Site Readiness Questionnaire
Appendix
ADT
Organization Name: [Organization Name]
Date Completed: ___________________________________________________
Completed by: ______________________________________________________
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Purpose of Document
The information requested in this document will enable the IEHIE team to develop a customized
onboarding strategy for your organization to connect to IEHIE. The information within this form will be a
starting point needed for you to identify your team members, provide us with information about your
organization, and to begin to understanding the process for your organization to become a part of the IEHIE
and bring value to your healthcare providers and patients. When the completed form is returned to us, the
IEHIE team comprised of Project Managers, Interface Developers, and Quality Analysts will review your
document and clarify any questions you may have prior to scheduling your implementation process.
Program Structure
Listed below are key participants involved in your HIE project.
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Participant Contact
The following contact information is requested for project participants involved in connecting your
organization to the Inland Empire HIE.
Executive Sponsor
Name:
Email:
Phone:
Clinical Sponsor
Name:
Email:
Phone:
Technology Sponsor
Name:
Email:
Phone:
Security Officer
Name:
Email:
Phone:
Project Manager
Name:
Email:
Phone:
System Analyst
Name:
Email:
Phone:
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HIE Clinical Champion
Name:
Email:
Phone:
HIE SuperUser
Name:
Email:
Phone:
Training Coordinator
Name:
Email:
Phone:
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RACI Chart
Diagram below depicts roles and responsibilities within the program throughout the project life cycle.
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Facility Information
This information helps to determine size, location, and general utilization in the HIE
Facility Physical Mailing Address (multiple lines if multiple locations)?
Number of patients seen previous year?
Number of anticipated clinical portal users on the HIE?
Workflow Impact
Patient Consent
Consent management on the HIE is about allowing a patient to ‘opt-out’ of displaying their personal
clinical data within the HIE, as the default behavior in the IEHIE is opt-in. The opt-out functionality is less
about data movement, but rather the use of the patient data within the HIE. When a patient opts out of
the HIE, a flag will be set to prevents any end user of viewing their data for any reason, other than an
administrator to opt them back in, if they so choose. The responsibility of the participating organization is
to facilitate this communication and notification to the patient to obtain this information so the
configuration can be correctly established. It is not recommended for the participating organization to
modify the data feeds to the HIE, as this may cause data gaps in data and notification issues going
forward in the event the patient opts back in from another facility.
As a participating organization with HIE, it is important to understand that this responsibility of notification
and communication to the patient, rest on the organization. It is expected that some level of impact to
the intake workflow process will be realized. The data capturing process can be completed in couple of
ways and more information about this will be discussed during the implementation process. At a
minimum, an administrative console on the HIE can be used for this purpose by your staff members if
necessary or some other form of automation can be designed.
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Questionnaire
This information helps to determine how to plan and implement your project into the HIE.
Do you use Quest, LabCorp, or BioData? Do you have an internal lab? If yes, please specify.
If you have a discharge firm. please indicate.
What role/access will your Administrative / Clinical staff need?
Does your organization provide auditable HIPAA training?
Planning
Do your Emergency Department (ED) physicians have a separate System or do they document the visit
in your EHR?
Do your Hospitalist utilize your EHR?
Are you intending on submitting immunization information to the state via IEHIE?
Are you intending on submitting Disease & Surveillance information to the state via the IEHIE?
Are you intending on submitting Electronic Lab Reporting (ELR) to the California Department of Public
Health (CDPH) for reportable disease and conditions via the IEHIE?
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Implementation
Are you planning on integrating the ‘patient consent’ functionality into your Admission system?
Do you intend to communicate with your patients using the IEHIE patient portal?
Do you wish to load clinical historical data for your patients?
Operating Environment
Will your network support outbound to *.iehie.org
Do you have a non-production EHR/EMR for testing purposes?
What browser version are you currently using to access clinical data?
Does your EMR/EHR/interface engine support export of a HL7 message version 2.5.1?
System Overview
EHR/EMR Product Name (hosted versus cloud):
Product Vendor:
Current Version:
Do you have scheduled activities that will conflict with the objective of creating an HL7 interface in the
next 6 to 9 months?
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Project Duration
The diagram depicts the ideal state for implementation of the different message types available. This
diagram should be used as a template for project time duration but many factors must be considered before
a project to adhere strictly to the prescribed durations and guideline.
Feedback
Please provide any additional comments in the space provided below.
Contact Information
IEHIE Contact:
Jomo Starke (Project Management): jstarke@iehie.org
Mariaelena Robolledo (Quality Assurance): mrobelledo@iehie.org
Kathy Thunholm (Operations): kthunholm@iehie.org
Leo Pak (CTO): lpak@iehie.org
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Definitions
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ADT – A required message containing patient demographic to establish or match your patient’s
data within the IEHIE. ADT messages also includes limited clinical information such as allergies,
procedures and diagnosis

California Immunization Registry (CAIR and RIDE) – A secure, confidential, statewide
computerized immunization information system for California residents

California Reportable Diseases Information Exchange (CalREDIE) – California's project for
a PHIN-compliant electronic disease reporting and surveillance system integrated with electronic
laboratory reporting (ELR)
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Clinical Sponsor – Individual who can provide clinical support and direction in the use of the HIE,
as well as supporting clinical integrity
Direct Secure Messaging (DSM) – Fast and secure electronic communication services for
provider-to-provider communication
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Electronic Laboratory Reporting (ELR) – The electronic transmission from laboratories to public
health agencies for reporting of communicable diseases
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Executive Sponsor(s) – Executive members of each organization providing oversight, direction
and approval
Health Information Exchange (HIE) – Facilities, systems, and data policies that enable peer-topeer clinical sharing
HIE Clinical Champion – Clinical lead responsible for setting policies and procedure with regards
to HIE utilization
HIE Super-User – Technical lead that supports the HIE clinical champion in implementation of
strategy
HL7 Message Types – Which populate the IEHIE with “your data”
Minimum Data Requirement (MDR) – The baseline data required for successful interface and
message type development
ORU – Message type which includes results and transcribed reports, if lab results are implemented
they must contain a valid LOINC code
Logical Observation Identifiers Names and Codes (LOINC) – Is a database and universal
standard for identifying medical laboratory observations
Project Manager – Assigned personnel who are responsible for all aspects of the HIE
implementation
PPR – Message type for the problem list
RDE – Message type for medications
Technology Sponsor – Technology leader that can provide technical oversight and direction
Security Officer – Individual who is responsible for security and compliance support
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System Analyst – Assigned personnel who are responsible for technical and business
requirements
Training Coordinator – Assigned personnel responsible for training individuals on use of the
Clinical, Patient, and DSM portal
VXU – Message type for immunizations
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