EHR Pathways to Successful Adoption: ARRA/HITECH Opportunities and Network Service Offerings. Clinic Webcast June 23 and 30, 2009

Transcription

1 EHR Pathways to Successful Adoption: ARRA/HITECH Opportunities and Network Service Offerings Clinic Webcast June 23 and 30, 2009

2 Agenda EHR Pathways to Successful Adoption Overview ARRA/HITECH: What does it mean to you? Network Service Offerings: What they are and why they matter EHR Demonstrations: Clinical Scenarios review Discussion, Q&A 2

3 EHR Pathways to Successful Adoption: Agenda July 8 Sacramento OR July 9 Anaheim 8:00 am Registration and Breakfast 9:00 am Opening Plenary Jonah Frohlich, Deputy Secretary, Health Information Technology, California Health and Human Services Agency and Cheryl Austein-Casnoff, Director, Office of Health Information Technology, Federal Health Resources and Services Administration 10:30 am Panel Discussion: No Need to Go it Alone 11:30 am Clinic Experiences in Adopting E.H.R.s Topics: How to Implement: Big Bang or Incremental Rollouts, Practice Re-Design and Quality Reporting and Population Management 1-5 pm Afternoon Events E.H.R. Demonstrations and One-Hour Panel Discussion on The Network Experience 3

4 ARRA Overview Significant opportunity for funding for health care Extremely favorable federal match rates in many programs Strong focus on safety net providers and programs Some funds already released, others coming soon Many programs still developing rules and proposal processes 4

5 Key Drivers of Change 5

6 First Key Mechanism of Change Yesterday Today Tomorrow Images courtesy of Microsoft Health Vision Presentation, 2008 and Google Image 6

7 Medical Records in

8 Medical Records in

9 ARRA Overview Multiple Funding Sources/Purposes Appropriations for Health IT $2 billion for loans, grants & technical assistance for: National Resource Center and Regional Extension Centers EHR State Loan Fund Workforce Training Research and Demonstrations New Incentives for Adoption New Medicare and Medicaid payment incentives for HIT adoption $20 billion in expected payments through Medicare to hospitals & physicians $14 billion in expected payments through Medicaid ~$34 billion expected outlays, Appropriations for HIE At least $300 million of the total at HHS Secretary s discretion for HIE development Funneled largely through States or qualified State-designated entities For planning and/or implementation Community Health Centers $1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems Broadband and Telehealth $4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants 9

10 ARRA Overview Funding Sources, Recipients Funding Source Program Distribution Agency Funding Use Fund Recipients / Beneficiaries Entitlement Funds ~$34-36B Appropriated Funds $2B - $3B Medicare Payment Incentives ~$20B Medicaid Payment Incentives ~$14B HIE Planning and Development (at least $300M) EHR Adoption Loan Program Health IT Extension Program Workforce Training Grants CMS CMS ONC ONC HHS Agency TBD HHS, NSF Medicare Carriers and Contractors State Medicaid Agencies Requires 30% share of Medicaid (except Children s Hospitals) Planning Grants Implementation Grants Loan Funds for States Loan Funds for Indian Tribes Health IT Research Center Regional Extension Centers Medical Health Informatics EHR in Med School Curricula Designated State Entity State Gov t Indian Tribes Non-profit Consulting Vendors Loans Services Acute care hospital Children s hospitals Physicians Nurse Practitioner Midwife Federally Qualified Health Centers Non-profit Consulting Vendors Provider Organizations Least Advantaged Providers Requires Meaningful use of EHR New Technology R&D Grants NST, NSF Health Care Information Enterprise Integration Research Centers Higher Education Medical School Graduate schools Federal Gov t Labs 10

11 ARRA Overview Funding and Policy Timing 11

12 ARRA Overview Medicaid Incentives Providers Providers must must demonstrate demonstrate Meaningful Meaningful Use Use of of Certified Certified EHR EHR Technology Technology to to receive receive payments payments Eligible Provider Percent Match/ Limit Medicaid Patient Volumes Independent physician Pediatrician Dentist Nurse mid-wife Nurse practitioner 85% net average allowable costs 85% net average allowable costs 85% net average allowable costs 85% net average allowable costs 85% net average allowable costs Maximum Net Allowable Costs >30% $25,000 for purchase, $10,000 for operations/maintenance >20% $16,667 for purchase, $6,667 for operations/maintenance >30% $25,000 for purchase, $10,000 for operations/maintenance >30% $25,000 for purchase, $10,000 for operations/maintenance >30% $25,000 for purchase, $10,000 for operations/maintenance Acute care hospital >10% Limited to amount calculated under Medicare, by Medicaid share Children s hospital N/A Limited to amount calculated under Medicare, by Medicaid share FQHC-based practicing physician 85% net average allowable costs > 30% of patient population are needy individuals including but not limited to Medi- Cal patients $25,000 for purchase, $10,000 for operations/maintenance It remains unclear whether providers who have purchased EHRs prior to the onset of HITECH funding can apply purchase funds toward implementation if they can demonstrate meaningful use, although they will receive incentives for use based upon initial year of participation and reporting. 12

13 Incentives Tied to Meaningful Use of Certified EHRs Initial Requirements for Meaningful Use Electronic prescribing as determined to be appropriate by the Secretary of HHS, Health information exchange to improve the quality of health care, such as promoting care coordination, and Reporting on clinical quality measures and such other measures as selected by the Secretary of HHS. Health Outcomes and Policy Priorities and Care Goals Released June 16 Improve quality, safety, efficiency, and reduce health disparities Engage patients and families Improve Care coordination Improve population and public health Ensure adequate privacy and security protections for health information Objectives and Measures Although initial set of recommendations was released on June 16, (see state has the ability to weigh in on Medicaid use and make requirements more stringent. 13

14 Additional ARRA/HITECH Funding for Clinics ARRA Program EHR Planning/ Implementation Regional Extension Centers EHR Adoption Loan Funding Indian Health Service Funding Telehealth and Broadband Funding Funding Amount and Purpose $2 B for EHR planning, implementation, regional extension centers, workforce training, EHR loan fund, research and development. REC awards will average $1M to $2 M with a maximum award per REC of $10 M. $85 M for telehealth, related infrastructure and EHR Infrastructure $4.7 B through BTOP for service expansion, $2.7 B through DLTB for infrastructure and technical assistance. Distribution Process and Recipients ONC distributes planning/implementation grants to states and state designated entities to distribute to health care providers. ONC to regional HIS offices for hardware and Hosting NTIA/FCC (BTOP) and USDA (DLTB) to community organizations including providers and entities facilitating access to care. Award Dates Beginning 2010 TBD December

15 Health Center Controlled Networks well positioned in ARRA Network deployment models HITECH Act Statutory language provides that Medicaid incentives... may also be paid to an entity promoting the adoption of certified EHR technology, as designated by the state, if participation in such a payment arrangement is voluntary for the eligible professional involved and if such entity does not retain more than 5 percent of such payments for costs not related to certified EHR technology (and support services including maintenance and training) that is for, or is necessary for the operation of, such technology. Establishes Health IT Regional Extension Centers to provide technical assistance and disseminate best practices. Regional Extension Centers are charged with providing technical and change management assistance to health care providers struggling with implementing and adopting EHR technology. Physicians must be meaningful users of certified EHR products that connect to local or regional HIEs

16 Network Offerings to Clinics Discussion Objectives: Define the value proposition of an EHR network and how an EHR network differs from a standard vendor offering Identify considerations that community clinics and health centers (CCHCs) are likely to use in selecting an EHR network Review field case studies who have adopted EHRs through an EHR network model 16

17 What is an EHR Network? An EHR Network is a health information technology (IT) partnership focused on CCHCs that provides services to support the adoption of EHRs and other applications. Health Center Controlled Networks (HCCNs) support the creation, development, and operation of networks of safety net providers to ensure access to health care for the medically underserved populations through the enhancement of health center operations, including health information technology. -Health Resources and -Services Administration (HRSA) 17

18 CCHC Barriers to EHR Adoption Barriers Financial barriers Technical barriers Staffing resources CCHC customizations Rationale Inflexible reimbursement environment leaving a lack of financial resources to meet upfront and ongoing costs of implementing and maintaining EHRs Lack of basic hardware and software infrastructure Difficulty in securing reliable access to the Internet, particularly for rural areas Challenges in recruitment and retention of staff Few in-house clinical, quality improvement and technical expertise Many CCHCs lack the financial resources to hire objective third party expertise, such as consults to assist with the adoption process Support unique billing and reporting requirements (UDS and performance data, Medicaid billing requirements) Population health management functions Multiple patient education tools 18

19 Common Approaches to EHR Adoption CCHC CCHC CCHC CCHC Vendor Standard Vendor Partnership with local healthcare organization EHR Network CCHC CCHC Hundreds of EHR vendors Commonly used CCHC EHR vendors include: o NextGen o GE Centricity o Epic o Sage o ecw Direct partnerships with: o Local hospitals o Public health departments Children s Clinic in LA is partnering with Long Beach Memorial hospital to adopts its existing EHR ~ 34 EHR networks* Health Resources and Services Administration (HRSA) refers to EHR networks as Health Center Controlled Networks (HCCN) * 19

20 EHR Network Value Proposition Components for successful EHR adoption Typical vendor offering 20

21 Why a Centrally Hosted/Network Approach to EHRs? Access more sophisticated resources necessary Improve profile with vendors Reduce cost Leverage accumulated knowledge and experience Develop CCHC sector resources to reduce dependency on commercial vendors Provide opportunities for clinical collaboration and data sharing Address gaps in commercial products and services 21

22 Comparison of Vendor & EHR Network Products and Services Necessary Services for EHR Adoption Executive Commitment Vendor EHR Network Collaborative environment to facilitate peer learning Change management resources Care Process Change Readiness and needs assessments Customized workflow training Workflow re-engineering Workforce development Ongoing staff training Operational support : Service typically provided in a basic offering : Service typically not provided in a basic offering : Service may be provided and may require additional cost 22

23 Comparison of Vendor and EHR Network Products and Services Necessary Services for EHR Adoption Quality Improvement Vendor EHR Network Educational resources QI Expertise Population-based services Hardware and Technology Operations Data center Software configuration Vendor management Help-desk support Disaster/recovery : Service typically provided in a basic offering : Service typically not provided in a basic offering : Service may be provided and may require additional cost 23

24 Is an EHR Network the Right Approach? An EHR network is more suitable for CCHCs with one or more of the following characteristics: Seeks products and services tailored to safety-net without need for extensive customization Small or mid-sized organizations without an existing, robust technical or quality improvement infrastructure Inability to dedicate substantial time to the EHR implementation, training customization, workflow redesign and optimal adoption Interest in leveraging requirements of other CCHCs that have already adopted an EHR Interest in implementing disease management (DM) and QI programs that leverage and EHR 24

25 National Network Examples CCHC EHR Network Value Proposition Community Health Alliance of Pasadena (CHAP) West Hawaii Community Health Center (WHCHC) St. Anthony s Free Clinic OCHIN Oregon Health Choice Network (HCN) Florida Alliance of Chicago (AOC) Illinois Robust technical and operational support Services and offerings have been developed and customized for clinics Mission-driven organization Focus on quality improvement, including integration of guidelines and clinical expertise Responsiveness to clinic concerns Well developed, detailed implementation plan including role-based descriptions customized to safety-net providers and training process CCHC leverage with EHR network versus a vendor Sustainability and dependability ASP model 25

26 Afternoon Session Agenda Time 1 1:30 E.H.R. Demonstrations Structured Demonstrations of Clinical Scenarios 1:30-2 Scenario 1 Wel l 2 2:30 Child and Dental 2: :30 3:30-4 Scenario 2 -Population 4 4:30 Health Management 4:30-5 The Network Experience Panel 26

27 Vendor Demonstration of Clinical Scenarios: Scenario #1 - Well Child and Dental Summary: Pediatric patient with complicated well child visit and subsequent hospitalization Physician s office is contacted by the mother of a five year-old patient for the scheduling of a child health and disability prevention visit. The child has a history of poor weight gain, asthma, and urinary tract infection, all of which are addressed during the visit. Appropriate immunizations and screenings are performed during the visit, as well as acute care for an asthma exacerbation. A referral is made for dental care and testing is ordered with regard to UTI. Followup visits for review of tests are scheduled. After the visit, the patient s asthma worsens, requiring admission to the hospital. 27

28 Key EHR-Related Events: Scenario #1 Scheduling and update of contact information Review of coverage and benefits eligibility Entry of patient history and physical data into EHR Notice to physician/staff of arrival and in office location of patient Review of immunization status, prompting, entry into database Scanning of information into EHR Notification of drug allergy Generation of patient education sheets for specific conditions Access of clinic EHR by ER physician Generation of patient history summary for use by admitting physicians; access to clinic EHR by admitting physicians through HIE Notice upon admission of scheduled diagnostic testing, rescheduling based on severity of asthma exacerbation Entry of discharge summary into hospital EHR accessible through HIE Delivery of follow-up test results and notifications to physician 28

29 Care Goals for Meaningful Use: Scenario #1 Provide access to comprehensive patient health data for patient s health care team Use evidence-based order sets and CPOE Apply clinical decision support at the point of care Provide patients and families with access to data, knowledge, and tools to make informed decisions and to manage their health Exchange meaningful clinical information among professional health care team Provide transparency of data sharing to patient 29

30 Vendor Demonstration of Clinical Scenarios : Scenario #2 - Population Health Management Summary: Use of E.H.R. to facilitate population-based interventions by identifying at-risk patients Clinic searches E.H.R. data for all hypertensive patients in the clinic E.H.R. system. Criteria are set to identify patients who have not had a primary care visit in the last year, patients whose last blood pressure reading was over a threshold number regardless of time of last visit and those who have ongoing hypertension, but have not had a renal work-up completed, and to identify the next scheduled visit (if any) for all such patients. Once identified, patients are categorized as needing (a) automated follow-up (telephone or otherwise) as a reminder to schedule visit, (b) targeted follow-up by nurse for patients with blood pressure over the threshold number, or (c) renal evaluation, in which case the chart is flagged to remind the physician of the need for evaluation. 30

31 Key EHR-Related Events: Scenario #2 Access and search EHR database of all patients using user-specified criteria Flag EHR of each patient selected for follow-up and integration of follow-up plan into EHR Automatic notification of providers for each follow-up step Update of EHR based on follow-up status Update searches to gauge follow-up and efficacy of intervention 31

32 Care Goals for Meaningful Use: Scenario #2 Generate lists of patients who need care and use them to reach out to patients (e.g., reminders, care instructions, etc) Report to patient registries for quality improvement, public reporting, etc Communicate with public health agencies Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law 32

33 Vendor Demonstration of Clinical Scenarios : Scenario #3 - Behavioral Health (OPTIONAL) Summary: Adult male with complex medical and mental health issues requiring in-office intervention, home health follow-up and on-going management of therapy Adult male arrives and is seen for scheduled appointment. The patient has a history of obesity, diabetes, back injury, depression and anxiety. Prior to the visit, a confirmation notice is automatically generated by the E.H.R., and contact and coverage information are updated when the patient calls or logs in to the clinic website to confirm the appointment. History and physical records are entered into the E.H.R. during the visit, based on guide templates for management of diabetes and depression. During the office visit, the patient is treated for mild opiate withdrawal, seen by a clinical social worker and has stat lab work done. Discharge instructions include scheduling of a home health visit, referral to Addiction Medicine and Diabetic Clinic, and changes to medications for which new prescriptions are transmitted electronically to the patient s pharmacy. Follow-up actions including checking on the patient s status, reviewing notes from referred clinics, denying requests for certain additional medications and prescribing alternatives in response to requests through electronic prescribing system and based on clinical guidelines for use of opiates and behavioral health available in the E.H.R. 33

34 Key EHR-Related Events: Scenario #3 Automatic reminder of visit Website access to update coverage information Review of coverage and benefits eligibility Entry of patient history and physical data into EHR Notice to physician/staff of arrival and in office location of patient Generation of problem list in EHR (clinic patient summary) EHR based calculation of BMI Automatic behavioral health note template with appropriate confidentiality safeguards Referral scheduling with special notation Follow-up alerts to appropriate staff Guidance on withdrawal treatment Automatic updates to bill and coding for encounter Electronic signature of note and bill Delivery of e-script service with handling for controlled substances Receipt of refill notice from pharmacy via EHR, e-script service or fax Incorporation of home health note into EHR Delivery of lab results to EHR with alert to physician 34

35 Care Goals for Meaningful Use: Scenario #3 Provide access to comprehensive patient health data for patient s health care team Apply clinical decision support at the point of care Provide patients and families with access to data, knowledge, and tools to make informed decisions and to manage their health Exchange meaningful clinical information among professional health care team Provide transparency of data sharing to patient Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law 35

36 Discussion Q&A 36

37 HITECH and ARRA Incentive Reference Information 37

38 ARRA and Privacy & Security Extends HIPAA directly to Business Associates Establishes first national data security breach notification law Creates new restrictions on use & disclosure of PHI Expands individuals rights over flow of information Grants State AGs authority to bring civil actions Toughens HIPAA s civil penalties - No knowledge of violation: max penalty $100 per violation up to $25,000 per year - Reasonable cause : $1,000/$100,000 - Willful neglect : $500,000/$1.5 million 38

39 HIE Planning & Implementation Grants Funding Mechanism Appropriations, subject to annual review & authorization Timeline and Status TBD through procurement expected in Summer 09 Payment Agent ONC Payment Recipients State or state-designated entity Level of Funding TBD, but majority of funds expected to go to implementation State matching funds may be required in FY 09 & 10 (and will be required in FY 11). Requirements for Funding Submission of a plan, approved by HHS, that describes the activities to facilitate and expand the electronic movement and use of HIE according to nationally recognized standards and implementation specifications Use of Funds Enhancing broad and varied participation in nationwide HIE Identifying State or local resources available towards a nationwide effort to promote health IT Complementing other federal programs and efforts towards the promotion of health IT Providing technical assistance to develop & disseminate solutions to advance HIE Promoting effective strategies to adopt and utilize health IT in medically underserved communities Assisting patients in utilizing health IT Encouraging clinicians to work with Health IT Regional Extension Centers Supporting public health agencies access to electronic health information Promoting the use of EHRs for quality improvement 39

40 Health IT Regional Extension Centers Funding Mechanism Appropriations, subject to annual review & authorization Timeline and Status ONC to publish notice of program description and availability of funds by May 18 Payment Agent ONC Payment Recipients Centers should be affiliated with nonprofit institutions Level of Funding Up to 50 percent of capital and annual operating budget for two years, Secretary has discretion to waive matching requirement if economic conditions warrant Continuing support possible Funds available upon enactment Requirements for Funding Centers must prioritize assistance to public or not-for-profit and critical access hospitals, FQHCs, rural or other providers that serve uninsured, underinsured or medically underserved patients, and individual or small group practices Use of Funds Centers are designed to promote provider adoption of HIT through Assistance with implementation, effective use, upgrading, and ongoing maintenance of HIT, including EHRs Dissemination of best practices and research on HIT implementation Participation in HIE Integration of HIT into the training of health professional Other 40

41 State EHR Loan Program Funding Mechanism Appropriations, subject to annual review & authorization Timeline and Status Funds available as of Jan 1, 2010 Payment Agent ONC Payment Recipients States Indian Tribes Level of Funding TBD, at the discretion of HHS/ONC States may accept contributions from private sector States are on the hook for $1 in matching funds for every $5 in federal funding Requirements for Funding States and Indian tribes must submit strategic plans that include A list of the projects to be assisted through the loan fund A description of the criteria and methods established for the distributions of funds A description of the financial status o f the loan fund Short and long-term goals for the fund Use of Funds States may grant loans to providers for Purchases of certified EHRs EHR upgrades Personnel training Improvements in HIE 41

42 Grants to Expand Medical Health Informatics Programs Funding Mechanism Appropriations, subject to annual review & authorization Timeline and Status TBD Payment Agent HHS & NSF Payment Recipient/Applicants Institutions of higher education may qualify for funding under this program, though the stimulus package does not reference specific types Level of Funding/Timing Matching grants may fund up to 50 percent of a recipient institution s total costs Grantees may request a higher federal proportion of funding on the grounds that national economic conditions are such that they would render the cost-share requirement detrimental to the program. Requirements for Funding TBD HHS to give priority to existing education and training programs and to programs designed to be completed in less than six months Use of Funds Certification, undergraduate, or master s degree programs for both health care and information technology students may be developed with funding under this program Grant funding may be used to develop and revise curricula in medical health informatics and related disciplines; recruit and retain students; acquire equipment necessary for student instruction in these programs; and establish or enhance bridge programs in the health informatics fields between community colleges and universities 42

43 Health Care Information Enterprise Integration Research Centers Funding Mechanism Appropriations, subject to annual review & authorization Timeline and Status TBD Payment Agent NIST, NSF, Others TBD Payment Recipients/Potential Applicants Institutions of higher education (or consortia thereof which may include nonprofit entities and Federal Government laboratories). Level of Funding/Timing The stimulus package sets aside $20 million to NIST for continued work on advancing health care information enterprise integration through activities such as technical standards analysis and establishment of conformance testing infrastructure No mention of a match requirement Timing TBD Requirements for Funding Applicants must submit an application to NIST detailing the following: The research projects that will be undertaken by the Center and the respective contributions of the participating entities; How the Center will promote active collaboration among scientists and engineers from different disciplines, such as information technology, biologic sciences, management, social sciences, and other appropriate disciplines; Technology transfer activities to demonstrate and distribute the research results, technologies, and knowledge; and How the Center will contribute to the education and training of researchers and other professionals in fields relevant to health information enterprise integration. Use of Funds Establishment of Centers for Health Care Information Enterprise Integration, which are tasked with generating innovative approaches to health care information enterprise integration by conducting cutting-edge research on the systems challenges to health care delivery and with developing health information technologies. Areas of research may include: interfaces between human information and communications technology systems, voicerecognition systems, software that improves interoperability and connectivity among health information systems, software dependability in systems critical to care delivery, health information enterprise management, health information technology security and integrity, and measurement of the impact of information technologies on the quality and productivity of health care. 43

44 Grants to Integrate EHRs into Medical School Curricula Funding Mechanism Appropriations, subject to annual review & authorization Payment Recipients/Potential Applicants Eligible institutions include: Schools of medicine, osteopathic medicine, dentistry, or pharmacy, a graduate program in behavioral or mental health, or any other graduate health professions school; Graduate schools of nursing or physician assistant studies; A consortium of two or more schools; or Institutions with a graduate medical education program in medicine, osteopathic medicine, dentistry, pharmacy, nursing, or physician assistance studies Payment Agent HHS Level of Funding/Timing Matching grants may fund up to 50 percent of a recipient institution s total costs Grantees may request a higher federal proportion of funding on the grounds that national economic conditions are such that they would render the cost-share requirement detrimental to the program Timing TBD Requirements for Funding Applicants must submit a strategic plan for integrating certified EHR technology in clinical education as a means by which to reduce medical errors and enhance health care quality Applicants must also have the capacity to collect data on the effectiveness of the demonstration project in improving patient safety, increasing the efficiency of care delivery, and in increasing the likelihood that graduates will adopt and incorporate EHRs in their clinical practice Use of Funds Integration of EHRs into the recipient s clinical education program(s). Grant funds may not be used to purchase hardware, software, or technology services 44

45 Broadband Technology Opportunities Program (BTOP) Funding Mechanism Federal appropriations Payment Recipients/Potential Applicants Eligible recipients include: State and local governments Foundations and nonprofit corporations, institutions, and associations Any entity, including broadband service or infrastructure providers, is eligible if the NTIA s assistant secretary determines that the funds will promote public interest The assistant secretary shall consider if applicants are socially and economically disadvantages small business concerns Payment Agent National Telecommunications and Information Administration Level of Funding/Timing $4.7 billion Funds available starting April June 1009 through September 30, rounds of competitive grants Round 1: April June 2009 Round 2: October December 2009 Round 3: April June 2010 Requirements for Funding Recipients or a third party must contribute at least 20% of the total cost This criteria may be waived for financial hardship Use of Funds At least $250 million for innovative programs that encourage sustainable adoption of broadband services At least $200 million to upgrade technology and capacity at public computing centers $10 million to the Office of Inspector General for BTOP oversight/audits Up to $350 million will fund development and maintenance of statewide broadband inventory maps 45

46 Distance Learning, Telemedicine, and Broadband (DLTB) Program Funding Mechanism Federal appropriations Payment Recipients/Potential Applicants ARRA does not specify which entities are eligible. However, current or former borrowers under Title II of the Rural Electrification Act of 1936 and traditional telecommunications borrowers receive priority. Payment Agent Rural Utilities Service (RUS) Level of Funding/Timing $2.5 billion Funds are expected to be available around June 2009 No deadline for expenditure of funds Requirements for Funding 75% of a project area must be rural and have insufficient access to high-speed broadband The criteria for rural are being defined Certain applicants receive priority, including those Whose projects will begin promptly after approval Whose projects will be fully funded if they receive aid That offer a choice of multiple service providers With the highest proportion or rural residents who do not have broadband access No area of a DLTB-funded project may receive funding from BTOP for the same purpose. However applicants may apply for and receive funding from both programs Use of Funds Specific uses of funds are being defined, with the focus expected to be on broadband infrastructure 46