Project Information

 
  ex. 01/01/2013    

 
 
Principal Investigator's Information
 
 
 
  ex. 111-222-3333  
 
 
 
 
 
 
  If PI possesses both UPMC and University affiliations, please select University of Pittsburgh.

 
 
 
Requestor's Information
  ex. 111-222-3333  
 
EMR Access

Select all individuals and/or groups that will be accessing and/or extracting from the UPMC electronic medical record (EMR) for this research project. Select all that apply.
If you need any assistance from CARe (e.g., provision of a cohort list, data extraction from EMR, etc.) you must check the CARe box below.

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Please choose a Request Type


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Please provide your Honest Broker information

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Please answer the questions below
Does this individual have access to the EMR through their job responsibilites?

Has this individual completed the HIPAA for Researchers module (formerly Module 6)?

* Completion of the HIPAA Researchers Privacy Requirements module is a requirement for University of Pittsburgh faculty, staff, students, collaborators and others who participate in human subjects research at the University of Pittsburgh and/or UPMC that involves protected health information. Click on the link to access this module via your HS Connect account.

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Please list all persons accessing the UPMC EMR for this research project and answer the questions below

Does this individual have access to the EMR through their job responsibilites?

Has this individual completed the HIPAA for Researchers module (formerly Module 6)?

* Completion of the HIPAA Researchers Privacy Requirements module is a requirement for University of Pittsburgh faculty, staff, students, collaborators and others who participate in human subjects research at the University of Pittsburgh and/or UPMC that involves protected health information. Click on the link to access this module via your HS Connect account. PI is also responsible for overseeing all data extractions and management

Scope

No specified record start date

 
No specified record end date
 
 
 
Will any racial or ethnic subgroups be explicitly excluded from the participation?
If yes, please specify the subgroups to be excluded
 
Report / Data Extraction Criteria

Complete this section to request assistance from CARe analysts with data extraction from the electronic medical record. Specify inclusion/exclusion criteria in the fields below and please be as specific as possible. If a field is not applicable, type N/A.

Research Recruitment Alert

Complete this section to request an alert in the EpicCare to indicate when a patient meets criteria for participation in a specific research study. Please be as specific as possible. If a field is not applicable, type N/A.

If a patient declines, should they ever be asked again?


If yes, specify number of days
   

When a patient agrees, an order will be sent to the inbasket. Please specify the following:

Note: If a pool member does not have access to EpicCare, a view-only access request must be submitted to IMS at https://ims.upmc.com.

Data Source(s)

Select all electronic data sources that will be accessed for this research project. If you are unsure of the system in which data will be accessed and/or extracted, please check “Unknown.”










 
De-identification of Data



Data Storage




 

*Reminder: Data must be stored in a secured environment at all times. This includes ensuring that the computer and any media (such as CD-ROMs, thumb drives, removable drives) are encrypted and password protected. Data should not be sent through e-mail, unless it is encrypted (with the key being sent separately). Data are not permitted to be stored in or transferred via personal, unprotected, unencrypted files or devices.