1. Structured Data Capture (SDC) Pilots Template Insert the Name of Your Pilot / Organization Here MM/DD/YYYY

2. Pilot Team (Lead Organization) Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information 2 NameRoleEmail

3. Full Disclosure? Please document any items you believe should be shared with the community or other pilot and project teams, in the spirit of ‘full disclosure’. You may also use this section to document any other risks or concerns you may have.

4. Goal of the Pilot Please download and review the IHE SDC Profile: http://wiki.siframework.org/IHE+SDC+Profile (a link to the IHE Website where you can obtain the latest version of the profile is provided in the Announcements section) http://wiki.siframework.org/IHE+SDC+Profile Please include a write up or create a diagram of what you intend to show/prove/support during the pilot process. –Make this an actionable statement with specifics. –Also include in this description what you hope to gain from this pilot. –Note than an example SDC Workflow and the SDC Solution Plan are provided as references in the next two slides. 4

5. CDE Library 4 1 5 Sends requested form/template Fills, stores/transmits structured data Sends request for form/template 3 Converts, populates and displays form Extract, Transform, and Load Data by form/ template Forms Manager Forms Filler Actor Key 2 Form Library External Repository SDC Scope Form/Template Repository Form/Template Repository SDC Workflow (Reference)

6. SDC Solution Plan is presented in terms of 3 Transactions: Transaction 1A: Form/Template Request and Response without Patient data EHR System sends request for blank form/template to Form/Template Repository Form/template Repository sends requested blank form to EHR System Transaction 1B: Form/Template Request and Response with Patient data EHR System sends request for form/template with relevant patient data to Form/Template Repository Form/Template Repository sends form/template with pre-populated patient data to EHR system Transaction 1C: EHR System sends completed form/template to External Data Repository See the IHE SDC Profile for more details: –http://wiki.siframework.org/IHE+SDC+Profilehttp://wiki.siframework.org/IHE+SDC+Profile 6 SDC Solution Plan (Reference)

7. Pilot Team (Roles) Please use this section to identify which role your organization (and any partner organizations) will take on, based on those outlined in the IHE SDC Profile. 7 IHE Profile RoleDescriptionOrganization Name Form FillerRetrieves forms from a Form Manager as and when required. When requesting a form, the Form Filler can optionally provider EHR context information by providing pre-population xml data in the request for use by the Form Manager. Form ManagerSupplies forms to Form Fillers based upon form retrieval requests. May return a form, or the returned form may be selected or constructed based upon context information supplied in the form retrieval request. Form ReceiverReceives and processes completed or partially completed forms instance data from a Form Filler.

8. What Relevant Purpose (from the Use Case) does your Pilot support? Please read the SDC Use Case and identify what area your pilot will focus on. Link to download Consensus Approved Use Case: http://wiki.siframework.org/Structured+Data+Capture+Use+Case http://wiki.siframework.org/Structured+Data+Capture+Use+Case Clinical Research Patient Centered Outcomes Research (PCOR) Patient Safety Reporting Public Health Reporting Determination of Coverage Other: ____(Please specify)

9. Minimum Configuration What is your current technical / infrastructure set up? What systems / applications will you be using to conduct the pilot? Examples: –Ambulatory Electronic Health Record (EHR) system –Form/Template repository –External database (which one/type) –Existing interfaces –New interfaces (to be developed as part of the pilot)

10. Timeline What is your proposed timeline? Guidance: ~6 months minimum / ~1 year maximum Evaluation: starts @ 6-9 months / final evaluation when pilot is complete Milestones/Activities are examples. Please feel free to edit as needed. Milestone / ActivityTarget DateResponsible Party Kickoff Design Development QA and Test Demonstration Evaluation

11. Success Criteria What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible. –Example: Establish a process within your organization where XX% of their Incident Reports are completed electronically.

12. In Scope / Out of Scope If you already know what will be in and out of scope for your pilot (beyond the Implementation Guidance (IG) or the Use Case) please document it here.

13. Risks & Challenges Please identify any risks or challenges. Be sure to include proposed mitigations/solutions for each risk.

14. Questions / Needs Please include those items you wish to consider any questions you have or hope the pilot addresses. Additionally, please include those items you need in order to succeed. We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and SDC (and resource availability).

15. Useful Links SDC Wiki Main Page: http://wiki.siframework.org/Structured+Data+Capture+Initiative Use Case: http://wiki.siframework.org/Structured+Data+Capture+Use+Case IHE SDC Profile: http://wiki.siframework.org/IHE+SDC+Profile Pilots Wiki Page: http://wiki.siframework.org/Structured+Data+Capture+Pilots

16. SDC Contact Information For questions, please contact your support team –Initiative Coordinator: Ed Hammond (william.hammond@duke.edu)william.hammond@duke.edu –ONC Lead: Farrah Darbouze (farrah.darbouze@hhs.gov)farrah.darbouze@hhs.gov –Project Manager: Jenny Brush (jennifer.brush@esacinc.com)jennifer.brush@esacinc.com –Technical Lead and Harmonization Support: Vijay Shah (vshah@jbsinternational.com)vshah@jbsinternational.com –Standards Development Support: Perri Smith (perri.smith@accenturefederal.com)perri.smith@accenturefederal.com