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63duDuPt2z7m4LAaZUL538NXvkgTz2g9h2iKmdYbvGcqxzjqJtGp9mAPp6BFS7bwBTLgbdxbrQhti

Pediatric Analytics Support Request

Returning?

A A A

Thank you for your interest in obtaining analytic support from the Pediatric Enterprise Analytics Team.

Our goal is to assist investigators and employees across both Intermountain and the U of U in developing tools and reports for research and quality improvement.

If you are in need of our assistance please complete the request form below.

INTERNAL - Notes for Division or Department (optional)

INTERNAL- Does this project have Intermountain Privacy approval?

Yes

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INTERNAL Who is the primary analyst assigned to this project?

Kelly Huynh

Freddy Novoa

Tanya Stout

Allison Neeley

Not Research

Ed Wicker

Jeff Povilus

Jeff Lutz

Jennifer Sweatman

Jeremy Nielsen

Mariah Daniels

Rich Juluson

Sarah Abdelaziz

Sean Soisson

Tina Wadhwa

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INTERNAL - Assigned Analyst Email

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INTERNAL- OTHER Analyst, If another member of Peds Analytics Team will be assigned a significant portion of the request, who will it be?

INTERNAL- Billing Analyst,

If another member of Peds Analytics Team is primarily assigned, who will be reviewing IRB and billing notifications from the Research Team?

INTERNAL - What types of PHI are approved by the Intermountain Privacy Board in this request?

Medical Record Numbers (e.g. MRN/EMPI)

Account Numbers (e.g. FIN)

Dates (e.g. Dates of Service)

Birth Dates

Patient Names

Address,

Zip code

Phone number

Other

INTERNAL - Estimated Time to Completion

INTERNAL - Anticipated Start Date

M-D-Y

INTERNAL Estimated cost

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INTERNAL - Should we skip the notification to Michelle?

Yes

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INTERNAL- Placeholder for requests that get put on hold. Is this project being moved to on hold?

What type of request are you submitting?

* must provide value

Research Requests (IRB Approved/pending IRB approval/pre-study numbers etc)

All other Pediatric Requests (QI, operational, volumes, etc.)

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Prior to submitting this request,

Make sure your division chief, mentor, and division manager are aware you are submitting this request.
- After an initial meeting with a member(s) of our team, a copy of the intake form will be sent to you and your division leadership. At this time a payment chartfield or project number will be requested.
Research Enterprise is willing to cover up to three hours of intake and scoping of the project when funding is not available.
Project funding should not be a barrier to using the analyst's service, rather it's a way to capture costs where they are occuring.
The rate is $60/ hour*.
A typical project can range between 40 and 80 hours (i.e. $2,400 to $4,800)

* Can be subject to change.

Date Request Submitted

M-D-Y

Project Title

* must provide value

Investigator

* must provide value

Investigator Email Address:

* must provide value

Preferred Contact Email Address:

* must provide value

Are you (or the PI) affiliated with Primary Children's Hospital?

* must provide value

Yes

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Office Phone:

What division is this project under?

* must provide value

Division Chief:

* must provide value

What is your Division Chief's Email?

* must provide value

Division Manager:

* must provide value

What is you Division Manager's Email?

* must provide value

Mentor/Advisor:

What is your mentor's or advisor's email?

Co Investigator(s):

Statistician:

Request Purpose:

Grant Application

Publication

Abstract

Prestudy (Patient population estimate)

Other

Purpose: Other

Is this a Heart Center related request?

* must provide value

Yes

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How will this project be funded?

Grant

Division Financial Support

Fellow Request- Division Sponsorship

Other:

Funding Source: Other

U of U Project Number or Division Chartfield

* must provide value

Project Information and Background

Next we will collect more information about the project.

Does this project have IRB Approval?

* must provide value

Yes

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Please provide your IRB Number

In this next section, please summarize your project.

This can be a short summary of your project objectives, you can include things like:

inclusion and exclusion criteria
patient/participant ages
Primary research question

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What types of PHI do you expect to receive in this request?

Medical Record Numbers (e.g. MRN/EMPI)

Account Numbers (e.g. FIN)

Dates (e.g. Dates of Service)

Birth Dates (Age)

Patient Names

Geographic data (e.g. Address, zip code)

Other PHI (email, phone number, etc.)

By what date is your data needed?

M-D-Y

Have you previously spoken to, or worked with any other member of the larger Pediatric Analytics Team who may have some additional background about this request?

Kelly Huynh

Freddy Novoa

Jacob Wilkes

Tanya Stout

Allison Neeley

Ed Wicker

Jeff Povilus

Jeff Lutz

Jennifer Sweatman

Jeremy Nielsen

Mariah Daniels

Rich Juluson

Sarah Abdelaziz

Sean Soisson

Tina Wadwha

Primary Contact Name for this request:

* must provide value

Primary Contact Email for this request:

* must provide value

What team or group is this request for?

Is this a new request, an enhancement to an existing report or does an existing report need to be fixed?

* must provide value

New Request

Enhancement of existing request

Fix for an existing report

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Are there analysts you usually work with or who may have background on this request? If so, please select their name(s) below?

Tanya Stout

Allison Neeley

Mariah Daniels

Ed Wicker

Freddy Novoa

Jacob Wilkes

Jeff Povilus

Jeff Lutz

Jennifer Sweatman

Jeremy Nielsen

Kelly Huynh

Rich Juluson

Sarah Abdelaziz

Sean Soisson

Tina Wadwha

Not Applicable (new request or other analyst)

What is the report name that needs fixing or an enhancement?

If the report was not created by an analyst listed above, please include the author's name as well.

* must provide value

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Brief Request Description

For example:

How is the patient cohort identified?
What data values are we needing to see in the report?
Will any of this data be needing to be exported? If Yes, what form? (Excel, PDF, HTML, etc.)
Will visuals be needed to display on the report? (Charts, Tables, Bars graph, etc.)
Has someone outside of the Pediatric Analysts team worked on a similar project you would like us to connect with?

* must provide value

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What is the primary problem/concern we are trying to solve/resolve?

How will you use the end product in relation to the probem/concern?
Who is the intended audience?

* must provide value

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Is this related to a KPI or Strategic Initiative? If yes, which one(s)?

* must provide value

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Is this request related to a patient safety issue?

Yes

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Please explain or provide more information regarding the patient safety issue

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What impact will this report have?

For example:

How many patients will be affected by it?
Are there potential cost savings?

* must provide value

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Time frame of completion?

For example:

What date are you aiming for this request/report to be completed? MM/DD/YYYY
What is the urgency for this report?
- Is there a meeting where it needs to be shared?

*Note: Please understand this does not guarantee the request will be completed by this date but it will inform our prioritization process.

* must provide value

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If you have any supplemental files or work examples of what you are looking for, please attach them here.

Upload file

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