edelivery Service Request Form

Transcription

1 Section 1 REQUEST TYPE (Completed by Clinic) edelivery Service Request Form Choose ONE of the following requests: Request Type A Initial Set up for edelivery (Complete Sections 2, 3, 4, 5, 6, 7, 8, 9) The clinic needs to be set up for the first time use of edelivery OR The clinic has moved* Paper/fax results will be sent in parallel with edelivery results. The Clinic must compare both to ensure accuracy for a sufficient duration prior to submitting a request to Turn off/suppress paper/fax delivery. B edelivery Termination (Complete Sections 2, 4, 6, 8, 9) The Clinic (including all its providers) no longer wish to receive edelivery results. EMR BIS Team will work with data source(s) to reinstate paper/fax results delivery when edelivery Termination is requested, for the listed source(s) and provider(s). C Vendor Change (Complete Sections 2, 3, 6, 7, 8, 9) A change to the use of a new EMR Software vendor is taking place at the clinic. Old Vendor Name: It is the Clinic's responsibility to communicate and arrange a cutover date (see section 7) with the old and new Vendors. Paper/fax results will be sent in parallel with edelivery results. The Clinic must compare both to ensure accuracy for a sufficient duration prior to submitting a request to Turn off/suppress paper. D Add Health Care Provider(s) and/or Data Source(s) (Complete Sections 2, 3, 4, 5, 6, 8, 9) Provider(s) will be working at the clinic. His/her edelivery results will be routed to this Clinic. And/Or Results from one or more new edelivery sources are required for one or more Provider(s) at the Clinic All the Data Sources listed in Section 5 will be applied for all Providers listed in Section 4. E Remove Health Care Provider(s) and/or Cancel Existing Data Source(s) (Complete Sections 2, 4, 5, 6, 8, 9) Provider(s) no longer work at the clinic. His/her edelivery results should no longer be routed to this clinic. And/Or Results from one or more edelivery sources needs to be terminated for one or more Provider(s) at the Clinic All the Data Sources listed in Section 5 will be removed for all providers listed in Section 4. F - Turn OFF Paper/Fax Delivery Initial setup period is completed and verified and paper/fax copies are no longer required. OR One or more Provider(s) no longer require paper copies. DO NOT USE THIS FORM. Contact EMR BIS Team (servicedesk.emrbis@ahs.ca) for the Validation Sign-off & Paperless Distribution Form G Other (Complete Sections 2, 4, 6, 9) i.e. physician name change, clinic name change Description: * If a clinic is moving to a different location and the old location is/will be closed down, please submit two requests (A- Initial Set up for edelivery for new location and B-eDelivery Termination of previous clinic). Page 1 of 6 Version 4.9.1, Nov 2017

2 Section 2 CLINIC INFORMATION (Completed by Clinic) Clinic Information *Clinic Name: Does this clinic go by any other name? If so, please state the name: *Address: *City: *Clinic *Clinic Representative Name: *Clinic Phone: Facility ID (Also referred as AH Billing ID) (CLS/Provincial Lab requests only): *Postal Code: Must be an address that is checked regularly. *Title/Role: Clinic Fax: Section 3 PIA DETAILS (Completed by Clinic) PIA Privacy Impact Assessment Information In accordance with the Office of Information and Privacy Commissioner (OIPC), an OIPC file # is required to route results via edelivery. Please note that this request cannot be processed without an OIPC file #. Check the following link to see the status of your PIA submission. OIPC File # or H #: Section 4 HEALTH CARE PROVIDERS (Completed by Clinic) List ALL Providers pertinent to this request. First Middle Last Locum (Y/N) **If Yes, Specify END Date *Mandatory Fields **End Date for Locum is required in order to notify the data source(s) if setting up a new provider is feasible or not. Some data sources will not activate Locums or short term providers for edelivery. Page 2 of 6 Version 4.9.1, Nov 2017

3 Section 5 DATA SOURCE GRID (Completed by Clinic) Check ALL data sources required for edelivery Coverage FHE Data Sources Refer to Appendix B for Zone map Laboratory Reports Diagnostic Imaging & Other Transcribed Reports (DITR): South Zone Calgary Zone Chinook Palliser Calgary, Physician Documentation (PDOC) AHS Lab (Calgary Lab Services) AHS Calgary Diagnostic Imaging EFW Radiology/RCA Diagnostics 3 Central Zone Edmonton Zone North Zone Provincial David Thompson East Central Capital Aspen Peace Country Northern Lights Canada Diagnostic Centres (CDC) 3 AHS Lab (Dynalife Labs, SGO Labs) AHS Diagnostic Imaging (AGFA, Insight Medical Imaging (IMI), Medical Imaging Consultants (MIC)) 1 Endoworks 1 AHS Lab (Dynalife Labs, SGO Labs) 2 AHS Rural Diagnostic Imaging (Meditech) 1 AHS Provincial Lab, Mitogen Advanced Diagnostic Labs (MADL) Dictation Speech Transcription (DST, Nuance escription) 1 NOTE: Important edelivery Information: 1 Due to technical routing limitations, results can be delivered to only one clinic location per Provider, as determined by the Provider. 2 Northern Lights Lab results are mapped to Capital Health Lab results. 3 Feed is currently not yet active; EMR BIS is accepting commissioning requests in advance of release. Page 3 of 6 Version 4.9.1, Nov 2017

4 Section 6 VENDOR INFORMATION (Completed by EMR Vendor) POS Vendor Information *Vendor Company Name: *Clinic FTP/Username: (Required for Request Types 2-7) *Software Product: * *Company Phone: Certified Version: *Representative Name: Section 7 PUBLIC ENCRYPTION KEY (Completed by EMR Vendor) Please attach a Public Encryption Key (do not attach private key) to this request. It must be zipped and in 2048 bit RSA SECSH format. Section 8 LIVE DATE (Completed by Clinic and/or EMR Vendor) The EMR BIS team will complete the request as soon as possible, and it can take approximately 10 business days, unless a specified go-live date is provided. Alternate Proposed Go-Live Date: o-li Additional Section 9 SIGNATURE (Completed by Clinic and EMR Vendor) The above information is correct to the best of my knowledge and I have read and understand the service guidelines: Date Name of Clinic Representative (PRINT) Signature Date Name of Vendor Representative (PRINT) Signature In order to process this request, please ensure all sections are completed based on the type of request you selected and submit to servicedesk.emrbis@ahs.ca. Reset Page 4 of 6 Version 4.9.1, Nov 2017

5 Appendix A Data Sources Result Schedule edelivery Service Request Form Please contact your Vendor for EMR scheduled download times. These times are the times when results are available for download not when results will be available in your EMR. The availability of results in the EMR is different for each vendor. Please contact your vendor for further details. Zones FHE Data Source Results Ready For Pick up from Server South Zone Chinook AHS Rural Laboratory (Meditech) Palliser AHS Rural Laboratory (Meditech), Physician Documentation (PDOC) Calgary Zone Calgary AHS Calgary Lab Services (CLS) AHS Calgary Diagnostic Imaging Canada Diagnostic Centres (CDC) EFW Radiology/RCA Diagnostics Central Zone David Thompson AHS Rural Laboratory (Meditech) East Central AHS Rural Laboratory (Meditech) Edmonton Zone Capital AHS Lab (Dynalife Labs, SGO Labs) AHS Diagnostic Imaging (AGFA, Insight Medical Imaging (IMI), Medical Imaging Consultants (MIC)) Endoworks North Zone Aspen AHS Rural Laboratory (Meditech) Peace Country AHS Rural Laboratory (Meditech) Provincial 04:30, 11:30, 23:30 04:30, 11:30, 23:30 TBD TBD 04:00 Northern Lights AHS Lab (Dynalife Labs, SGO Labs) 04:00 AHS Provincial Lab, Mitogen Advanced Diagnostic Labs (MADL) 04:30, 11:30, 23:30 Dictation Speech Transcription (DST, Nuance escription) 04:00 Page 5 of 6 Version 4.9.1, Nov 2017

6 Appendix B Health Regions An online copy can be accessed at Health Regions from 2003 to March 2009 The below map on the right shows the nine Former Health Regions ( FHE ). The FHE were consolidated into AHS Zones and are now referred to as such. We have changed Section #5 above to reflect this Provincial change. Former Health Regions Current AHS Zones Page 6 of 6 Version 4.9.1, Nov 2017