Illinois HIT Regional Extension Center Qualification Survey

Primary care physicians in an ambulatory care setting may be eligible for subsidized technical assistance for implementing electronic health record (EHR) and other health information technology (HIT) activities through the new, federally-funded Health Information Technology Regional Extension Center (HITREC) program. The federal government is making funds available to provide technical assistance for EHR and other HIT activities to help providers become eligible for Center for Medicare & Medicaid (CMS) meaningful use incentives.

The Illinois HIT Regional Extension Center provides services to physicians to adopt and meaningfully use electronic health record systems for primary care physicians in Illinois outside of the City of Chicago. The cost of these services is 90% subsidized through an award from the Office of the National Coordinator, Department of Health and Human Services (Grant 90RC0023/01). Participating physicians provide the remaining cost, $1,000 per provider per year with a two year commitment. Fee based services are also available to providers who are not designated by the Office of the National Coordinator to receive subsidized services.

Services provided to participating providers include:

• Vendor Selection & Group Purchasing
• EHR Implementation and Project Management
• Practice and Workflow Redesign
• Functional Interoperability and Health Information Exchange
• Privacy and Security Best Practices
• Attaining Meaningful Use as defined by ONC

IL-HITREC is administered by Northern Illinois University in partnership with the Southern Illinois Healthcare Foundation, Quality Quest for Health of Illinois, and the Metropolitan Chicago Healthcare Council. IL-HITREC also collaborates with the Chicago Health Information Technology Regional Extension Center administered by Northwestern University which serves physicians in the city of Chicago.

We encourage you to participate by completing the following Qualification survey if you are interested in utilizing IL-HITREC services. For general information, call 815-753-1136 or email us at info@ILHITREC.org.

Contact Information

Practice Name
Practice Tax ID (FEIN)		Organizational NPI
Address		County
Primary Contact		Email
Telephone		Fax

Practice Information

1. Number of primary care providers in this practice:

Family Practice		Nurse Practitioner with prescribing privileges
General Practice		OB-GYN
Geriatrics		Pediatrics
Internal Medicine		Physician Assistant with prescribing privileges
Other		Nurse Midwife with prescribing privileges
List specialties

2. Are you affiliated with a:
(check all that apply)

	Small Group Practice (10 or less providers)
	Critical Access Hospital
	Rural Hospital (< 50 beds)
	Community Health Center
	Rural Health Clinic
	a setting serving predominately uninsured, underinsured, or underserved populations

3. What is your primary practice hospital?

4. EHR Status
Our practice currently uses an electronic health record system.
System and Version
Our practice plans to implement an EHR on (date).
System and Version
Our practice does not currently use an EHR.

5. What percent of your patients are Medicaid eligible? %

6. Did your practice receive more than $75,000 in Medicare reimbursements in 2009?
Yes No

Completed By:

Name
Phone
Email

Thank you for taking time to complete the Qualification survey.

web design by trittenhaus design