HIT Project Request Form v9
Title of Request: [Title]
Section 1 - To Be Filled by Requestor
Business Unit (BU):
☐ CHM
☐ COM
☐ CON
Requestor Name:
☐ HT
☐ RAD
Department:
☐ HIT
Date:
Problem Statement:
Current approach for
solving this problem:
Proposed approach for
solving this problem:
Request Scope
(IN scope):
Request Scope
(OUT of scope):
Risks of not addressing
this problem:
BU Sponsor Name:
Sponsor Approved:
BU Sponsor Date:
☐
☐
Yes
No
Section 2 - To Be Filled by HIT in Collaboration with Requestor
Request Number:
PM Name:
Proposed Solution:
List Systems/Services
Impacted:
Existing System: ☐ Upgrade ☐ Enhance
1.
2.
3.
4.
☐ New System Implementation
Resource Estimates:
Resources
(+/- 50%)
Budget Estimates:
(+/- 50%)
Hrs
$ Est
HIT Infrastructure
HIT Clinical
HIT App/Web Dev
HIT Ed Tech
HIT Service Desk
Category
☐ New Module
Resources
☐ Retire
Hrs
$ Est
HIT Desktop
HIT PMO
Business Unit
RAD Dev
RAD Ops
Capital Exp
Operating Exp
Hardware
Software
Internal Resources (does not include BU)
Professional Services
Contingency (10%)
TOTAL: Flag unbudgeted expense with *
Portfolio Impact
Analysis:
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HIT Project Request Form v9
Title of Request: [Title]
Section 3 – To be Filled by HIT in Collaboration with Requestor
Project Prioritization Scoring
Project Security/Compliance/Expansion/Foundational Override
#
Legal/Regulatory Override
Scoring Factor
1 Required for Regulatory Compliance
Yes/No
2 Required to support Unit Expansion
Yes/No
3 Required to meet Security Standards
Yes/No
4 Vendor mandated activity without which Yes/No
we lose support
If Override selected, skip to Project Scoring Summary
Project Value Assessment
#
Criteria
Scoring Factor
Score
1 Addresses Unit Strategy or Goal
Low = 1; Medium = 2; High= 3
Academic:
 Increase student enrollment
 Enhance and innovate education
experience
 Facilitate distance learning
 Engage and manage organization
constituents (students, faculty,
and alumni)
Clinical:
 Promote patient care
 Enhance patient experience
 Improve Physician/Patient
interaction
2 Improves Customer Satisfaction (Patients, Low = 1; Medium = 2; High= 3
Students, Faculty, Staff) OR
Supports Innovation in Learning and
Patient Care OR Supports Research
Opportunities
3 Creates Monetary Savings OR
None = 0;
Generates Revenue (thru Federal
$1K-10K = 1;
Incentives, Grants, Increased Student or
$10K-30K or Headcount
Patient Population)
Avoidance = 2;
>$30K or Headcount
Reduction = 3
4 Improve Organizational Effectiveness
Low = 1; Medium = 2; High= 3
(Effectiveness is about doing the right
things and achieving goals or intended
results)
5 Improves Operational Efficiency
Low = 1; Medium = 2; High= 3
6
Stabilizes Core Services and Systems
(Predictive Maintenance and Upgrades)
Critical Systems/Services = 3;
Ancillary Systems/Services =
2;
Override
Weight
20
Total
20
15
15
20
20
15
15
10
10
10
10
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HIT Project Request Form v9
Title of Request: [Title]
7
Project Align with Technology Architecture
Low Priority Sys/Serv = 1
Low = 1; Medium = 2; High= 3
10
Total
10
100
Project Risk Assessment
#
1
Risk
Have We Ever Done This Type of Project
2
3
Project Rely on 3rd Party Resource
Does this Project Have Project Dependencies
or pre-requisites
Will Multiple HIT Departments Need to Be
Involved
Business Resources Available to Execute &
Support
HIT Resources Available to Execute & Support
How Much Combined Effort does this Project
Require
What is the Impact to End User Community
4
5
6
7
8
Scoring Factor
Yes (Successfully) = 0; Yes (Challenges) =
1; No = 2
Extensively = 2, Minimal = 1; No = 0
Extensive = 2; Minimal=1; None = 0
Score
Four or More Depts = 2;
Two or Three Depts = 1; One Dept = 0
Yes or N/A = 0; Spread Thin = 1; No = 2
Yes = 0; Spread Thin = 1; No = 2
>1040 Hours = 2; 400 to 1040 Hours = 1;
<400 Hours = 0
Low = 1; Medium = 2; High= 3
Total
Project Scoring Summary (Please add them here and highlight the appropriate section):
1. Security/Compliance/Expansion/Foundational Override =
a. Yes = Project Must be Completed to Meet a Legal, or Regulatory Requirement (1st Tier)
b. Yes = Project Must be Completed to Support Unit Expansion (1st Tier)
c. Yes = Project Must be Prioritized for Completion to Meet a Security Mandate (1st Tier)
d. Yes = Project Must be Completed to meet Vendor Mandated Activity (1st Tier)
2. Project Value Score =
a. 190-270 = Highly Aligned; High Priority – Must be Completed (1st Tier)
b. 130-189 = Well Aligned; Medium Priority –Prioritize for Completion (2nd Tier)
c. 90-129 = Fairly Aligned; Low Priority – Recommend Approval only if Low Risk and
Resources Available (may be canceled as needed) (3rd Tier)
d. 0-89 = Poorly Aligned, Recommend Denial (Denied)
3. Project Risk Score =
a. 10-14 = High Risk
b. 6-9 = Medium Risk
c. 0-5 = Low Risk
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HIT Project Request Form v9
Title of Request: [Title]
Project Request Approval
Requestor Name/Title:
Signature:
Date:
Sponsor Name/Title:
Signature:
Date:
HIT Intake Manager Name/Title:
Signature:
Date:
HIT Subcommittee/Committee Approval
Required
☐
☐
☐
☐
☐
Committee
Next Scheduled Date
Date
Reviewed
Status
Signature
Administrative
Technology
Clinical
Informatics
Educational
Technology
Financial
Executive
Steering
Assumptions:

Requestor is keeping Business Sponsor in communication loop throughout Project Intake Process

Business Sponsor is communicating with Committee members regarding Project Requests prior to next
committee meeting

Business Sponsors are (CHM-Barbara Forney, COM-Mark Notman, CON-Terry Viau, RAD-Suresh Mukherji, HTRichard Ward, and HIT/Clinical-Tracey Holland; Hit/Academic –Tawnya McKinizie)

Project requests fully funded by Radiology will be forwarded to Committee for notification (Approval not
required)
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