Source Integration Application

"*" indicates required fields

Step 1 of 6

16%

Request for:*

eChart

eHealth_Hub

Both

Part 1 Requestor Information

Last Name*

First Name*

Daytime Phone*

Email*

Organization Name*

Job Title*

Business Owner

Part 2 Business Workflow

1. Days of Operation

Mon

Tue

Wed

Thurs

Fri

Sat

Sun

Hours of Operation

24 Hrs

8 Hrs

Other

Other Hrs

2. Check all clinical data requesting to send?

Labs

Medications

Immunizations

Radiology

Clinical Documents

other

Other Data

Lab 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 Lab

What 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

If yes please list:

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

4. Does your application/system use terminology standards (e.g., LOINC, SNOWMED CT)?

Yes

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 standards

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

5. List the expected benefits of having this data displayed in eChart and/or sent through the eHealth_hub service to Manitoba Certified EMRs

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

6. 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 descriptions

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

7. Do you have data management processes (security/privacy, standard compliance and quality/integrity) in place?

Yes

If yes, please explain

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

8. When would you be ready to engage in a project?

The approximate duration for adding a source is 14 months depending on the project size.

DD slash MM slash YYYY

PART 3 Privacy

9. Do you have a completed privacy impact assessment for your application/system?

Yes

10. Do you have a custodian/trustee responsible for information in your application/system?

Yes

11. Is your organization the primary owner of the data?

Yes

If your organization is not the primary owner of the data, who is?

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

12. Are your processes (data collection, use, and disclosure) PHIA compliant?

Yes

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 integrated

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

14. 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 identifiers

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

15. 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 Assessment

Name of Vendor

Application Name

Version

16. Does your organization use the Shared Health Network, Provincial Health Access Network or an alternate secure network?

Yes

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.

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

17. Do you have dedicated technical resources to support your application/system?

Yes

18. Please explain the usual schedule for upgrades/patches/hot fixes

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

19. Do you have an outbound interface in place?

Yes

How many interfaces do you have?

20. Is the interface compliant with Health Level Seven (HL7) standards?

Yes

N/A

What HL7 version are you using?

21. Do you have a test environment?

Yes

22. What is your current method of data delivery?

Electronic

Flat File

Interface

Fax

Paper

Other

Other current method of data deliver, please specifiy

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

23. 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?

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

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

26. Are you capable of sending reports/results to Copy To providers electronically?

Yes

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

28. In event of a downtime, do you have the capability to switch to fax/paper delivery?

Yes

PART 5 Data Remediation

29. Are you prepared to send amendments / addendums of clinical data or patient demographic information?

Yes

Please identify why you do not have the ability to send amendments/addendums, if known.

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

30. Do you have dedicated resources and processes in place to handle remediation of reports/results?

Yes

Explain your process

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

31. What is your average turnaround time to remediate reports/results?

Hourly

Daily

Weekly

Other

Please specify

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

PART 6 Integration Funding

32. Does your organization/project have funds available to put towards the cost of integrating?

Yes

Additional comments

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).

If there is anything additional you would like to share with us, please specify

To avoid security issues, do not use special characters in form field below (eg. !, ', #, $, %, ^, &, *, (, ), ?, etc.).