Form 0917-xxxx EHR Data Call

IHS Congressional Tribal/UIO EHR Data Call - General Instructions

Please complete a data collection form FOR EACH facility that uses an Electronic Health Record (EHR) system.

If the facility uses RPMS only for its EHR, please complete STEPS 1,2, and 5 (skip STEPS 3 & 4).

If the facility uses a Commercial Off-the-Shelf (COTS) EHR, please complete all STEPS (1-5).

Please include any additional information or clarifications in STEP 5.

STEP 1: Please enter Tribe/UIO Name, Facility, and Point of Contact.

Tribe/UIO (name)

Facility (name)

Point of Contact (name)

Point of Contact (email)

STEP 2: Please answer Questions A, B, and C.

General Questions

Answers

A

Does your facility utilize the RPMS EHR, a Commercial (COTS) EHR, or Both? (Please respond with RPMS, COTS, or Both.)

Comments/clarifications:

B

Does your EHR connect to a Health Information Exchange (HIE)? (Yes / No)

Comments/clarifications:

STEP 3: If you utilize a COTS EHR, please enter your estimated annual costs below in thousands ($K).

Total COTS EHR Costs

FY11 ($K)

FY12 ($K)

FY13 ($K)

FY14 ($K)

FY15 ($K)

Please enter annual costs ---->

FY16 ($K)

FY17 ($K)

FY18 ($K)

FY19 ($K)

FY20 ($K)

FY21 ($K)

TOTAL

If preferred, please enter total costs for your COTS EHR investment to date (in thousands of dollars):

STEP 4: If your facility uses COTS systems, please list the separate modules you have acquired and the implementation year. COTS modules might include EHR, Pharmacy, Laboratory, Scheduling, Billing, etc.

COTS EHR Module Name/Description

Implementation Year

A

B

C

D

E

Step 5: (Optional) Additional information and clarifications.

Are there RPMS functions that you have not been able to replace with COTS (e.g. Purchased/Referred Care)?

Additional comments/clarifications:

Finally: Do you authorize IHS to share your identifiable responses with Congress?