Form CMS-10296 - 2010 Inpatient EHR Testing Application

Application to Participate in 2010 Voluntary Inpatient EHR Testing Program

Where you are instructed to provide details, please submit this information along with this completed application. You may submit a separate document providing these details along with this application.

Name of EHR Vendor/Hospital: ______________________________________

Name of Inpatient EHR Product: _____________________________________

EHR testing contact name/position: __________________________________

EHR testing contact e-mail: ________________________________________

GENERAL EHR VENDOR/HOSPITAL INFORMATION

1. Tell us briefly about your Organization (i.e., history, how long in existence, experience with hospital quality measurement, etc).

2. Are you able to submit EHR test data elements for each of the following measurement sets: Emergency Department (ED) Throughput, Stroke, and Venous Thromboembolism (VTE)?

[ ] Yes

[ ] No  Please provide details

3. Have you participated in an IHE Connectathon?

[ ] Yes  Please provide details regarding the results of your prior

Connectathon participation to us with this application.

[ ] No

4. Do you intend to participate in the 2010 IHE Connectathon?

[ ] Yes  Please submit the results of your participation in this

Connectathon to us by September 1, 2010

[ ] No

5. Can you commit to having a representative from your Organization attend all mandatory support calls (one or two 60 minute calls per month) and the Kick-off meeting (details to be announced on the http://www.cms.hhs.gov/hospitalqualityinits webpage)?

[ ] Yes  Indicate name and contact information of individual

[ ] No

6. Do you have a dedicated IT security officer whom we can contact regarding privacy and security issues?

[ ] Yes  Indicate name and contact information of individual

[ ] No

7. Have you previously used the Nationwide Health Information Network (NHIN) to transmit data to other entities?

[ ] Yes  Please provide details

[ ] No

INPATIENT EHR PRODUCT INFORMATION

8. Is your Inpatient EHR Product currently CCHIT Certified?

[ ] Yes  Please indicate year

[ ] No

9. How many hospitals have implemented the Inpatient EHR product that you intend to test?

10. What modules are captured within your Inpatient EHR product (clinical treatment, labs, radiology, pharmacy, ED etc.)? What types of staff are the intended main users of your inpatient EHR product (nurses, doctors, lab, radiology, pharmacy, ED etc.)?

11. Is your Inpatient EHR able to gather and report data from multiple sources such as lab, physician documentation, nursing documentation etc?

[ ] Yes  Please provide details

[ ] No

12. Is the inpatient EHR product you intend to test currently being used to generate quality measures?

[ ] Yes  Please provide details (measure names, and developer)

[ ] No

13. Does your inpatient EHR product support the codes/coding systems listed in the HITSP specifications for the Emergency Department (ED) Throughput, Stroke, and Venous Thromboembolism (VTE) measures?

[ ] Yes  Please provide details

[ ] No

14. Does your inpatient EHR Product have the capability to create a performance report for individual facilities?

[ ] Yes

[ ] No

15. Will your inpatient EHR be able to provide the following data elements for test patient records?

1. Facility NPI

2. Facility CCN

3. EHR Measure Set #

4. Measure #

5. Patient’s Birth Date

6. Patient’s Gender

7. Patient’s Race

8. Patient’s Ethnic Group

9. Patient’s Paysource

10. Denominator Inclusion and Exclusion data elements (e.g. SNOMED, LOINC, Codes, Coding Systems, Date of Encounter/Diagnosis/Drug Administration)

11. Numerator Inclusion data elements (e.g. Codes, Coding Systems, Date of Encounter/Diagnosis/Observation, Result Units and Values)

12. Other data elements as needed to comply with QRDA

DATA SUBMISSION

16. Do you have the ability to submit EHR data using an XDS wrapped QRDA (Release 2.0 standard)?

[ ] Yes  Please provide details

[ ] No

17. Will you be able to submit 30 test patient records using current HITSP standards for each of the three measure sets (Emergency Department (ED) Throughput, Stroke, and Venous Thromboembolism (VTE)) within 2 to 3 months of submitting this application? (more details to be provided in support calls and on the http://www.cms.hhs.gov/hospitalqualityinits webpage)

[ ] Yes

[ ] No

18. Will you be able to submit test extracts of the data elements based on the test patient records for the Emergency Department (ED) Throughput, Stroke, and Venous Thromboembolism (VTE) measure sets on a DVD using current HITSP standards for within 2 to 3 months of submitting this application? (more details to be provided in support calls and on the http://www.cms.hhs.gov/hospitalqualityinits webpage)

[ ] Yes

[ ] No

ADDITIONAL INSTRUCTIONS:

Thank you for providing information about your organization and your inpatient EHR product through this application. Please submit any supporting documentation for this application by September 1, 2010. You may be contacted to provide additional information about the answers and supporting documentation you provide. For questions about your application, or to withdraw your application at any time, please contact:

[email protected].

Additionally, application for inpatient EHR testing will involve the submission of test records and test data extracts. You will be asked to submit 30 full patient test cases as would be captured in your Inpatient EHR product at a later date. You will also be asked to submit a DVD containing extracts of the data elements needed to calculate the measures from each test case. The test cases will be used to verify the extracts that you submit by DVD. We will then notify you of your eligibility to participate in testing the transmission of EHR test data to CMS systems via a Portal and Gateway.

More information on this process will be made available on the CMS website: http://www.cms.hhs.gov/hospitalqualityinits/ .

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-XXXX, and it will expire May 2013. The time required to complete this information collection is estimated to average 10 hours or 600 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The average time expected for participants to complete the entire testing process is estimated at 521 hours. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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