Source Integration Application Source Integration Application "*" indicates required fields Step 1 of 6 16% NameThis field is for validation purposes and should be left unchanged.Request for:* eChart eHealth_Hub Both Part 1 Requestor InformationLast Name*First Name*Daytime Phone*Email* Organization Name*Job Title*Business Owner Part 2 Business Workflow1. Days of Operation Mon Tue Wed Thurs Fri Sat Sun Hours of Operation 24 Hrs 8 Hrs Other Other Hrs2. Check all clinical data requesting to send? Labs Medications Immunizations Radiology Clinical Documents other Other DataLab Selections Biochemistry Hematology Immunology Serology Virology Other Radiology Selections Aniography Cardiology Chemistry Computed Tomography Fetal Assessment Fluoroscopy Magnetic Resonance Nuclear Medicine Positron Emission Tomography Radiography Ultrasound Radiography Selections Bone Mineral Densitometry Mammography X-ray Please specify for Other LabWhat is your approximate daily message volume for the data you wish to send? less than 1000 1000 to 5000 more than 5000 3. Do you adhere to accreditation standards? Yes No If yes please list:4. Does your application/system use terminology standards (e.g., LOINC, SNOWMED CT)? Yes No Terminology standards(check all that apply) LOINC (Logical Observation Identifiers Names and Codes) UCUM (Unified Code for Units of Measure) SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) ICD-10-CA (International Classification of Diseases, 10th Revision, Canada) other Other terminology standards5. List the expected benefits of having this data displayed in eChart and/or sent through the eHealth_hub service to Manitoba Certified EMRs6. Select all options that describe your patient database Manitoba Health insured residents Out-of-province clients seeking care Anonymous and non-nominal testing Test/quality assurance samples Other Other patient database descriptions7. Do you have data management processes (security/privacy, standard compliance and quality/integrity) in place? Yes No If yes, please explain8. When would you be ready to engage in a project? (dd-mm-yyyy)The approximate duration for adding a source is 14 months depending on the project size. DD dash MM dash YYYY PART 3 Privacy9. Do you have a completed privacy impact assessment for your application/system? Yes No 10. Do you have a custodian/trustee responsible for information in your application/system? Yes No 11. Is your organization the primary owner of the data? Yes No If your organization is not the primary owner of the data, who is?12. Are your processes (data collection, use, and disclosure) PHIA compliant? Yes No 13. Indicate the source of your data All data is manually entered by internal staff We use an integrated system Please indicate the system name and the data that is integrated14. Which of the following unique patient identifiers do you collect and can share/disclose? Check all that apply. Personal Health Identification Number (PHIN) Hospital Medical Record Number (MRN) Enterprise Regional identifier Other Please specify other unique patient identifiers15. Which of the following provider identifiers do you collect and share/disclose?Check all that apply Provider Billing Number College License Number Provider Name PART 4 Technical Readiness AssessmentName of VendorApplication NameVersion16. Does your organization use the Shared Health Network, Provincial Health Access Network or an alternate secure network? Yes No If your organization does not use the Shared Health Network, Provincial Health Access Network or an alternate secure network, please describe what type of connection you would use to connect to Shared Health, e.g., internet.17. Do you have dedicated technical resources to support your application/system? Yes No 18. Please explain the usual schedule for upgrades/patches/hot fixes19. Do you have an outbound interface in place? Yes No How many interfaces do you have?20. Is the interface compliant with Health Level Seven (HL7) standards? Yes No N/A What HL7 version are you using?21. Do you have a test environment? Yes No 22. What is your current method of data delivery? Electronic Flat File Interface Fax Paper Other Other current method of data deliver, please specifiy23. What is your electronic delivery of data? Route by provider Route by location Route by provider and location Can you provide more details about your routing method?24. What is the frequency of data delivery? Real time Batch If Batch, please specify frequency: Weekly Daily Hourly 25. Do you send reports/results to Copy To (CC) providers? Yes No 26. Are you capable of sending reports/results to Copy To providers electronically? Yes No 27. Do you have the ability to route reports/results electronically to ordering and CC providers combined with other report/result delivery method(s), for example fax? Yes No 28. In event of a downtime, do you have the capability to switch to fax/paper delivery? Yes No PART 5 Data Remediation29. Are you prepared to send amendments / addendums of clinical data or patient demographic information? Yes No Please identify why you do not have the ability to send amendments/addendums, if known.30. Do you have dedicated resources and processes in place to handle remediation of reports/results? Yes No Explain your process31. What is your average turnaround time to remediate reports/results? Hourly Daily Weekly Other Please specify PART 6 Integration Funding32. Does your organization/project have funds available to put towards the cost of integrating? Yes No Additional commentsIf there is anything additional you would like to share with us, please specify
