Public Health Data Modernization Implementation Center Expression of Interest Form

Please respond to the following questions to the best of your ability. At this time, only one Expression of Interest (EOI) may be submitted per Public Health Agency (PHA). All questions must be answered to be considered for the Implementation Center (IC) program.

If you have any questions while filling out the EOI form, please submit them here.

If you’d like to coordinate responses among your organization before submitting them, we have provided the questions in this Word document. Note that responses must be submitted via this web form to be considered for the IC program.

1. Name*

First NameLast Name

2. Email*

example@example.com

3. Public Health Agency (PHA) Name *

By completing and submitting this form, you confirm that you have the authority to act on behalf of this PHA.

4. Jurisdiction Type*

StateLocalTerritory or Freely Associated State

5. Names and Email Addresses of Any Additional Points of Contact (if applicable)

Additional Point of Contact 1

First NameLast Name

Email Address of Additional Point of Contact 1

example@example.com

Additional Point of Contact 2

First NameLast Name

Email Address of Additional Point of Contact 2

example@example.com

5. Names and Email Addresses of Any Additional Points of Contact (if applicable)

6. What type of project do you have an interest in pursuing? For the Implementation Center Program, prioritization in Wave 1 will be given for PHAs focused on eCR and/or Immunizations as an implementation project use case.*

Use the latest health IT standards to exchange data for a proposed use case? (Outcome 1)Participate in Trusted Exchange Framework and Common Agreement (TEFCA)-based exchange for a proposed use case? (Outcome 2)Both Outcome 1 and Outcome 2

6. What type of project do you have an interest in pursuing? For the Implementation Center Program, prioritization in Wave 1 will be given for PHAs focused on eCR and/or Immunizations as an implementation project use case. Select all that apply.*

Use the latest health IT standards to exchange data for a proposed use case? (Outcome 1)Participate in Trusted Exchange Framework and Common Agreement (TEFCA)-based exchange for a proposed use case? (Outcome 2)

6a. Have you already joined a TEFCA connector? Select one of the options below.

Our PHA participates in an HIE that has signed an agreement with a QHINOur PHA participates in an HIE that has not signed an agreement with a QHINOur PHA does not participate in an HIE but has signed an agreement with a QHINOur PHA does not participate in an HIE and has not signed an agreement with a QHINOther

7. For the items listed below, please provide an overview of your agency’s interest and the proposed implementation project and use case. Please provide a response for each question, and indicate items that will need to be discovered or clarified through engagement with the Implementation Center program:

Description of implementation project and use case (150 word limit):*

0/150

Project goals (150 word limit):*

0/150

Expected outcome(s) and impact(s) of the project (150 word limit):*

0/150

Key actors, systems, and data involved (150 word limit):*

0/150

Description of what implementation, financial and sustainability support you anticipate needing to complete project (150 word limit):*

0/150

If your agency has interest in implementation project use cases outside of eCR or immunizations, please describe them here (150 word limit):*

0/150

8. When considering the time required for contracting and implementation activities, approximately how much time do you anticipate this project would need to accomplish the project goals with IC support?*

< 6 months6 - 12 months1 - 1.5 years> 1.5 years

9. For your proposed implementation project and use case, with which external partners do you currently exchange data? Select all that apply.

Healthcare providers and/or hospitalsOther PHAs, including state or local agenciesWe are not currently exchanging data with any partners for our proposed use case.Other Partners

10. Will your PHA be able to sign a Participation Agreement and any other required agreements (e.g., a DUA or BAA if access to PHI is necessary) with an IC and the PHIG National Partners to conduct your proposed project?

YesNo

11. Approximately how long do you estimate it would take to sign such an agreement?

12. Do you foresee any legal barriers to pursuing the project proposed above for Outcomes 1 and/or 2 (e.g., legislation that may preclude data exchange for the use case you’re interested in pursuing or the ability to sign TEFCA agreements)?

YesNo

13. Is your PHA registered on SAM.gov?

YesNo

14. Have you received buy-in and support from your health agency leadership (e.g., the State/Territorial Health Official) and other required decision-makers to pursue the proposed project and use case?

YesNo

For those interested in participating in the initial wave, we ask PHAs to provide a letter of support or attestation by October 15, 2024.

For State/Territorial Health Departments: Please provide a letter of support from your State/Territorial Health Official.

For Local Health Departments: To encourage alignment between PHAs, please submit an attestation that your agency has notified the State/Territorial Health Official and/or DMI Director that you plan to submit an EOI for this Program. If there are challenges identifying the appropriate state point of contact, please contact us for assistance.

You are welcome to use your own letter or you can download and use this example letter of support or example letter of attestation.

15. Are you able to provide a letter of support / attestation? (If yes, please upload, if no, please provide reasoning.)

YesNo

15a. Please upload letter of support / attestation.

15a. Please provide the reason for not being able to provide letter of support or attestation.

16. Have you previously worked with or are currently working with any of the ICs (or their partners) on DMI-related activities, particularly related to the two outcomes of the IC Program (e.g., implementation of health IT standards and/or TEFCA-based exchange)? Note: Previous work does not guarantee engagement with any particular IC in this Program but may inform decision-making around IC pairing. Select all that apply.

CRISP Shared Services (Partners: Insenna, Zane Networks, Burton)Guidehouse (Partners: Lantana and Civitas)Mathematica (Partners: Altarum, J2, DAS)None

16. Have you previously worked with or are currently working with any of the ICs (or their partners) on DMI-related activities, particularly related to the two outcomes of the IC Program (e.g., implementation of health IT standards and/or TEFCA-based exchange)? Note: Previous work does not guarantee engagement with any particular IC in this Program but may inform decision-making around IC pairing. Select all that apply.