Interface Development Grants Solicitation

MASS HIWAY

INTERFACE DEVELOPMENT GRANTS SOLICITATION

(SolicitationNo. 2013-MeHI-12)

ATTACHMENTA

APPLICATION FORMS

Mass HIway Interface Development Grants SolicitationSolicitation No. 2013-MeHI-12

Part 1. Project Proposal

These sections should be prepared so that if the applicant is awarded a grant, they can be easily cut and pasted into the Grant Agreement (See Attachment B) to expedite the contracting process.

Description (100-characters with spaces)

Provide a very brief description of the effort. This will be used to quickly communicate the project, as needed.

Abstract (250-words)

Provide a brief overview of your proposed project. Include a description of your product, description of your client base, your proposed use cases and an overview of your HIway connection approach.

Section 1: Product & Client-base Description

Please use Part 4 of this attachment.

Section 2: ProjectProposal

Summary

A description of the project including the proposed use cases, the anticipated number of customers in Massachusetts benefitting from the project, interface deployment model, the implementation cost to the providers, and any special considerations that MeHI should be aware of and/or consider. Please include comments on how you will meet the requirements of the grant from Section 2.3 of the solicitation

Use Cases

Descriptions of the in-bound and out-bound business scenarios that the interface enhances. For the out-bound workflow include where in the product workflow the CCD will be initiated and by whom, how the user looks up a Direct address, and how the user sends the message. For the in-bound workflow include how the application retrieves the incoming message and notifies the recipient that the message has arrived. If the interface loads data into the application, document how patient matching occurs and what happens to unmatched transactions.

Overview of Your HIway Connection Approach

Description of the architecture of the integration with the Mass HIway: how the interface is integrated into the application, the technology used (S/MIME, XDR, other), and any 3rd party gateways or services used to transmit and receive messages.

Section 3: Project Work Plan and Milestones

A clear and concise task-oriented work plan and timeline of the tasks to be completed for the development and implementation of the project showing when each of the relevant development, testing and deployment tasks, grant milestones and any deliverables will be completed. This work plan may be submitted as a separate .pdf document. In addition, please enter your grant milestone dates and payment percentages to the Key Dates and Deliverables table (Attachment A, Part 5).

Section 4: Logical Architecture Diagram

A diagram showing the logical components of the proposed integration solution.

Section 5: Anticipated Challenges

Outlinetheanticipatedchallengesandproblemsthatyouenvision may occur andwaysthattheteamwillbe abletoaddressthem.

Section 6: Budget & Budget Justification

See: Part 3 of this attachment.

Please use the included Budget Template to provide full details of the budgetary items for which the grant funds will be used from the beginning of the grant period through January 31, 2014. Provide a brief narrative in this section to justify the project costs.

•Describewhytheattachedbudgetisappropriatefortheproposedwork.

•Items to be budgeted may include, but are not limited to: personnel (e.g. project manager), consultants, equipment, interface development, process migration planning and analysis, supplies, travel, other expenses related to the project. Each budgeted item shall include a description of the cost, the basis for the cost estimate, and the value to the project. All costs must be allowable costs under the applicable federal guidelines and any indirect costs must be based upon a federally-approved rate or, if proposer does not have a federally-approved rate, then the method for calculation must be included in the justification and is subject to review and approval by MeHI and Mass Tech.

•Propose the Milestone payment percentage for each milestone in Part 5 of Attachment A. Milestone payments cannot exceed the actual cumulative costs incurred for the projects during the grant period. No milestone payment may exceed 50% of the grant amount. The last milestone payment cannot be less than 25% of the grant amount. All invoices must be received by January 31, 2014.

Describe any additional cash or in-kind resources that will be utilized to achieve the project aims

Section 7: Grant Agreement Exceptions

Summarize any issues with the Grant Agreement (Attachment B).

Part 2.ApplicantSummaryForm

ApplicantInformation
PrimaryApplicant–Organization / Partners (if any):
DUNSNumber / ApplicantTaxpayerID#andjurisdiction
(e.g.,“a Massachusettscorporation”)
MailingStreetAddress: / TotalMTC/MeHIFundingRequested:
State: / City/Town:
Website / ZipCode:
PointofContactInformation
Applicant’sProjectDirector:Authorizedtocommitorganization;notifiedupondecision ofgrantaward
Name: / Title:
Organization:Ifdifferentfromapplicant / Phone:
EmailAddress: / Fax:
MailingStreetAddress:Ifdifferentfrom
Applicant / City/Town:IfdifferentfromApplicant
State:IfdifferentfromApplicant / State:Zip +4Code:IfdifferentfromApplicant
Applicant’sProjectManager:Contactovercourseofproject
Name: / Title:
Organization: / Phone:
EmailAddress: / Fax:
MailingStreetAddress: / City/Town:
State: / State:Zip +4Code:

Part 3. BUDGETFORM

Applicant: / SolicitationNo.:
Address: / Title ofProposedProject:
MTC FundingRequested:
TotalProjectCost:
CostElements:(see instructions)
I.Direct Labor / Amount
name/title / hours / rate/hr
$0
$0
$0
$0
TotalDirect Labor / $0
II.Subcontractors/Consultants
name/title / hours / rate/hr
$0
$0
$0
$0
TotalSubcontractors/Consultants / $0
III.DirectMaterials
PurchasedParts
Other
TotalDirectMaterials / $0
IV.Travel
V.Other DirectCosts(list bytype)
Total Other Direct Costs / $0
VI.General& AdministrativeExpense/Overhead / Rate(%): / $0
TotalCost ofProject / $0.00
CostSharing:Source / Amount
TotalCostShare / $0
Total$ amount offunding soughtfromMTC: / $0
Totalfunding soughtfromMTC asa percentage oftotal project cost:
Provide a brief narrative in this section to justify the project costs.
Describewhytheattachedbudgetisappropriatefortheproposedwork

Part 4. Product Description and Customer List

Product Name:
Application version:
Product type
(Ambulatory EHR, Inpatient EHR, Departmental/Specialties, Access/administration, Decision support, Managed Care…)
Product Description
Installation Method (On-Premises, SaaS)
Primary Market Segment served (Hospital, Practice, Long-term Care facility…)

1. Customer Name

Customer Address
Customer Business type and size
(Hospital, Ambulatory practice, long-term care facility…)
Customer Contact Name
E-mail
Phone
Product Name and Version

1. Customer Name

Customer Address
Customer Business type and size
(Hospital, Ambulatory practice, long-term care facility…)
Customer Contact Name
E-mail
Phone
Product Name and Version

1. Customer Name

Customer Address
Customer Business type and size
(Hospital, Ambulatory practice, long-term care facility…)
Customer Contact Name
E-mail
Phone
Product Name and Version

1. Customer Name

Customer Address
Customer Business type and size
(Hospital, Ambulatory practice, long-term care facility…)
Customer Contact Name
E-mail
Phone
Product Name and Version

Part 5. Key Dates and Milestones

Please add the target completion dates to the list, proposed milestone payment percentages, based upon an estimate of actual costs that will be incurred for each, and any additional items you will need to complete the project.

Item / Description / Deliverable Documentation / Target Completion Date (no later than 1/31/2014) / Proposed Payment % (none can be greater than 50% and Milestone 4 cannot be less than 25%)
Milestone 1 / A signed Mass HIway Grant Agreement, letters of support from two MA customers who agree to implement this interface along with their product names and versions, An updated work plan to develop and implement the interface, and updated logical architecture diagram. / All documents provided to MeHI Project Manager
Milestone 2 / A detailed use case description (to include details on the data to exchanged), and information about any 3rd party applications or services included in the solution. / All documents provided to the MeHI project manager.
Milestone 3 / Test transaction exchanged using the Mass HIway. The outbound transactions will be verified by sending the transaction to a Mass HIway test account. The inbound transaction will be verified by sending a standard test transaction from the Mass HIway test account that must be received and processed by the vendor application. / Test transaction success confirmed via an email from HIway Ops
Milestone 4 / The interface implemented at 2 or more Massachusetts customers that have joined the Mass HIway; a test transaction exchanged demonstrating the interface functionality; Final Report; and all required support documentation provided to MeHI. / Evidence from the customers that the interface was installed and transactions processed
Mid-term report / Mid-term report summarizing progress from date of grant to through September 30, 2013. / Mid-term report / 10/7/2013
Final Report / Overall review of the project and performance against milestones. / Final report / January 31, 2014
Project Close / All invoices and documentation submitted to MeHI Project Manager / January 31, 2014

Part 6. AuthorizedApplicant’sSignatureandAcceptanceForm

MassachusettseHealthInstitute

MassHIwayInterface DevelopmentGrant Solicitation

AuthorizedApplicant’sSignatureandAcceptanceForm

The undersigned is a duly authorized representative of the Applicant listed below. The Applicant has read and understands the requirements of this Solicitation. The undersigned acknowledges that all of the terms and conditions of this Solicitation are mandatory.

The Applicant specifically acknowledges the application of the procedures regarding submission of sensitive information as set forth in Section 5.1, and specifically agrees that it shall be bound by those procedures. The Applicant understands that all materials submitted as part of the application are subject to disclosure under the Massachusetts Public Records Law; and acknowledges and agrees that the Mass Tech Collaborative and/or MeHI have no obligation, and retains the sole discretion to fund or choose not to fund the application set forth herein, and that MeHI’s receipt of the application does not imply any promise of funding at any time.

The undersigned has either:

agreed to the terms and conditions of the Agreement; or

provided exceptions and/or counterproposals to the Agreement in its application.

The undersigned acknowledges and agrees that the failure to submit exceptions and counterproposals with this Application shall be deemed a waiver and the Agreement shall not be subject to further negotiation.

I certify that the statements made in this application, including all attachments and exhibits, are true and correct to the best of my knowledge.

Applicant:

(Printed Name of Applicant)

By:

(Signature of Authorized Representative)

Name:

Title:

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