Reachnet Data Request Form

Name of PI:

REACHnet Data Request Form

CONTACT INFORMATION

1.) Name of person completing this form:
2.) Institution/Organization:
3.) Role on project:

TITLE AND DESCRIPTION

4.) Title of proposed study:
5.) Provide a description of theproposed project. (≤250 words)
Note: If applicable, upload Letter of Intent (LOI) to Eco.
6.) List the research objectives and/or specific aims of the study.

GENERAL INFORMATION

7.) Funder and mechanism:
8.) Title of funding announcement (and link), if applicable:
9.) Funding amount: / 10.) Duration:
11.) Provide the due date(s), if applicable:
a.) Letter of Intent:
b.) Funding application:
12.) Are you requesting a letter of support from REACHnet to include in your submission? If so, by when are you requesting to receive this?

STUDY POPULATION

Note: To request a prep-to-research query, please complete the REACHnet Query Request Form. If you are not in need of a prep-to-research query (e.g. for a funding application), the information on this Data Request Form is sufficient for REACHnet to review your data request. If your request is approved, a limited dataset will be provided only after the study has received IRB approval and the appropriate data sharing agreements have been executed.

13.) Describe the study’s target populationand planned subgroup analyses (2-5 sentences).
14.) List all inclusion and exclusion criteria,including clinical and demographic characteristics.
15.) Desired sample size for this project:
16.) From which REACHnet participating systems/sites would you like to request data?Select all that apply:
Note: Health systems may approve or decline the data request.
Tulane University Medical Center
Ochsner Health System
Lallie Kemp Regional Medical Center (LSU affiliate)
Baylor Scott and White Health(North & Central)
Partnership for Achieving Total Health (PATH)/Greater New Orleans Health Information Exchange (GNOHIE) sites
(e.g. EXCELth, Access Health, etc.)

BACKGROUND

17.) Describe how the condition or disease being studied is associated with a significant burden in the US population in terms of prevalence, mortality, morbidity, individual suffering, or loss of productivity. Alternatively, explain how the condition or disease imposes a significant burden on a smaller number of people who have a rare disease (5-7 sentences).
18.) Describe how variations in current practice suggest clinical uncertainty (2-5 sentences).
19.) Describe how the research is novel or innovative in its methods or approach, in the population being studied, or in the intervention being evaluated in ways that make it likely to improve care (2-5 sentences).
20.) Describe how the proposed research will help patients address one or more of the following key questions (5-7 sentences).

Given my personal characteristics, conditions, and preferences, what should I expect would happen to me?
What are my options and what are the potential benefits and harms of those options?
What can I do to improve the outcomes that are most important to me?
How can clinicians and the care delivery systems they work in help me make the best decisions about my health and health care?

TIMELINE

21.) General timeline for the proposed project:

DATA NEEDS

22.) Describe the project’s data needs by answering the following questions.
a.)If you are interested in REACHnet’s clinical data, please check the boxes below to indicate which CDM tables house the clinical data elements needed for your project. For each box (i.e. CDM table) that you check, list the exact clinical data elements you are interested in obtaining. Reference the PCORnet Common Data Model to answer these questions (see page 5 for variables). If you are not interested in leveraging REACHnet’s clinical data for your project, leave this section blank.
Demographic (e.g. sex, age range, race/ethnicity)
Demographic variables:
Enrollment (e.g. period of observed medical events)
Enrollment variables:
Encounter (e.g. interactions between patients and providers)
Encounter variables:
Diagnosis (e.g. results of diagnostic processes)
Applicable ICD-9 and ICD-10 codes:
Procedures (e.g. medical interventions, such as surgical procedures)
Applicable CPT codes:
Vital (e.g. height, weight, diastolic, systolic)
Vital variables:
Lab Results (e.g. laboratory results from blood and other body specimens)
Applicable LOINC codes:
Condition (e.g. diagnosed or self-reported health conditions)
Condition variables:
Prescribing (e.g. medication orders)
Applicable RXNORM CUI codes:
Death (e.g. mortality information)
Please provide additional specifying information below for any boxes checked:
b.)If your study requires clinical data elements that are not included in the PCORnet Common Data Model(e.g. not listed on page 5 of the attachment), REACHnet may be able to facilitate the acquisition of this data from partner health systems. If you are interested in this assistance, please describe the data element(s), indicating whether they are structured or unstructured in EMRs.
c.)For which age group are you requesting the above data? Adults Minors Both adults and minors

PATIENT & CLINICIAN ENGAGEMENT

Note: If you are interested in working with REACHnet to convene stakeholder advisory groups or develop an engagement plan for your proposal, please also complete the Request for Engagement Services Form.

23.) Describe the types of patients and/or other stakeholders that will be engaged in the research process (2-5 sentences).
24.) Describe how the aforementioned individuals will be involved in the following project components (5-7 sentences).

Formulating research questions

Defining essential characteristics of study participants, comparators, and outcomes
Identifying and selecting outcomes that the population of interest notices and cares about (e.g.,survival, function, symptoms, health-related quality of life) and that inform decision making relevant to the topic
Monitoring study conduct and progress
Informing plans for dissemination and implementation activities

25.) If applicable, describe how patients and clinicians have been involved in project development up to this point.

DISSEMINATION

Note: All studies are required to disseminate results to REACHnet’s partners and stakeholders through the network’s dissemination mechanisms. Please refer to PCORI’s Dissemination Policy for guidance.

26.) Specify dissemination mechanisms for specific stakeholder groups (e.g. study participants, the target clinical community, etc.).

Version Date: May 2017