outcomes, while preserving the 
Network's main health center mission and functions.
    Comment(s): Comments noted the need for standardization of 
performance and health outcome measurements that support 
interoperability and data sharing. They also noted the need to consider 
the reliability of such measurements when applied to special 
populations, and that HRSA should collaborate with health centers to 
develop such measures. One comment also recommended that HRSA work 
directly with the Office of the National Coordinator for Health 
Information Technology (ONC) and its standard-setting activities.
    Response: One of HRSA's goals is to assist with the integration of 
performance outcome and quality improvement measurement with reporting 
requirements across the agency programs. HRSA is aware of data and 
statistical challenges of measurement for special populations. In 
addition, HRSA is working closely with ONC in its efforts to adopt 
uniform HIT standards. HRSA encourages safety net providers to 
participate in public comment periods around such standard-setting 
activities.
    Comment(s): Several comments emphasized population management 
technology as a means to improve health outcomes, and to address 
special populations in need of quality healthcare and reduce 
disparities.
    Response: HRSA's HIT funding opportunities encourage HIT projects 
that help grantees and patients manage health care in ways that are 
quantifiable or produce quantifiable results. In addition, HRSA is 
working closely with other Federal Agencies to share best practices as 
they approach HIT from a population health perspective.
    Comment(s): The comments also noted a need for technical assistance 
in

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the areas of basic HIT readiness and implementation requirements, HIT 
strategies on sustainability and stability, support services, HIT 
integration with other clinical and administrative initiatives, 
evaluation and performance measurement as well as reporting.
    Response: HRSA intends to include these comments for consideration 
into its HIT strategic planning and HIT technical assistance and 
related activities. HRSA has conducted several focus groups to date 
around technical assistance needs. The resulting TA resources, such as 
online toolboxes, will serve as dynamic resources to meet the changing 
needs of grantees over time.

II. Quality Improvement

    Quality improvement comments focused on quality in general, public 
health and safety issues that could be addressed with the appropriate 
use of HIT in the safety net organizations, recommendations to assure 
improving quality is the ultimate goal of HRSA's HIT strategy, and 
finally, recommendations on specific performance measures that indicate 
progress/success of HRSA-funded HIT initiatives.
    Comment(s): Several comments asserted that quality and safety could 
be improved with effective HIT use in the areas of increased patient 
access, decreased adverse drug events and increased communication among 
providers which can ultimately lead to a decrease in medical errors. 
The appropriate use of HIT was indicated to increase the quality and 
safety of health care by aiding in health prevention, tracking 
immunization, diagnostic tests and procedures reminders, provider 
prompts, proper patient identification based on Joint Commission on 
Accreditation of Healthcare Organizations (JCAHO) standards, integrated 
patient registries, continuity and coordination of care and patient 
treatment compliance. In addition, it was noted that HIT can prevent 
duplication of laboratory and radiology services, reduce waiting time, 
improve patient education, track population health trends and 
accelerate response to a disease outbreak. Several comments affirmed 
that electronic prescriptions will help with the appropriate 
identification and referral of drug seeking patients and help track 
compliance patterns. Comments stressed that clinical decision-trees 
based on best practices can enhance the quality of health care. 
Furthermore, HIT can aid in reducing health care disparities by 
tracking regional, local, State, and national outcome measurements for 
specific interventions. In turn, this can assist in the establishment 
of evidenced-based best practices that meet the often complex needs of 
underserved populations. The comments also noted the advantage of 
forming various partnerships within the Federal and private sectors in 
developing standards that will address the timeliness and quality of 
data captured. As a result, any outcome areas that need improvement 
will be properly identified and HRSA will be able to mentor grantees in 
the areas where they need assistance. The addition of data warehouse 
capability was suggested, combined with highly capable analysis and 
reporting tools to provide the information needed to assist quality 
assurance and quality improvement programs on both the network and 
health center level, as well as providing surveillance and assistance 
in state and national reporting. It was also suggested that data be 
made available for epidemiological studies at the network or national 
level.
    Response: HRSA concurs that HIT is a tool that can be used to 
improve quality and safety; HRSA delineates the significance of 
aligning quality measures and having grantees report on such measures 
in the funding opportunities. HRSA has included specific measures in 
its funding opportunities to address the areas of effectiveness, 
efficiency and safety to measure the impact of HIT on quality. 
Moreover, HRSA is working internally across its Bureaus, Programs and 
Offices, and externally with other Federal agencies, existing grantees, 
associations, Networks and other partners to develop new reporting 
requirements for clinical outcomes and other program data. The agency's 
goal is to simplify and integrate performance measurement information 
reporting.
    Comment(s): One comment stressed that the adoption of electronic 
health records does not automatically lead to quantum improvements in 
the quality of health care. In its estimation, quality could be 
improved if Federally Qualified Health Centers have action plans to 
achieve stability, an effective management team, and the development of 
at least one Quality Improvement leader. In one observer's view, it is 
not the use of EHRs and data management that improves quality and 
reduces disparities, but instead it is the use of population management 
software. In its view, EHR systems improve the legibility of 
documentation and ease of access of data of an individual patient but 
do not do the same for populations of patients. Population management 
software systems are much less complex and less expensive than EHRs 
which allow health center staff more time to manage their patients 
instead of managing the EHR system. In this observer's view, HRSA 
should consider promoting adoption of population management systems as 
a step towards building capacity for quality improvement of population 
health. In turn, this would help ensure that future EHR vendor 
selections would look critically at the population management issue, 
and the workflows developed with EHR implementation would not 
unintentionally hurt quality.
    Response: HRSA views HIT as a tool that can be used to improve the 
quality of care. While published research recognizes that many quality 
improvements can come from registries, others may not be achievable 
with this tool such as medication error prevention and live clinical 
decision support; for example, EHRs that integrate population 
management tools represent an ideal future model.
    HRSA recognizes that effective implementation of HIT system 
improvements in care delivery settings requires organizational 
leadership commitment, clear definition of goals, and effective 
planning. HRSA grantees occupy a spectrum of organizational readiness 
to implement EHRs, and HRSA intends to assure its HIT strategy is 
flexible enough to support the appropriate range of individualized HIT 
needs and capabilities.
    Comment(s): In terms of assuring linking quality of care and 
improvement of patient outcomes to HRSA HIT strategy, comments included 
a range of recommendations on the development and implementation of 
performance measures. Comments focused on HRSA's clinical 
collaboratives to help link quality of care to improvement of patient 
outcomes using HIT strategies. One comment stated that rather than 
opening up opportunities for criticism of performance, the goal of 
performance measures should be the sharing of the results and 
demonstration of a system that will result in clinical quality 
improvement.
    Response: HRSA is committed to demonstrating the impact of its 
programs on the underserved populations served by the agency. As such, 
HRSA acknowledges the significance of having grantees report on a core 
set of measures and incorporates this into funding opportunities. HRSA 
also acknowledges that the measures should be appropriate to the 
various stages of HIT adoption and integration among our grantees. One 
of HRSA's goals is to coordinate, simplify, and improve its systems of 
reporting. This has begun with the Electronic Handbook

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(EHB) as well as the alignment of performance measurement across HRSA 
programs. HRSA's OHIT and Center for Quality (CQ) are working very 
closely together to align the efforts in HIT adoption and quality 
improvement.
    Comment(s): One comment stated that ensuring access to a 
comprehensive panel of services is paramount to quality of care 
outcomes. It was illustrated that providing comprehensive primary care 
without an integrated service system linking safety-net providers to 
secondary and tertiary care providers has created an increasing health 
disparity based on socio-economic status and ethnicity. Networks 
providing clinical integration for access to specialty and hospital-
based services for patients served by member sites helps bridge the 
quality chasm for the poor and racially at risk. Using HIT to ensure 
accurate and timely exchange of information between the provider groups 
is an appropriate step in reducing overall costs of a currently 
redundant system of care.
    Response: HRSA concurs with this comment and has included health 
information exchange within its funding opportunity announcements to 
promote innovative practices. HRSA recommends grantees choose HIT 
systems that are flexible enough to incorporate new and changing 
measures.
    Comment(s): In terms of recommendations on specific performance 
measures (process and/or outcome) to indicate progress/success of HRSA-
funded HIT initiatives, several comments noted that performance 
measures may be defined based on the HIT project being undertaken. They 
also suggested that HRSA develop a short list of performance measures 
to be used by grant applicants. Some suggestions included clinical 
operational and outcome measures, financial measures, productivity 
sustained, population health measures, patient satisfaction, and 
patient safety issues. Measures should complement not only Bureau of 
Primary Health Care (BPHC) required data, but also Health Plan Employer 
Data and Information Set (HEDIS) and Consumer Assessment of Healthcare 
Providers and Systems (CAHPS). In addition, suggestions were made to 
incorporate measures recommended by the Centers for Medicaid and 
Medicare Services (CMS) and National Committee for Quality Assurance 
(NCQA) in the development of HRSA requirements. The comments also 
affirmed that quality of life measures should be monitored for 
improvements in known areas of health disparities measured by race, 
income, citizenship and other barriers to health. Several complex and 
simple measures were proposed. Complex ones included decreased 
inpatient admits, total inpatient cost, outpatient visits, total 
outpatient cost, total emergency department visits, total emergency 
department cost, and total lab cost. Several simple performance 
measures were also suggested including reduction in medication errors, 
increased clinical documentation and accuracy in diagnosis and 
treatment. As for HIT integration, several measures were proposed in 
assessing a successful integration including the number of clinics 
which adopt and operationalize integrated practice management/HIT 
disease management, the number of clinics which utilize reports from 
HIT as part of a quality management program and to inform clinical 
decisionmaking and the increased number of interoperability points. 
Other suggested HIT integration measures included: Reaching identified 
participation levels in terms of the number of centers and/or providers 
utilizing the EHR system; and achieving quality/patient outcome 
measures (on a network-wide basis), provided that such measures are 
carefully scaled to avoid penalizing health centers that have already 
made strides in improving patient outcomes. It was also stated that 
performance measures should include a cost per encounter to provide 
categories of service (i.e. HIT, financial management, clinical 
leadership support, central billing) and that specific clinical 
measures be identified (i.e. HbA1C). The comments also indicated that 
performance measures should be as flexible as possible until a 
coordinated pay for performance strategy is determined at HRSA. One 
health center suggested reviewing the original process/outcome measures 
by the HCCN Work Group and to revive the Work Group and task it with 
developing performance measures.
    Response: HRSA is committed to measuring the impact of its programs 
on the underserved populations served by the agency. Thus, HRSA 
acknowledges the significance of aligning quality measures with 
nationally recognized organizations and of having grantees report on 
such measures in the funding opportunities. HRSA intends to provide 
flexibility to grantees to achieve these measures and is positioning 
itself to provide and share information on the quality improvement 
process. HRSA intends to pilot any standard measures among grantees 
across HRSA programs with various technology capabilities.
    Comment(s): Some comments noted that HRSA should include lessons 
learned from the Health Communities Access Program (HCAP) grants, 
formerly supported by HRSA. HCAP provided funding for Management 
Information Systems (MIS) that interface with other systems to support 
community based collaborative care. This program asked grant applicants 
to describe the goals and functionality of the MIS project and how the 
changes/enhancements would improve the effectiveness, efficiency, and 
coordination of services for uninsured and underinsured individuals in 
the communities served, thus providing quality health care at a lower 
cost.
    Response: HRSA used lessons learned from HCAP and other health 
systems oriented programs, such as the Health Disparities 
Collaborative, the Telehealth Network Program, and the HCCNs, in 
developing the new HIT funding opportunities.

III. Collaboration

    Comment(s): Comments regarding collaboration focused on the role of 
Telehealth in the overall HIT strategy, collaboration between State 
Primary Care Associations (PCA) and HCCNs, recommendations for 
approaches to include State Medicaid agencies, public health 
departments, other HRSA grantees, and other providers and stakeholders 
in HIT adoption as well as approaches to a coordinated approach in a 
State or community for health information technology/exchange, use and 
support.
    Many comments discussed the central role that Telehealth plays in 
assuring access to quality health care, especially for rural and 
transient populations, and its critical role in the overall HIT 
strategy, specifically to health centers. The ability to successfully 
integrate Telehealth and HIT at the health center level is necessary. 
Additionally, there must be capacity to build or change the technology 
as it continues to develop. With Telehealth enabled by EHRs, 
specialists can provide services from a remote location to patients in 
a safety net clinic. While many comments focused on Telehealth's effect 
on rural access, some comments addressed the benefits in urban 
settings, illustrating that it is a common myth that persons living in 
urban communities have access to all the medical services they need. 
These comments noted that providing access to specialty care consults 
in urban settings, as well as rural ones, would increase HIT adoption 
and quality of care to underserved populations.
    Response: HRSA concurs that Telehealth plays a key role in the 
access to quality health care and is a critical component in HRSA's HIT 
Strategy. The

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Office for the Advancement of Telehealth (OAT), within HRSA's Office of 
Health Information Technology, promotes the effective use of Telehealth 
as a tool to assure access to quality health care, regardless of 
location. Although initially focused on rural communities, HRSA has 
placed greater emphasis on both urban and rural applications of 
Telehealth technologies. As of December 2006, 16 programs funded under 
the Telehealth Network Grant Program have included FQHCs. These 
programs have provided services, such as cardiology, mental health, 
dermatology, radiology, and pharmacy in over 77 FQHC sites. Over the 
coming year, HRSA's OHIT will collaborate with BPHC to provide TA to 
health centers through OHIT's Telehealth Resource Centers and BPHC's 
State and National Technical Assistance Cooperative Agreements. This 
collaboration will address challenges and opportunities of health 
centers in deploying Telehealth services in underserved urban as well 
as rural communities. In addition OHIT is developing a Telehealth 
Technical Assistance toolbox that will be made available over the Web 
to assist health centers in deploying Telehealth services in their 
communities.
    Comment(s): Another comment pointed out that EHRs alone will not 
create access to specialty and diagnostic services for isolated 
populations and small, rural health centers; that ongoing investment in 
Telehealth connectivity infrastructure and other technology is equally 
critical; and that, ideally, EHR systems supported by HRSA should be 
able to engage in Telehealth services. Another comment noted Telehealth 
can be used to support home and community based services through 
network access and that personal health records can be used to help 
engage home based patients in their own medical care.
    Response: HRSA/OAT recently awarded 3 three-year grants to 
organizations to support Telehealth based home services. This was the 
first funding opportunity to support such an endeavor, and HRSA will be 
working closely with the grantee community to develop best practices in 
this area. HRSA concurs that the need for specialized support services 
in health centers represents an excellent opportunity for Telehealth 
services. Moreover, the emphasis on EHR development in health centers 
provides an outstanding opportunity for creating synergy between the 
adoption of interoperable EHRs and the cost-effective deployment of 
Telehealth services that can build on that HIT infrastructure. 
Increasingly the Telehealth Networks have emphasized the integration of 
EHRs into their services. However, one barrier to doing so has been the 
lack of interoperability among the various health information systems. 
With the implementation of interoperable EHRs, the application of 
Telehealth technologies becomes a much more feasible and cost-effective 
option for health centers.
    Comment(s): One comment described Telehealth as one technical 
capability that is best addressed in a network environment. Trained 
personnel and technical resources required to provide the service and 
equipment infrastructure needed to provide Telehealth services would be 
facilitated in a network environment. Given the technical staff and 
infrastructure limitations of individual FQHCs, Telehealth may be best 
deployed in an HCCN environment. Another comment illustrated that if 
the HCCN has a large number of members, it can create a market that 
might be attractive to specialists and providers of devices and 
services to fill identified needs not conveniently or cost-effectively 
available to remote centers or disproportionate providers with limited 
budgets. It was suggested that HCCNs can provide information technology 
(IT) data and consultation conducive to Telehealth and can arrange for 
and/or provide the appropriate connectivity.
    Response: HRSA is pleased that both the HCCN program and the TNG 
program are in the same office, due to the similarities in the network 
model, both in terms of advantages (cost efficiencies and expertise) as 
well as challenges (diverse needs of network members). HRSA's OHIT will 
continue to foster collaboration among the Telehealth network grantees 
and HCCN grantees. One example is the consideration of planning grants 
for HCCNs to adopt Telehealth Technology to bridge the gap of needed 
services.
    Comment(s): Finally, one comment noted HRSA should include 
Telehealth in the overall HIT strategy and consider working with the 
appropriate Federal agencies to expand Medicaid and Medicare 
reimbursement for these services. Medicaid and Medicare currently limit 
reimbursement for Telehealth services. For example, Medicare requires 
that a patient be located at a site such as an FQHC clinic or hospital 
that is in a rural area for provider reimbursement. A comment stated 
that urban areas experience similar shortages in linking uninsured 
patients with specialty care, and therefore should also be eligible for 
reimbursement. In addition, although some Medicaid programs reimburse 
for Telehealth services in urban areas, there is great variation in 
which types of Telehealth services are reimbursed. For example, in some 
States, Medicaid will reimburse for group Telehealth visits for 
nutrition counseling, but not for Telehealth group therapy or smoking 
cessation sessions, despite the fact that both types of group visits 
have proven to be very successful with patients.
    Response: OAT has funded 6 technical assistance resource centers to 
assist HRSA grantees, in addition to other health care organizations in 
the implementation of cost-effective Telehealth programs to serve rural 
and medically underserved areas and populations. The five regional 
Telehealth Resource Centers serve as a focal point for advancing 
effective use of Telehealth technologies in their respective 
communities and regions of the Nation, and the national Telehealth 
Resource Center provides a mechanism for sharing experiences across the 
Nation in addressing legal and regulatory barriers to the effective 
implementation of Telehealth technologies. A listing of the resource 
centers can be found at http://www.hrsa.gov/healthit.
    Comment(s): In terms of collaboration between State Primary Care 
Associations (PCA) and HCCNs, most comments noted that collaboration 
between the two entities is important to ensure that FQHCs have access 
to all available resources and that those resources are effectively 
used. Coordination and collaboration between HCCNs and PCAs on HIT 
should be a requirement for seeking grants, especially with the onset 
of statewide health information exchanges (HIE). Other comments noted 
that collaboration between PCAs and HCCNs should be allowed, but not 
required, as some PCAs view HCCNs as competitive and not collaborative. 
Comments noted that PCAs can facilitate communication about issues 
related to HIT, be a resource for technical assistance, and assist with 
the expansion of the infrastructure to promote HIT throughout the State 
in health centers. Comments noted that a network model is more 
appropriate to take on a business venture of actual implementation. It 
was suggested that PCAs and Networks convene around meeting their 
common member obligations with HIT systems and work on similar 
priorities for synergy.
    Response: HRSA will continue to encourage collaboration among 
community partners, including PCAs and HCCNs, to best serve the needs 
of the health centers. HRSA sees both

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PCAs and HCCNs as valuable resources for health centers. HRSA 
recognizes that there are additional local partnerships which continue 
to be developed and improved that can serve as effective models in 
leveraging supportive resources.
    Comment(s): There were several recommended approaches to include 
State Medicaid agencies, public health departments, other HRSA 
grantees, and other providers and stakeholders in HIT adoption as well 
as approaches to a coordinated approach in a State or community for 
health information technology/exchange use and support. The comments 
noted that applicants should be required to address how other agencies 
will be included in discussions of HIT adoption for health centers 
including the requirement to identify existing capacity in stakeholders 
and what collaboration efforts have been attempted. It was suggested 
that members of reform committees, executives of the State Medicaid and 
Medicare programs, members of the local hospital Networks, and 
clinicians should coordinate for HIT exchange and support. The comments 
indicated that HRSA should support links to statewide or regional 
health information exchange (HIE) initiatives and encourage HCCNs to 
use this initiative as leverage for support. In addition, a few 
comments noted that HRSA should take the lead and work closely with 
relevant agencies to ensure that health centers' needs are addressed 
and that safety-net organizations are able to overcome the barriers to 
technology adoption.
    If the HIT infrastructure is to be successful within a State, it 
was emphasized that Medicaid, public health and other HRSA grantees 
should have linked systems. On an FQHC level, it was cited that HRSA's 
support could be critical in: (a) Getting HIT acquisition and 
maintenance costs to be effectively included in determining Medicare/
Medicaid FQHC reimbursement levels; and in (b) providing clear 
direction to state Medicaid agencies to incorporate HIT costs in 
determining state Prospective Payment System (PPS) rates. The comments 
indicated that HRSA should work in tandem with entities like the 
National Association of Community Health Centers, the Center for 
Medicaid and Medicare Services (CMS), and others to advocate for a pay-
for-performance demonstration at health centers with HIT adoption as a 
component of the part of the demonstration. The use of pay-for-
performance incentives from state Medicaid agencies could serve to 
support clinic quality improvement efforts while offsetting HIT 
operating costs.
    As systems are developed for care coordination, interoperability 
was strongly illustrated to be the key to an effective and coordinated 
information exchange. This is especially critical for statewide 
syndromic surveillance systems and information sharing related to 
public health alerts and disaster preparedness. Ensuring safety net 
representation in HIT advisory committees, such as the American Health 
Information Community (AHIC), was noted as critical to ensure that 
safety net providers' concerns are addressed in any interoperable 
health care communications system.
    Response: HRSA will continue to work closely with the Office of the 
National Coordinator (ONC) and with CMS in these areas. It should be 
noted that AHIC's bioserveillance committee has been renamed the 
Populations Health Committee, with HRSA's safety net sister agency, the 
Indian Health Service (IHS), as a Federal representative. In addition, 
HRSA encourages its safety net providers to participate in public 
comment periods around such activities.

IV. Specific HCCN-Related Comments

    Comment(s): Specific HCCN-related comments included challenges and 
opportunities in restructuring the HCCN grant program, other approaches 
to consider in promoting quality of care and improvements in patient 
outcomes through HIT adoption for minority and underserved populations, 
key considerations that should be taken into account when designing the 
new funding opportunities, and if and/or how HRSA should consider 
retaining the HCCN administrative, financial and clinical core services 
in the proposed funding opportunities as they relate to promoting HIT 
adoption.
    Overall, financial and organizational concerns were two of the main 
topics for consideration in restructuring the HCCN grant program. As 
one comment noted, safety net providers will be challenged to have the 
necessary hardware equipment, consistent power and connectivity to take 
advantage of EHRs. Comments described financial concerns such as start 
up costs to purchase application software, hardware and networking 
equipment, training and implementation services, and ongoing costs to 
maintain systems for support and maintenance and operational funds.
    Comments also provided mixed viewpoints on how teamwork and 
collaboration should fit into a restructured HCCN program; however, 
many acknowledged the need for teamwork and for collaboration in and of 
itself. One comment explained that the shared collaborative approach 
provides great opportunities but that it needs significant ongoing 
support and funding to ensure the mobilization of stakeholders, the 
development of governance guidelines and the participation in the HCCN. 
The most significant challenge facing the restructuring of the HCCN 
grant program is to design a grant that rewards and enhances the 
teamwork skills that are required of FQHCs while supporting the needs 
of the HCCN to successfully develop a network environment. Another 
comment felt that an additional challenge is how to best attract and 
engage the appropriate additional members to the existing network 
environment.
    Comments indicated that HRSA should collaborate with the Agency for 
Health Care Research and Quality (AHRQ), the Substance Abuse and Mental 
Health Agency (SAMHSA), IHS, the Federal Communications Commission, 
ONC, CMS and State Medicaid agencies to develop incentives for EHR 
adoption. For example, it was suggested that the CMS Medicaid 
Transformation grants could have encouraged State Medicaid agencies to 
work with Networks and with the community health centers that would 
have helped both the Medicaid and the uninsured populations. In 
addition, it was suggested that HRSA explore adapting the IHS's EHR.
    Response: HRSA has given priority to partnering with other Federal 
agencies and national organizations including the National Governors 
Association, The National Conference of State Legislatures, the 
Association of State and Territorial Health Officers and the National 
Association of County Health Officials, among others. HRSA has also 
developed an internal HRSA HIT Policy Council to enhance communication 
and collaboration across all of its offices and bureaus. HRSA is also 
working actively with its Federal Government partners including IHS, 
AHRQ, CDC, ONC, CMS, SAMHSA, and the FCC to encourage support for 
HRSA's HIT activities.
    Comment(s): Many comments also indicated that without Federal 
funding and support, it is unlikely that the utilization of HIT to 
transform health care delivery systems will take place. For example, 
one comment described how the HRSA investment in HCCNs has allowed the 
recruitment of highly skilled staff that health centers would not have 
been able to afford on their own. Another indicated that financial 
support should come from a dedicated

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funding stream separate from the financial support health centers 
receive to provide care to uninsured and underinsured patients. It was 
also suggested that HRSA should seek special funding from Congress and 
resources from other agencies to assist centers and Networks in 
upgrading and adopting the technology needed to communicate with other 
providers.
    The comments also recommended several avenues in HIT support and 
technical assistance such as centers for excellence and disease 
management modules in order to support each community health center's 
technological evolution in a manner that reflects the clinic's comfort, 
its user sophistication, budgetary restrictions, operational strengths 
and challenges.
    Response: HRSA concurs with the comments that funding for HIT will 
come from a variety of funding streams. HRSA is committed to building 
partnerships with other Federal agencies, foundations, and State and 
Federal organizations to help support the safety net. In addition, HRSA 
encourages it grantees to reach out to these types of public and 
private organizations to emphasize the contributions that safety net 
providers can make to the adoption and effective use of HIT to improve 
access and quality of care for all populations.
    Comment(s): In terms of key considerations that should be taken 
into account when designing the new HCCN funding opportunities to 
increase EHR adoption and to improve quality and health outcomes, 
comments provided a range of considerations. One comment stated that 
HRSA should structure the program so that it provides a predictable 
source of funding that can be used to build and maintain network 
information system infrastructure, technical assistance, appropriate IT 
systems and quality improvement, and medical informatics staff to 
implement and manage an EHR program. One comment indicated that funding 
should go beyond technology to address the process and workflow 
redesign needed to enhance EHR adoption as well as to address the 
infrastructure improvement requirements. Comments also noted that 
funding should be provided for various activities including: needs 
assessments, training and building a team of experienced personnel, 
evaluation of various business models, further development of 
technology enhancements and system interfaces, and the support of 
quality management including quality assurance and quality improvement. 
One comment stated that HRSA should address three components in EHR 
adoption: Outlay expenses for the system, an experienced team to 
oversee implementation, and ongoing support post implementation. 
Comments noted that costs were considerable and that start-up and on-
going sustainability expenses of new HIT systems must be recognized. 
Several comments stated that funds should be provided only when 
collaboration and linkages to the community could be delineated. 
Overall, many comments expressed agreement with requiring collaboration 
and linkages to the community as conditions for funding. Some comments 
also suggested that HRSA should commit to long-term funding of HCCNs 
that have integrated progressive HIT systems.
    Response: HRSA reflected many of these comments as part of its 
funding opportunities, including the need to recognize the continuum of 
readiness for HIT adoption. However, HRSA believes funding for HIT 
adoption and sustainability must come from a variety of funding 
sources, and that grantees must develop HIT models that are sustainable 
over time.
    Comment(s): In terms of if and/or how HRSA should consider 
retaining the HCCN administrative, financial and clinical core services 
in the proposed funding opportunities as they relate to promoting HIT 
adoption, the majority of the comments responding to this question 
indicated that the administrative, financial, and clinical core 
services of the HCCNs are necessary. Retaining established core HCCN 
services was indicated to be critical because these provide the basis 
for participation in HIE and will play an important part in a RHIO or 
in a broader safety net specific HIE network. It was recommended that 
HRSA support these core functions within an HCCN network when the 
function is clearly integrated into the overall HIT and quality 
improvement goals of the network. In addition, it was emphasized that 
HCCNs provide cost effective administrative, financial and clinical 
core services that are thoroughly intertwined with HIT services. The 
combined integrated services allow more effective adoption of HIT and 
increased sustainability for existing centers, new starts and new 
access points while enhancing their ability to reach underserved 
communities.
    Response: HRSA has reflected many of these comments as part of its 
funding opportunities.

V. General Network-Related Comments

    General network-related comments focused on the benefits of funding 
Networks to provide HIT support to health centers and other safety net 
providers, types of incentives, if any, to encourage health centers, 
and other HRSA grantees to join Networks, and the capacity needed for a 
Network to promote HIT among a group of health centers and other HRSA 
grantees, such as number of health centers and/or number of patients.
    Comments provided specific descriptions of the benefits of HIT in 
Networks and also recommendations of incentives to expand Networks. 
Description of benefits included: The ability to recruit and retain 
quality staff, reductions in operating costs, greater purchasing power, 
ability to compare data, ability to evaluate patient outcomes, and the 
creation of data for research and quality improvement. The comments 
cited additional benefits to funding HIT in Networks such as: economies 
of scale, interoperability systems, improved data access, increased 
rate of HIT adoption among safety net providers, minimized waste and 
duplication of efforts, standardized interfaces and data exchange 
agreements to ancillary providers, alignment with national directives 
to build HIT infrastructures and data exchange standards and 
functionalities, public health surveillance, improved medication 
management, ability to eliminate fragmentation, redundancy, and 
incomplete information for existing personal records, clinical decision 
tree capability and collaborations allowing for a greater level of 
shared resources and expertise among the network based HIT entities.
    Specific recommendations for creating incentives to expand the 
Networks included increasing the grant award amount available to 
Networks with numerous health centers, and building financial 
incentives to compensate Networks for increasing the number of 
participating health centers. Comments indicated HRSA should offer 
financial incentives to centers to encourage their membership in the 
Networks for integrated functions. One comment explained that HRSA 
could provide concrete incentives such as preference points on grant 
applications for FQHCs that participate in an HCCN network and another 
stated that HRSA should fund assistance for HCCNs and health centers to 
participate in RHIOs and state HIEs. One comment indicated that 
applicants choosing to remain outside of a Network model for its HIT 
project should have to demonstrate the economic, competitive, and 
functional advantage of their decision.
    Response: HRSA has supported expert panels and studies around the 
use of HIT to improve the quality, safety,

[[Page 4590]]

efficiency and effectiveness of health care in the health centers as 
well as models for successful systems implementation. One notable study 
was funded by the U.S. Department of Health and Human Service's Office 
of the Assistant Secretary on Planning and Evaluation entitled, 
``Community Health Center Information Systems Assessment: Issues and 
Opportunities.'' Key among the themes from the expert panels and 
studies is that the HCCN model is an efficient and effective way to 
promote HIT among health centers. HRSA will continue to stress the 
importance of health centers coming together as a network to implement 
HIT in order to maximize scarce resources and minimize risk, waste and 
duplication of effort, as comments noted.
    Comment(s): In terms of capacity needed for a Network to promote 
HIT among a group of health centers and other HRSA grantees, such as 
number of health centers and/or number of patients, comments varied 
greatly from supporting a large to a small network. Additional comments 
were provided related to capacity but not directly to size and often 
these comments provided specific details to delineate the level of 
complexity involved in addressing this topic. Several comments 
indicated that size should not matter. One comment explained small 
numbers can have greater impact than large numbers because the focus 
can be more targeted. Another comment stated that the capacity of a 
network should be limited only by the ability to adequately address the 
potential of stakeholders' shared requirements and that it is important 
for the network to be inclusive, whereas other comments proposed 
specific metrics for the capacity size. A comment stated that size does 
matter and indicated that a larger network is better. This comment 
explained that with initial IT investments being as large as they are, 
scaling the implementation is critical. The comment further explains 
that when too many organizations are involved, the necessity to define 
a single approach can be crippling. Implementation of HIT in existing, 
large health centers should be a priority in order to gain the highest 
impact with the lowest complications. Another comment indicated a 
preference for a larger size because it is critical to have a network 
that connects all primary care providers, specialists, as well as 
facilities in order to assure timely transmission of information and 
data to any provider involved in a patient's care. Another comment 
noted that regional Networks that include participation by local 
hospitals, county services, laboratories, and pharmacies would be 
beneficial to clinics regardless of the number of patients served. The 
comment further explains that Networks that are solely clinic based 
could potentially support data collection and regional trending, but 
may not optimize the interoperability necessary to support delivery of 
a comprehensive continuum of care. Another comment also expressed 
support for a larger size indicating that HIT focused Networks should 
be required to demonstrate a solid integrated network with an ability 
to reach significant geographic regions, a sound business plan and 
governance, and economies of scale to enable future sustainability on 
an established timetable. Finally, one comment suggested the 
combination of smaller, more business like boards, combined with a 
large membership that has operational and programmatic advantages in 
order to deliver sophisticated HIT capabilities and services quickly.
    Response: While HRSA will continue to foster HCCNs that consist of 
at least three organizations in order to promote both horizontal and 
vertical integration, HRSA also recognizes the contributions of large 
multi-site health centers and if funding permits, will take this 
additional approach into consideration. Geographic consideration will 
be taken into account in the funding opportunities to assure a mix of 
both urban and rural Networks. HRSA will require applicants to specify 
a number of metrics (such as number of patients, centers, sites, 
encounters, and software licenses) so HRSA can continue to better 
assess the relationship between capacity and resources.

VI. Sustainability

    Sustainability comments focused on expectations for Networks around 
sustainability, including long-term sources of funding. The key themes 
in the response to this topic include HCCN's assuring their own 
sustainability, HRSA investing long term in HIT infrastructure, and 
HRSA working with payers, who benefit from the cost saving of HIT 
implementation and improved quality of care.
    Some comments stressed that application guidance should include a 
section requiring the applicant to address how they intend to develop a 
feasible and reasonable plan for sustainability. Comments noted that 
project-only funding for infrastructure development is a failed 
strategy because infrastructure itself (buildings, furniture, 
utilities) does not create benefit; people create benefit. Project-only 
funding for a well defined project with defined start and end times can 
be a successful strategy. Not every project requires ongoing support 
after completion. HCCNs should be expected to provide a sound business 
and governance plan that demonstrates the ability to take advantage of 
economies of scale. This is a key factor in assuring sustainability. 
Business plans should include agreements up front for reinvestment of 
some of the savings from economies of scale in maintenance of the 
network infrastructure needed to stay in business. It is critical that 
HCCNs develop business plans to prove their value to community 
stakeholders (including local businesses) in order to structure their 
requests to large corporations and to foundations. As a corollary to 
the business plan, a comprehensive marketing plan will be needed to 
attract new members. HRSA should also promote and assist HCCNs in 
obtaining and or facilitating HIT dedicated funds from other federal 
agencies and private sector partners.
    Response: HRSA has included many of these comments as part of its 
funding opportunities.
    Comment(s): Other comments noted that HRSA should not assume that a 
model of financial sustainability will appear in the future. 
Sustainability may be possible in only a few cases without ongoing 
external support. OHIT should encourage HRSA to sustain a long-term 
commitment to the development and sustainability of funding HIT 
solutions. The HCCN movement over the past decade has repeatedly 
demonstrated that fiscal improvements and cost efficiencies obtained 
through collaborative work are reinvested back into the HCCN member 
health centers' bottom lines and not as readily into the HCCN 
infrastructure. This occurs, in part because the mission of health 
centers does not include building for-profit or other non-profit 
organizations. A fundamental shift is necessary at both the Federal 
level and HCCN level that supports some continued ongoing funding for 
those HCCNs that demonstrate continued efficient use of Federal funds. 
Comments noted that Networks are an important infrastructure of the 330 
grantees and the long-term survival of these Networks should mimic 
those of the 330 grantees. The Networks must demonstrate cost savings 
in their support efforts, but the funding challenges faced by such 
Networks are the same as that found by the 330 grantees. Any other 
approach to funding the Networks places the burden of network 
sustainability on the 330 grantees that use the service. The realities 
about what it costs to provide

[[Page 4591]]

an agreed upon cadre of core required services needs to be agreed upon. 
Then long term planning with realistic funding sources (including HRSA) 
needs to be done in relation to cost realities. With the implementation 
of HIT, costs expand and CHC's are expected to absorb these increased 
costs while the benefits accrue to the data recipients (i.e. payers). 
By supporting network infrastructure, HRSA will help ensure that the 
CHC's HIT systems are affordable and available.
    Response: HRSA believes funding for HIT adoption and sustainability 
must come from a variety of funding sources.
    Comment(s): Since EHR systems have proven to be effective tools for 
reducing medical costs through improved quality, HHS should consider 
ways to get payers, such as Medicaid, Medicare, and Blue Cross, to 
include an additional incentive component in their reimbursement for 
health centers and other safety net providers which adopt HIT systems. 
Such broad-ranging strategies may prove to be critical in determining 
the overall sustainability of the President's HIT initiative.
    Response: HRSA is working closely with other Federal agencies, and 
with public and private sector organizations to promote the goals of 
HIT adoption among safety net providers. In addition, HRSA provides 
information on funding opportunities to current grantees and other 
interested applicants as they become available. HRSA has also created a 
special portal for health centers as part of the AHRQ HIT Resource 
Center to share information on best practices, literature and funding 
opportunities.

VII. Building HIT Capacity

    Comments on this topic focused on types of HIT investments, other 
than EHRs, that HRSA should consider investing in, to improve quality 
of care and health outcomes, as well as Model practices in other parts 
of the safety net or private industry to build key HIT capacities in 
under-resourced environments.
    The comments provided various HIT investments that HRSA should 
consider to improve the quality of care and health outcomes. Comments 
focused on HIT areas such as collaboration in advancing HIT adoption, 
health information exchange, quality improvement, Telehealth, and 
technical assistance. Some comments also indicated unique and specific 
HIT investments that may or may not require an operational EHR system 
such as practice management systems, clinical and fiscal reporting 
systems, templates (computer notes), e-mail, instant messaging and chat 
sessions in clinical settings, e-lab (ordering, tracking and 
reporting), e-radiology (tracking and reporting), e-pharmacy 
(formulary/interaction checks), telemedicine/teleradiology/video 
consultation to extend specialist access in shortage areas, electronic 
filing cabinets/scanning, clinical guideline software, chronic 
condition and disease management software, voice dictation, web 
portals, linkages/interfaces to community providers such as (SNO) and 
Regional Health Information Organizations (RHIO), e-prescribing, 
disease registries, clinical data capture technology, personal and 
community health record. These areas were primarily suggested to be 
potential HIT funding projects in addition to EHRs.
    Health Information Exchange (HIE) systems were mentioned as 
potential HIT investments for HRSA. Comments indicated that HCCNs 
should have the capability to operate or interface as a federated HIE 
infrastructure with government funded program systems such as Medicaid 
Management Information Systems and SAMHSA reporting systems. It would 
also provide an excellent opportunity to invest in an approach that 
leads to improved quality of care and coordination of services. Funding 
opportunities in alignment with the critical components of the ONC 
strategic framework such as health information Networks and personal 
health records were also mentioned. Electronic Data Exchange, data 
backup for redundancy, as well as preparing for an emergency or 
disaster were noted as having a key role in the buildup of data 
warehousing.
    Quality improvement initiatives were also a main theme. The 
comments requested that HRSA consider investing in the development of 
structured quality improvement programs within Networks where there is 
a commitment to openly share data among FQHCs within the Network and/or 
through community coalitions/collaborations.
    Telehealth initiatives were also mentioned as potential investments 
in improving quality of care and health outcomes, particularly in 
frontier communities where access is an issue. It was also suggested as 
one of the key tools in ensuring cultural competency.
    Investment in technical assistance and support is also one of the 
main themes of the comments. The comments requested technical 
assistance in the areas of planning and evaluation projects to assess 
utilization models, governance issues, development of infrastructures 
to support shared services collaborations, assistance to PCAs to 
conduct HIT strategic planning with members' organizations, HIT 
infrastructure development, funding, training and basic HIT start-up. 
These elements were generally indicated to be critical in establishing 
and maintaining a successful HIT initiative.
    Response: Many of the themes mentioned such as Telehealth, quality 
improvement, technical assistance and collaboration will form the basis 
of HRSA's HIT strategy. In addition, HRSA recognizes the continuum of 
HIT that can be used in efforts to improve health outcomes; therefore, 
HRSA has included many of the ideas mentioned in its HIT Innovation 
funding opportunity.
    Comment(s): In terms of model practices in other parts of the 
safety net or private industry to build key HIT capacities in under-
resourced environments, several comments noted that the existing 
Operational HCCN grantees are the models that can be used to build key 
HIT capacities in under-resourced environments due to their aggregate 
knowledge and experience. The IT support provided by a Network to 
several sites results in economies of scale and can promulgate best 
practices in HIT implementation and support. Existing models to promote 
HIT often require providers to produce matching funds in order to 
receive grants. This model is difficult for community health centers 
and other safety net providers due to limited matching funds. In 
addition, one comment noted that it is critical that HIT models are 
geared towards the community health center industry, that they provide 
full life cycle care, and emphasize chronic disease and maternal-and-
child management.
    Response: HRSA has included many of these comments as part of its 
funding opportunities.

VIII. Other Comments

    In general, the comments stated that adoption of an EHR does not 
automatically lead to health improvement. Factors that contribute to 
success include clinic stability, strong and effective management team 
and a focus on quality improvement. Comments recommended that HRSA 
solicit these items in the grantee's work plan and the focus on quality 
improvement should be strengthened at the clinic level.
    Population Management was frequently cited to improve quality and 
reduce disparities. Comments recommended that HRSA promote the adoption 
of population management systems as a step towards building HIT 
capacity for quality improvement. The comments also pointed out that 
although EMR adoption is a critical component of HIT, advancing the EHR

[[Page 4592]]

adoption should not necessarily preclude the other components such as 
population management systems.
    Comments also raised the issue that HIT is far from reality for 
most of the safety net providers. Because of lack of resources, HIT is 
not a priority. Many safety net providers are struggling with outdated 
practice management systems that need constant repair and with scarce 
resources available to maintain them. It was suggested that HRSA 
provide access to resources or approaches that can support 
sustainability of some level for Safety-Net Provider Networks.
    Response: HRSA appreciates that there are other HIT solutions in 
addition to EHRs and included many of these comments as part of its 
funding opportunities. In addition, HRSA believes funding for HIT 
adoption and sustainability must come from a variety of funding 
sources.

IX. Paperwork Reduction Act

    Should any of the HIT initiatives involve the collection of 
information applicable to requirements of the Paperwork Reduction Act 
of 1995, the agency will request OMB review and approval.

    Dated: January 16, 2008.
Elizabeth M. Duke,
Administrator.
 [FR Doc. E8-1301 Filed 1-24-08; 8:45 am]
BILLING CODE 4165-15-P