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

Pilot Team 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 NameRole

Full Disclosure?

Goal of the Pilot Please include a write up or create a Visio 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. 4

Which of the 4 SDC Standards are you Piloting? Please use this section to document which of the 4 SDC Standards (CDE Template, Form Template, Sharing API, or EHR Auto-populate) you are intending to pilot. Please be as specific as possible. 5 SDC Standard / GuidanceSpecifics to PilotNotes

What Relevant Purpose (from the Use Case) does your Pilot support? Patient Centered Outcomes Research (PCOR) Patient Safety Reporting Public Health Reporting Determination of Coverage Other: ____(Please specify) Link to download Consensus Approved Use Case:

Identify the Use Case Actors/Systems Involved: A pilot may involve the following participants from the structured data capture ecosystem: –Provider –EHR System –Form/Template Repository –External Data Repository

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)

Timeline What is your proposed timeline given we want to wrap-up Pilots by _______? Guidance: ~6 months minimum / ~1 year maximum Evaluation: 6-9 months / final evaluation when pilot is complete Example Timeline –September – Kickoff and Logistics –October – Start Pilots –November – Continue with Pilots –March – Conclude Pilots MilestoneTarget DateResponsible Party

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.

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. Example:

Risks & Challenges Identify any risks or challenges

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).

Useful Links SDC Wiki Main Page: Use Case: SDC Standards & Harmonization armonization+and+Standards+%28Implementation%29 Pilots Wiki Page:

Pilots & Testing … Standards & Harmonization Use Case & Functional Requirements Pre-Discovery Appendix A: SDC Workgroup Activities and Timeline FEB 13JUN 13MAR 13 APR 13MAY 13JUL 13AUG 13SEP 13OCT 13NOV 13 Kick Off 1/23/13 Evaluation... Technical Work Stream Technical Work Stream Standards SWG 3.EHR Interaction Standard 4.Auto-populate standard SDC All-Hands Work Group Use Case WG Forms SWG 1.CDE Structure Standard 2.Container/Template Standard Standards & Harmonization WG Content Work Stream Content Work Stream Common Formats SWG… AHRQ Lead PCOR Content SWG… NLM Lead