View equation Your role on the project
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Principal Investigator Coinvestigator Research Assistant Study Coordinator Other Student
PI first name:
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PI Last name:
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PI email address:
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Employer of the PI:
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Fairview Health Services University of Minnesota Other
Please name your employer.
College or School:
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School of Dentistry Medical School School of Nursing College of Pharmacy School of Public Health College of Veterinary Medicine Center for Allied Health Programs College of Biological Sciences College of Continuing Education College of Design College of Education and Human Development Extension College of Food, Ag, and Natural Resources Law School College of Liberal Arts School of Management School of Public Affairs College of Science and Engineering Other
Department (if applicable):
Other (please specify)
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Medical School Department:
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Anesthesiology Biobehavioral Health and Pop Sciences - Duluth Campus Molecular Biology, and Biophysics Biomedical Sciences - Duluth Campus Dermatology Emergency Medicine Family Med and Community Health - Twin Cities campus Family Med and Community Health - Duluth Campus Cell Biology and Development Integrative Biology and Physiology Laboratory Medicine and Pathology Medicine Microbiology Neurology Neuroscience Neurosurgery Obstetrics, Gynecology and Women's Health Ophthalmology and Visual Neurosciences Orthopedic Surgery Otolaryngology Pediatrics Pharmacology Physical Medicine and Rehabilitation Psychiatry Radiation Oncology Radiology Surgery Urology Research or Administration
Division within department (if applicable):
We understand that you are not the PI on the project. Please provide your contact information below. Thank you.
Your first name:
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Your last name:
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Your email address:
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Please list here the names, email addresses, and x.500s (UMN internet ID) of any people in addition to the PI who will be accessing the requested data.
Note: These collaborators should be named on your IRB application as well.
Anyone who will be accessing data must be an authorized AHC IE user.
University of Minnesota employees:
To be authorized, you must have completed the University's HIPAA Privacy and Data Security Training program and have signed the AHC IE Attestation Form (
sign here ) within the last year.
Fairview employees:
You will be authorized by the FV Data Steward. They will be in touch with you following submission of your request.
Purpose of consultation (please pick one):
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Clinical/EHR Data Data Storage BLS Dental Data Natural Language Processing Merative MarketScan CR3 C-QODE MCC Request Informatics Faculty Support Other
M Health Fairview/UMP CUHCC Axium- School of Dentistry FUHN Network OMOP
Primary Project Purpose
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Research
Quality/Healthcare Operations
Recruitment
Research
Quality/Healthcare Operations
Recruitment
Output Needs
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IRB Status- Does this study currently have IRB approval?
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Yes
No
Consultation- Do you need a BPIC consultation for the IRB HRP-595 abbreviated process?
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Yes
No
MCC Dashboard Change Request MCC Application Access Request MCC Sample Inventory
Does this request have any hard deadlines?
Yes
No
Today M-D-Y
Is this project being used to fulfill a student's academic research requirement?
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Yes
No
You have requested data for feasibility/recruitment purposes. Please choose from among the options below.
I need to know the size of the cohort to determine the feasibility of the study. Please provide me with the count of patients matching my criteria.
I am planning a study and want patient data to determine feasibility. My goal is not patient recruitment at this time.
I need to know the size of the cohort to determine the feasibility of the study. Please provide me with the count of patients matching my criteria.
I plan to recruit patients based on the data provided to me. If I want to send out recruitment letters to Fairview patients, I'll visit the Fairview recruitment instructions . If you'd like to explore recruitment options, please contact the CTSI recruitment center at ctsi@umn.edu . I am planning a study and want patient data to determine feasibility. My goal is not patient recruitment at this time.
If your request is for the purpose of determining feasibility, please consider using the i2b2 tool to discover the size of your cohort. Visit
the i2b2 page on the CTSI website to learn more. If you decide to use i2b2, please cancel this data request form. Thank you.
If you have existing IRB approval covering this request, please provide the IRB number here.
If IRB approval is pending, please review the
IRB website . If your research involves only the analysis of medical record data, the submission of the
Medical Record Chart Review (MRCR) application may suffice.
If you've already discussed this project with an informatics consultant or other BPIC team member, please indicate their name here.
Ashley Benner Sonya Grillo Gretchen Sieger Tony Tholkes Karen Baker-James Vidhyalakshmi Ramesh Lindsay Hoke Keith Landgrebe Thomas Pederson Wei Shen Charles Nguyen Reed McEwan Nikhita Kutala Talia Wiggen Natalie Jantschek Preeti Magesh Prajwal Pradhan Jaber Salem
Title of your project
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Please provide a brief description of your research question, project aims and your informatics needs.
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Funding
Choose the funding source that will support costs for services
(Updated Oct 2022)
Hourly ISO RatesBPIC $120/hr Masonic Cancer Center Members $95/hr
Departmental Support Agreements School of Dentistry Center for Pediatric Obesity Medicine Department of Anesthesiology Department of Dermatology Department of Family Medicine and Community Health Department of Pediatrics, Emergency Medicine Department of Pediatrics, Cardiology Department of Pediatrics, General Medicine Department of Surgery
*Departmental pre-approval may be required
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Departmental Contract Grant Support (%FTE) Grant Support (ISO Rate) Hourly Rate No Funding
Which departmental contract does this project fall under?
School of Dentistry
Center for Pediatric Obesity Medicine
Department of Anesthesiology
Department of Dermatology
Department of Family Medicine and Community Health
Department of Pediatrics, Emergency Medicine
Department of Pediatrics, Cardiology
Department of Pediatrics, General Medicine
Department of Surgery
School of Dentistry
Center for Pediatric Obesity Medicine
Department of Anesthesiology
Department of Dermatology
Department of Family Medicine and Community Health
Department of Pediatrics, Emergency Medicine
Department of Pediatrics, Cardiology
Department of Pediatrics, General Medicine
Department of Surgery
Is this data request associated with a project that you have already registered in the CTSI portal?
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Yes No I'm not sure
Please give us the CTSI Project ID #.
We will look up your project in the CTSI database. Please provide us with a few keywords to help locate it.
We will use the information you have provided to register your project within the CTSI portal. You will be emailed the CTSI ID #, which you can use should you want to request additional CTSI services for this project. However, there is no requirement that you visit the CTSI portal.
How is your research funded (e.g. Federal government, local government, U of MN, foundation, non-sponsored)?
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Help us understand which research areas and types are benefiting most from our services and help us ensure continued funding for CTSI services like this one.
Health Equity/Disparity - The study of differences in the quality of health care across different populations. This may include differences in the presence of disease, health outcomes, or access to health care across racial, ethnic, sexual orientation and socioeconomic groups.
Children's Health - Research that focuses on either preventing the onset of health-related situations or examines the safety and/or efficacy of health and development-related impacts or medications, devices, and preventative measures on children.
Community Engagement - Working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people, where the focus is on Minnesota but practices or procedures developed can be expanded nationally or globally.
Collaboration - multiple PIs with different areas of expertise, inter-CTSA collaboration, collaboration with for-profit or non-profit organizations.
None of these
Health Equity/Disparity - The study of differences in the quality of health care across different populations. This may include differences in the presence of disease, health outcomes, or access to health care across racial, ethnic, sexual orientation and socioeconomic groups.
Children's Health - Research that focuses on either preventing the onset of health-related situations or examines the safety and/or efficacy of health and development-related impacts or medications, devices, and preventative measures on children.
Community Engagement - Working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people, where the focus is on Minnesota but practices or procedures developed can be expanded nationally or globally.
Collaboration - multiple PIs with different areas of expertise, inter-CTSA collaboration, collaboration with for-profit or non-profit organizations.
None of these
Check as many as apply.
Is this a rerun of a previous data request?
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Yes No
Please provide an identifier or descriptive text to assist with locating your previous request.
You've requested data from the Minnesota Death Index. Please download this file and populate it with the list of individuals for whom you are seeking death certificate data. We can identify the individuals on your list if you provide social security numbers OR medical record numbers OR first names, last names, and dates of birth. The more information you provide us on each individual, the more accurate the match will be. You will be able to upload your list in the next item on this form.
Please upload here the document you created (using the format provided above) with the list of people for whom you are seeking death certificate data.
In the next three sections of this form, you'll be asked about the following:
Please describe in your own words the patients you are looking for.
Inclusion Criteria:
Male Female
Age range minimum (years):You can specify fractions of a year as decimal.
If there is only a maximum age, you do not have to provide a minimum.
Age range maximum (years):You can specify fractions of a year as decimal.
If there is only a minimum age, you do not have to provide a maximum.
You've requested to select patients by age. Which age do you want?
Age now Age at time of visit/encounter Age now
Age at time of visit/encounter
For recruitment, we recommend age now and, for EHR review, age at visit.
The race(s) to which you'd like to limit your cohort:
The ethnicities to which you'd like to limit your cohort:
You have indicated that your request is for recruitment purposes. By default, all recruitment requests assume a date range of the previous two years. If you'd like a different date range, you can specify it here.
Use this space to specify hospitals, clinics, or specific departments in which you are interested.
Hospitals to choose from: UMMC (East Bank, West Bank, or Amplatz); Southdale Hospital; Ridges Hospital; Lakes Medical Center; Northland Medical Center
Provide here the home zip codes to use in identifying your patients.
hint: 553*, 554*, 551*, and 550* would give you all residents of the greater Twin Cities area.
Diagnosis codes (ICD9 and ICD10):
*ICD-10 codes are used on and after October 1, 2015
*
You can look up ICD-9 codes here.
*
You can look up ICD-10 codes here.
* If you are seeking a range of codes, make sure to indicate that. A wild card can be indicated with "*"
* Don't forget to include any leading letters that may be part of the code.
Generally we search past encounters to find the diagnoses of interest. Would you like us to search the patients' problem lists and medical history as well?
Match all diagnosis codes?
All (i.e. only medical records that match all of the listed codes)
Any (i.e. include medical records that match any of the listed codes)
All (i.e. only medical records that match all of the listed codes)
Any (i.e. include medical records that match any of the listed codes)
CPT Procedure codes:
A good way to find the CPT codes you want is it to use the UMN i2b2! For more information on i2b2 visit
this web page .
This space is for CPT codes. There is space below if you'd like to provide ICD9 procedure codes.
Match all procedure codes?
All (i.e. only medical records that include all of the listed procedure codes)
Any (i.e. include medical records that match any of the listed procedure codes)
All (i.e. only medical records that include all of the listed procedure codes)
Any (i.e. include medical records that match any of the listed procedure codes)
You've indicated that you want to specify diagnoses and procedures in identifying your patients of interest. Are you interested in those patients who meet BOTH your diagnoses criteria AND your procedure criteria? Or is meeting only one of them sufficient to consider the patient responsive to your cohort definition?
Need diagnosis AND procedure to be included. Need diagnosis OR procedure to be included. Need diagnosis AND procedure to be included.
Need diagnosis OR procedure to be included.
Laboratory tests and values to be included (please provide Epic lab codes, test names, or LOINC names if you know them):
All (i.e. only medical records that match all of the listed lab tests)
Any (i.e. include medical records that match any of the listed lab tests)
All (i.e. only medical records that match all of the listed lab tests)
Any (i.e. include medical records that match any of the listed lab tests)
Medications to be included:
We will assume that you are interested in administered medications for inpatient and ordered outpatient encounters. If you would like some other exception to the above rule, please explain here.
Should the diagnoses, procedures, labs, and medications you specified be tied to the same encounter?
In identifying patients, please constrain the diagnoses, procedures, labs, and medications I have selected to have occurred within the same encounter.
The diagnoses, procedures, labs, and medications are independent requirements for my cohort; they do not have to be constrained to common encounters.
The constraints on my diagnoses, procedures, labs, and/or medications involve some other combination, which I'll describe in a text box below.
In identifying patients, please constrain the diagnoses, procedures, labs, and medications I have selected to have occurred within the same encounter.
The diagnoses, procedures, labs, and medications are independent requirements for my cohort; they do not have to be constrained to common encounters.
The constraints on my diagnoses, procedures, labs, and/or medications involve some other combination, which I'll describe in a text box below.
Please provide additional information here on constraints that exist between your different inclusion criteria.
If you'd like to upload a document that lists the diagnoses, procedures, lab tests, or medications to be used in filtering patients for your cohort, please use button on the right.
Clinical care start date:
Today M-D-Y If extensive data is needed from before the launch of Epic, data will be extracted from the Fairview PASS system and your request will take a longer time to complete (depending on the complexity of your request it will take 2-6 months).
Today M-D-Y If you put the current date as the last date of care, we'll assume you want the most recent data available.
By default we will use your specified clinical care date range to limit our search for encounters with the diagnoses , procedures , lab tests , and medications you've specified.
Provide any additional information here on the date ranges to be used in searching for your various inclusion criteria.
Please upload a file (.txt or Excel only, please) with the list of MRNs for which you are requesting data.
Please provide image order codes for the orders you're interested in.
in Epic these codes are named img#
Copy from i2b2 and paste here the full name of your query.
If there is a document you would like to upload that will clarify your requirement, please upload here.
Exclusion Criteria: Please use the check boxes to indicate the criteria you would like to use to exclude data from the results. You will be asked for details in subsequent questions.
Exclude diagnosis codes (ICD9):
A few notes on ICD9 codes:
*
You can look up codes here.
* If you are seeking a range of codes, make sure to indicate that. A wild card can be indicated with "*" (e.g. 300.* will give you all the codes that start with 300.)
* In ICD9 codes xxx.00 is not the same as xxx (zeros to the right of the decimal point make a difference!). Please be careful with these.
* Don't forget to include any leading letters that may be part of the code.
Exclude procedure codes:
Please indicate whether your codes are CPT or ICD9.
A good way to find the CPT codes you want it to exclude is the UMN i2b2! For more information on i2b2 visit
this web page .
Describe criteria by which to exclude patients:
Anything else you'd like to add regarding the inclusion or exclusion criteria for your cohort?
Which of these data elements regarding the patients identified through your search criteria would you like in your report?
patient name
medical record number
date of birth
sex
race
ethnicity (i.e. Hispanic or Latino, Non-Hispanic, Unknown Ethnicity)
primary care provider
diagnoses that were part of inclusion criteria (for other dx info on patient, check options in encounter section below)
procedures that were part of inclusion criteria (for other proc info on patient, check options in encounter section below)
lab test/values that were part of inclusion criteria (for other lab info on patient, check options in encounter section below)
medications that were part of inclusion criteria (for other meds info on patient, check options in encounter section below)
vital status and death data (if applicable)
other
patient name
medical record number
date of birth
sex
race
ethnicity (i.e. Hispanic or Latino, Non-Hispanic, Unknown Ethnicity)
primary care provider
diagnoses that were part of inclusion criteria (for other dx info on patient, check options in encounter section below)
procedures that were part of inclusion criteria (for other proc info on patient, check options in encounter section below)
lab test/values that were part of inclusion criteria (for other lab info on patient, check options in encounter section below)
medications that were part of inclusion criteria (for other meds info on patient, check options in encounter section below)
vital status and death data (if applicable)
other
What other information would you like regarding the patients in the cohort?
We've filtered for your patient cohort. What data elements regarding the encounters of those patients would you like?
I don't need any encounter-level data. The data you will provide me regarding the patients matching my criteria will be sufficient.
date(s) of encounter/visit
admission and discharge dates (for hospitalizations)
location (i.e. name of center, hospital, or clinic)
name of department
department specialty
encounter category (i.e. inpatient, outpatient, or emergency)
encounter type (e.g.,hospital, office visit, telephone)
associated provider
diagnoses
procedures
lab tests and results
medications
clinical notes
flowsheet measures
surgery / operating room data
other
I don't need any encounter-level data. The data you will provide me regarding the patients matching my criteria will be sufficient.
date(s) of encounter/visit
admission and discharge dates (for hospitalizations)
location (i.e. name of center, hospital, or clinic)
name of department
department specialty
encounter category (i.e. inpatient, outpatient, or emergency)
encounter type (e.g.,hospital, office visit, telephone)
associated provider
diagnoses
procedures
lab tests and results
medications
clinical notes
flowsheet measures
surgery / operating room data
other
Do you have a list of particular procedure codes, orders, labs, medications or flowsheet measures that you're interested in having in your report?
Option: upload a document specifying what you're interested in.
What other information would you like regarding the selected encounters?
Image order codes were part of your inclusion criteria. If you would like output associated with those orders, please specify here the information you are seeking.
Given that there are often many encounters for a given patient, even within a short time period, please tell us which encounters you are interested in.
As specified above, I do not need any encounter-level data.
Only the encounters that were responsible for the inclusion of the patient in the cohort (for example, encounters with one of the diagnoses I specified).
Provide me with all encounters in the dates covered by the start and end dates I specified above. (Make sure you've specified a date range!)
As specified above, I do not need any encounter-level data.
Only the encounters that were responsible for the inclusion of the patient in the cohort (for example, encounters with one of the diagnoses I specified).
Provide me with all encounters in the dates covered by the start and end dates I specified above. (Make sure you've specified a date range!)
Other filters for encounters:
Please use this space to specify additional information on the type of encounters in which you are interested.
Would you like your data as a de-identified dataset with all 18 HIPAA identifiers removed (dates will be obfuscated)?
Yes No
Today's date
* must provide value
Today M-D-Y Please click the "Today" button
Submit
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