Electronic Health Record (EHR) Initiative

Data Submission / Review Form

Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______

NOTE: PBIPs should list practice information in Section 3 below

Practice NPI: ______

(Required: Please accurately complete your 10-digit #)

Office Contact Name: ______Title: ______

Phone Number: (_____) ______-______Ext.______

NOTE:

î If several practice sites are under the same NPI, please complete one form per NPI.

î Submissions with incomplete or erroneous information will delay review of your submission by the QualityBLUE Submission Committee and could affect your QualityBLUE score.

Implementation activities are reviewed quarterly. The submissions must be postmarkED on or before the indicated quarterly deadline:

November 1 for 1st Quarter

February 1 for 2nd Quarter

May 1 for 3rd Quarter

August 1 for 4th Quarter

Section 2 Required: EHR Vendor Name, Software Solution, and Software Version

Please indicate selected EHR System: / Vendor Name: / ______
Software Solution: / ______
Software Version: / ______

Highmark is a registered mark of Highmark Inc. Blue Shield, and the Shield symbols are registered service marks, and QualityBLUE is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______

Section 3 Required: Proof of Purchase and Implementation of EHR System

3 points / Proof of purchase or Implementation of EHR system:
Acceptable Documentation: / Signature page from Signed Vendor Contract which includes, both Signatures of EHR Vendor and Practice: / *
OR
Signed Purchase order form: / *
5 points / Verification of Implementation:
in at least 50% of Total Practice Sites per NPI
Acceptable Documentation / Vendor letter acknowledging implementation by location, / *
Above proof of purchase, if not already submitted,
OR
Letter from practice verifying implementation by practice site. / *
3 or 5 points / Implemented Practice Site Address(es) / YES / NO
Please list each site location and indicate whether EHR has or has not been implemented.
Required:
Please accurately complete your
10-digit NPI.
If additional practices need to be listed, please use the form located on NaviNet via the QualityBLUE Program. / Practice NPI: ______
Practice Name: ______
Main Address: ______
City: ______State: ___ Zip Code: _____ / * / *
Practice NPI: ______
Practice Name: ______
Main Address: ______
City: ______State: ___ Zip Code: _____ / * / *
Practice NPI: ______
Practice Name: ______
Main Address: ______
City: ______State: ___ Zip Code: _____ / * / *
Practice NPI: ______
Practice Name: ______
Main Address: ______
City: ______State: ___ Zip Code: _____ / * / *
Practice NPI: ______
Practice Name: ______
Main Address: ______
City: ______State: ___ Zip Code: _____ / * / *

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Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______

Faxes will not be accepted. Please mail this entire form with attachments to:

Highmark Blue Shield

QualityBLUE Submission Review Committee

P.O. BOX 535098

Pittsburgh, PA 15253-5098

QualityBLUE Submission Review Results – Highmark use only

Date Received by Highmark: ____/____/_____

EHR Activity / Points Assigned / Approved / Not Approved / Review Date / Committee Signature
Documented commitment to purchase EHR / 3
Initiated implementation of EHR in at least 1 practice site / 3
EHR Implementation in 50% of Total Practice Sites per NPI / 5

Additional Committee Notes:

______
______
______

Highmark Blue Shield V1.1 07/08 Page 1 of 3

Electronic Health Record (EHR) Submission Form