HOSPITAL COMMITMENT FORM

MINNESOTA HOSPITAL ASSOCIATION
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) GRANT
ADDING LAB AND PHARMACY DATA

Hospital or System Name:________________________________________

Lab data Our hospital or health system will participate in this project by submitting lab data to MHA in addition to the administrative data already collected. I understand that MHA staff will be working with both lab and IT staff at the hospital or health system to facilitate this process.

Pharmacy data There will be two phases for pharmacy data collection. In phase I, a group of 15 hospitals are sought to participate in a pilot phase to develop data mapping tools to be used with Phase II hospitals. The main advantage to being in Phase I is that the mapping will be performed by MHA project staff, whereas Phase II hospitals will implement the mapping themselves. In order to participate in Phase I, hospitals must have CPOE or an alternative electronic order entry system.

Does your hospital have CPOE or an alternative electronic order entry system? Yes/ No

If yes, will you participate in Phase I of the pharmacy data collection? Yes/No/Maybe

Please contact me as I need more information _______

Please list your I.T. vendor for:

___________________________________________(Lab)

___________________________________________(Pharmacy)

For this project, we will need a single point of contact from your organization for communication and coordination purposes. Please give us that person’s name and contact information below: (if undecided leave blank)

________________________________________________(Name)

________________________________________________(Title/Dept.)

________________________________________________(Phone/Email)

Please sign and return this form.
Attn: Jenny Sanislo Fax (651)645-0002 jsanislo@mnhospitals.org

Date:__________________________________________

Signature:________________________________________

Title:___________________________________________

E-mail: ___________________________________________