Questionnaire--Contact, IT, Lab Info

Questionnaire--Contact, IT, Lab Info

Trading Partner Code*

Create a unique code by entering the current year and the name of your facility. Enter this code at the top of each of the four forms.

Onboarding Laboratory/Hospital Name*

PERSON COMPLETING FORM

INTEROPERABILITY DETAILS

Anticipated file name

Each file must have a unique name and the word "TEST" or "PROD". Please use the following file naming convention: ( <lab name>-ELR-TEST-<datetime stamp>.hl7).

Frequency of sending ELR once in production

Real Time (preferred by NMDOH)

Batched. If you select batch, specify Frequency in upcoming field.

Once a Day. If you select Once a Day, specify Time in upcoming field.

Frequency of sending batched ELRs

Answer only if you will send batch ELRs. How often will you send batch ELR?

Trigger for ELR to be sent to NMDOH

Will ELR be triggered by electronic algorithm set up in the system or manually by a laboratorian?

Trigger by algorithm

Trigger manually

Trigger by other means (explain in next question)

Description of "Other" trigger mechanism

Time Daily ELR is sent

Answer only if you will send daily ELRs. What time will you send your daily ELR?

Ability to send parent-child results

Can your lab send parent-child results for culture results that require antibody susceptibility results (AST)?

Yes

Only under certain conditions

N/A we don't do cultures

Ability of Compliance person to see ELR results

Does your lab have system that allows person responsible for compliance with state administrative code to see results sent via ELR?

Yes

Submission of messages to NIST for testing

Do you plan to submit messages to the NIST website to test message structure before moving to Testing Phase of ELR Onboarding with NMDOH?

Yes

Unknown

HL7 ELR sent to other state health departments

Is your facility sending HL7 ELR to any other state health departments?

Yes

Capacity to send ELR in snapshot mode

Can your facility send ELR in snapshot mode?

Yes

Unknown

Lab use of SNOMED

Does your lab use SNOMED internally?

Yes

MSH-3-1 Sending Application Name

MSH-3-2 Sending Application Universal ID (OID)

MSH-4-1 Sending Facility Name

MSH-4-2 Sending Facility CLIA or OID

Limit the number of characters in the OID to 49 characters or less

Date/Description of System Upgrade affecting ELR

Answer only if you have plans for a system upgrade that would affect the ELR feed.

Company that Maintains LIM System

Company that maintains EMR System

GENERAL CONTACT INFORMATION

Laboratory Director--NAME*

Laboratory Director--PHONE NUMBER*

Laboratory Director--EMAIL ADDRESS*

Infection Preventionist--NAME

Infection Preventionist--JOB TITLE

Infection Preventionist--PHONE NUMBER

Infection Preventionist--EMAIL ADDRESS

Primary Contact during Onboarding--NAME*

Primary Contact during Onboarding--JOB TITLE

Primary Contact during Onboarding--ORGANIZATION

Primary Contact during Onboarding--PHONE NUMBER*

Primary Contact during Onboarding--EMAIL ADDRESS*

Meaningful Use Contact--NAME

Meaningful Use Contact--JOB TITLE

Meaningful Use Contact--PHONE NUMBER

Meaningful Use Contact--EMAIL ADDRESS

Employee Responsible for Compliance--NAME*

Person in facility responsible for compliance with Administrative Code

Employee Responsible for Compliance--JOB TITLE

Person in facility responsible for compliance with Administrative Code

Employee Responsible for Compliance--PHONE #*

Person in facility responsible for compliance with Administrative Code

Employee Responsible for Compliance--EMAIL*

Person in facility responsible for compliance with Administrative Code

Contact if Issue with Feed--PHONE NUMBER

Contact if Issue with Feed--EMAIL ADDRESS

Followup Contact if Issue with Feed--NAME

Contact if Issue with Feed--JOB TITLE

LABORATORY STRUCTURE

First Reference Lab used by your facility--NAME

Second Reference Lab used by your facility--NAME

Third Reference Lab used by your facility--NAME

Do you have a micro lab in house?*

Yes

Able to report susceptibilities for CRE?

CRE=Carbapenem-Resistant Enterobacteriaceae

Yes

Able to report susceptibilities for CRPA?

CPRA=Carbapenem-Resistant Pseudomonas Aeruginosa

Yes

Influenza: Will you send rapid test results?

Yes

Lead: Able to differentiate serum/fingerprick?

Can you differentiate between serum and fingerprick results?

Yes

Does the LIMS System have ONC clearance?

Yes

Estimated # of ELRs sent to NMDOH per month

Excluding Lead Results

ELRs to be sent--choose one option

ELRs for all notifiable conditions, regardless of where test was conducted (we will send results done in our lab and in reference labs)

ELRs for all notifiable conditions where test was conducted in our lab only (other tests results will be faxed)

Another combination (see the next question to provide details)

ELRs to be sent--Pt 2

Answer only if you selected "Another Combination" in last field. Describe the ELRs you will send if not covered in previous choices.

Send me a copy of my responses

PERSON COMPLETING FORM

INTEROPERABILITY DETAILS

INFORMATION SYSTEMS

GENERAL CONTACT INFORMATION

LABORATORY STRUCTURE