Electronic Initial Case Reporting (EICR) Registration Greetings, Thank you for your interest in pursuing electronic initial case reporting (EICR) with the South Dakota Department of Health. We are able to accept all reportable conditions. Please answer these questions. Once the survey is completed, you will receive an e-mail confirming your registration with an attachment containing all of the information you provided. Thank you! Name(Required) First Last Title(Required)Organization(Required)E-mail Address(Required) PhoneIs your main facility EHR capable of generating a message following the "HL7 CDA R2 Public Health Case Report, Release 2 Standard for Trial Use Release 1.1" implementation guide?(Required) Yes No NOTE: This question may require research by your vendor contact; it is likely that someone within your vendor’s organization is engaged with this national initiative.Who is your EHR vendor?(Required)Is your main facility EHR capable of routing the message to the AIMS platform?(Required) Yes No When will your main facility EHR be capable to route messages to the AIMS platform?(Required)Example: Q4 2022, 9/1/2022Before continuing, please download and complete the facility name spreadsheet template. This is needed to complete the registration. Spreadsheet Template Registration InformationWhat type of facility are you registering?(Required) Healthcare Clinic/Provider Hospital (single site facility) Hospital and affiliated clinic locations or network of clinics Multi-hospital health system with network of clinics Facility, main clinic, or healthcare provider name(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Main facility contact for electronic initial case reporting(Required) First Last Main facility point of contact e-mail address(Required) Main facility point of contact phone #Upload the completed facility list spreadsheet(Required)Max. file size: 10 MB. Electronic Health Record (EHR) Functionality EHR system automation Can your EHR system (Required) flag a record that meets specific criteria, generate an HL7 CDA message, attach the HL7 CDA message to a Direct Secure Messaging e-mail, and send the e-mail automatically (without manual intervention)? Can your EHR system(Required) Yes No More complex response needed Please explain response to the question about EHR system automation.Does your EHR system have a way to consume 'Trigger Codes' (LOINC, SNOMED, ICD-10 codes) downloaded from an external source which are used to define the specific reporting criteria?(Required) Yes No More complex response needed Please explain response to the question about Consuming Trigger CodesIs there a mechanism in your EHR to check for 'Trigger Code' updates on a periodic schedule (monthly, quarterly, semi-annually)?(Required) Yes No More complex response needed Please explain your response to the question about Updating Trigger Codes Electronic Initial Case Report (EICR) Data Elements There is a pre-defined list of data elements in the HL7 CDA R2 Public Health Case Report, Release 2 Standard for Trial Use Release 1.1 Implementation Guide. These data elements are listed below; please identify those data elements that your EHR is capable of sending by marking the appropriate box beside each element.Date of Report: The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.) completes collection of minimum data for the EICR(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Report Submission Date/Time: The date and time at which the EHR system sends the EICR data to the jurisdictional public health agency or designee(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Sending Application: The name of the sending software application(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider ID: Identification code for the healthcare provider (e.g., NPI)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider Name: The first and last name of the healthcare provider(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider Phone: The provider's phone number with area code(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider fax: The provider's fax number with area code(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider Email: The provider's email address (for secure communication)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider Facility/Office Name: The provider facility's full name, not necessarily where care was provided to patient(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Provider Address: The geographical location or mailing address of the provider's office or facility. Address must include street address, office or suite number (if applicable), city or town, state, and zip code(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Facility ID Number: Identification code for the facility (e.g., Facility NPI)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Facility Name: The facility's name where the patient received healthcare; for follow up to identify contact exposure, appropriate treatment, etc.(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Facility Type: the type of facility where the patient received or is receiving healthcare for the reportable conditions (e.g., hospital, ambulatory, urgent care, etc.)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Facility Phone: The facility's phone number with area code(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Facility Address: The mailing address for the facility where the patient received or is receiving healthcare for the reportable condition. Must include street address, city/town, county, state, and zip code.(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient ID Number: Patient medical record number, or other identifying value – something OTHER THAN Social Security Number(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient Name: All names for the patient, including legal names and aliases; Must include the name type (i.e., legal or alias), first name, middle name, and last name(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Parent/Guardian Name: All names for the patient's parent or guardian, including legal names and aliases (if patient age is < 18); Must include the name type (i.e., legal or alias), first name, middle name, and last name(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient or Parent/Guardian Phone: All phone numbers and phone number types for the patient or parent/guardian(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient or Parent/Guardian Email: The email address for the patient or the patient's parent/guardian(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient Street Address: All addresses for the patient, including current and residential addresses; must include street address, apartment or suite number, city or town, county, state, zip code, and country(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Birth Date: The patient's date of birth(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient Sex: The patient's biological sex (not gender)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Race: The patient's race(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Ethnicity: The patient's ethnicity(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Preferred Language: The patient's preferred language(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Occupation: The patient's occupation (student, job title, etc.)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Pregnant: The patient's pregnancy status(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Visit Date/Time: Date and time of the provider's most recent encounter with the patient regarding the reportable condition(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Admission Date/Time: Date and time when the patient was admitted to the treatment facility (e.g., hospital, clinic)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future History of Present Illness: Physician's narrative of the history of the reportable event. Hopefully a place where information such as travel, contacts, etc. is captured(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Reason for Visit: Provider's interpretation for the patient's visit for the reportable event(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Date of Onset: The earliest date of symptoms for the reportable event(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Symptoms (list): List of patient symptoms (structured) for the reportable event(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Laboratory Order Code: Ordered tests for the patient during the encounter(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Placer Order Number: Identifier for the laboratory order from the encounter(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Diagnoses: The healthcare provider's diagnoses of the patient's health condition (all)(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Date of Diagnosis: The date of provider diagnosis(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Medications Administered (list): List of medications administered for the reportable event(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Death Date: The patient's date of death(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Patient Class: Whether the patient is outpatient, inpatient, emergency, urgent care, etc.(Required) Yes, this facility’s EHR can send this data element No, this facility’s EHR cannot send this data element currently, but expect to be able to in the future No, this facility’s EHR cannot send this data element currently and do not expect to be able to in the future Business Associates AgreementWould a business associates agreement (BAA) be required to route reportable information from your organization/facility to a third party, the Association of Public Health Laboratories (APHL), on its way to the South Dakota Department of Health?(Required) Yes No More complex response needed Please explain your response to the BAA questionIt is also possible that the reportability response could provide condition-specific treatment information or outbreak-specific guidance back to the healthcare provider after the report is made. Would this be something you would like?(Required) Yes No More complex response needed Please explain your response to the Reportability Response questionDo you have a planned date when you will start and/or be live? If Yes, please provide the dates.(Required)Add any additional information or questions. Or click submit below.