ExportID Request

Please complete the following form to request a report from the UH EMR through the UH CRC ExportID Process.

A query of the electronic medical record (EMR) will be conducted through TriNetX Software based on the information provided in this survey.

The query conducted in TriNetX to define the patient population of interest can include the following: diagnoses, procedure codes, medications, demographics, labs, and visit types. After the population is resulted and best defined, the information pertaining to those matching patients that is approved in the studies IRB Approved HIPAA Waiver (MRN, DOB, Name, Address, Phone, Email, Race, Ethnicity, PCP) will be sent in an Excel file via email directly to the Principal Investigaor of the study.

Date of Submission

M-D-Y

Requestor First Name

* must provide value

Requestor Last Name

* must provide value

Requestor Email

* must provide value

PI First Name

* must provide value

PI Last Name

* must provide value

PI Email Address

* must provide value

Study Department

* must provide value

Other Department

Study/Protocol Title

* must provide value

Expand

Short Study Title

* must provide value

IRB Number

* must provide value

Study Type

* must provide value

Anticipated Enrollment at local site:

* must provide value

ExportID Request:

Please complete the following fields based on the query you would like extracted from the EMR.

For best results, please:

1) Complete Primary Diagnosis and Age fields, as these are MANDATORY for entry into the program.

2.) ICD-10 and CPT codes are preferred if available. They will help provide the most accurate list of patients.

3) Copy and paste inclusion and exclusion criteria directly from the most recent protocol based on what data you would like queried from the EMR. Please be sure characters or symbols are entered correctly.

Start Date for Query

M-D-Y

Stop Date for Query

M-D-Y

Age Minimum

* must provide value

Age Minimum Units

Age Maximum (if none, leave blank)

Age Maximum Unit

Primary Diagnosis (ICD10)

* must provide value

Type to begin searching Loading...

Secondary Diagnosis (ICD10)

Type to begin searching Loading...

Additional Diagnosis (ICD9- Clinical Modification)

Type to begin searching Loading...

Additional Diagnosis (ICD10- Clinical Modification)

Type to begin searching Loading...

Optional: Procedure (ICD10 Procedure Coding System)

Type to begin searching Loading...

Optional: Procedure (ICD10 Procedure Coding System)

Type to begin searching Loading...

List out other ICDs and CPTs to be included here (specific as possible)
Inclusion Criteria #1

* must provide value

Expand

Inclusion Criteria #2

* must provide value

Expand

Inclusion Criteria #3

* must provide value

Expand

Would you like to include more inclusion criteria?

Yes No

reset

Please list additional inclusion criteria as a numbered list:

Expand

ICD-10 Code to Exclude:

Type to begin searching Loading...

2nd ICD-10 Code to Exclude:

Type to begin searching Loading...

Exclude CPT:

Type to begin searching Loading...

List out other ICDs and CPTs to be excluded here (specific as possible)
Exclusion Criteria #1

* must provide value

Expand

Exclusion Criteria #2

* must provide value

Expand

Exclusion Criteria #3

* must provide value

Expand

Would you like to include more exclusion criteria?

Yes No

reset

Please list additional exclusion criteria as a numbered list:

Expand

Email Notification

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

ExportID Request

Study Team Information

Study Information

Enrollment Information

You have selected an option that triggers this survey to end right now.