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1 Eligible Hospitals and Critical Access Hospitals EHs and CAHs Profile 1 Profile Please provide the Public Health Meaningful Use Registration of Intent information below. All fields are required. Type of Provider What is the Account Name for the provider or group of providers for whom you are registering? Parent Organization Affiliation Registering for Meaningful Use What is/was your Stage 1, year 1 reporting period start date? Stage 1 Stage 2 What is your Stage 2 start date? Public Health MU Objective Plan to Implement Plan to Exclude Reason for Exclusion Immunization Registry Syndromic Surveillance Reportable Lab Results (ELR) If you do not plan to implement any Public Health MU Objectives with AZDHS, you do not need to continue completion of this form. Which incentive program are you enrolled in? Medicaid Medicare Both Please list any Health Information Exchanges (HIE) in which you participate: Comments This worksheet can be used to gather the required information for Registration of Intent with Public Health. Please go to the AZ Public Health MU Portal using the link below to complete the Registration of Intent Process. For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 1
2 Eligible Hospitals and Critical Access Hospitals EHs and CAHs Hospital Information 1 Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) Please add all hospitals that will be implementing the Public Health Objectives with AZDHS. Once a hospital is added, please select all MU objectives the hospital plans to implement. *To add more Hospitals, please reprint this page.* Hospital Information I mmunizati on Registry Syndro mic Surveill ance Reportabl e Lab Results For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 2
3 Eligible Hospitals and Critical Access Hospitals EHs and CAHs Account Managers/Resources 1 Account Managers/Resources Please add all the resources that will be supporting the implementation and sending/receiving communication fot the Public Health objectives selected. You can include vendor contact information that will be working with each objective. The following requirements must be met: At least one person needs to be specified for each category on the right. At least one Account Manager must be an Internal Resource. At least one resource responsible for each objective. Although one Account Manager/Resource is required, we recommend that you have an additional Account Manager/Resource that can serve as a secondary point of contact. *To add more Account Managers/Resources, please reprint this page.* Account Manager I mmunizati on Registry Syndro mic Surveill ance Reportabl e Lab Results For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 3
4 Immunization Registry Please complete this page if you are implementing the Immunization Registry interface. Please provide the information requested below. All fields are required to Finalize your Meaningful Use Profile Current EHR vendor Current EHR software Current EHR version Name of the software tool that will be creating/sending HL7 Immunization Results message to public health Does your system have the capability to send an HL7 v message for Immunization Reporting? Is your EHR/software hosted? Is your EHR/software cloud based? Do you administer vaccines? If yes, how many per year? For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 4
5 Syndromic Surveillance Please complete this page if you are implementing the Syndromic Surveillance interface. Please provide the information requested below. All fields are required to Finalize your Meaningful Use Profile Current EHR vendor Current EHR software Current EHR version Name of the software tool that will be creating/sending HL7 Syndromic Surveillance message to public health 5 Version number of the software tool used to create/send HL7 Syndromic Surveillance message to public health 6 Is the software tool used to generate the HL7 messages ONC certified 7 ONC Certified EHR number of the software tool 8 Do you have the 2014 certified version implemented? 9 If no, when do you plan to have the 2014 version implemented 10 When do you anticipate being able to send your first test message? Is your EHR/software hosted? Is the EHR/software cloud based? Does your system have the capability to send an HL7 v message for Syndromic Surveillance? For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 5
6 Reportable Lab Results Please complete this page if you are implementing the Reportable Lab Results interface. Please provide the information requested below. All fields are required to Finalize your Meaningful Use Profile Current EHR vendor Current EHR software Current EHR version Name of the software tool that will be creating/sending HL7 Reportable Lab Results message to public health 5 Version number of the software tool used to create/send HL7 Reportable Lab Results message to public health 6 Is the software tool used to generate the HL7 messages ONC certified 7 ONC Certified EHR number of the software tool 8 Do you have the 2014 certified version implemented? 9 If no, when do you plan to have the 2014 version implemented 10 When do you anticipate being able to send your first test message? 11 Is your EHR/software hosted? Is the EHR/software cloud based? Does your system have the capability to send an HL7 v message for lab reporting? Does your system have the capability to send LOINC codes for test names? Does your system have the capability to send SNOMED CT codes for microbiology test results? Does your system have the capability to send SNOMED CT codes for specimen source/type? 17 For all the facilities in this registration combined approximately how many infectious disease results to do you report to public health in a week? Do not include send outs to LabCorp, Sonora Quest, or ARUP. 18 If you average less than one report per week, please explain the types of testing you perform for reportable conditions For questions or comments, please contact the AZDHS Public Health Meaningful Use Helpdesk: Phone (602) or : meaningfuluse@azdhs.gov. Page 6
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