Epic Connect Participation Interest

Trinity Health’s TogetherCare Connect is a program by which Trinity Health extends their instance of Epic to affiliated organizations in the community. This integration improves communication amongst providers in the Clinically Integrated Network and strengthens our ability to deliver coordinated care to patients. Please use this inquiry form if your practice, as a whole, is interested in using Epic Connect through Trinity Health.

Practices interested in becoming Trinity Connect clients should return this completed questionnaire and any additional documents within 14 days of receipt.

Name(Required)

First Last

Email(Required)

Company Name

Practice Demographics

List the number of providers in the practice.

Number of Physicians

Number of APPs

Other

Please list any additional types of providers in your practice or any specialty visits that may occur. Such as: Care Managers, Social Workers, PT/OT/SLP, Pharmacists, Residents, etc.

Is this a Primary Care practice? (Y/N)

Is this a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC)?

Please Specify

Existing Alignment

Active or Associate Privileges

Do practice providers have Active or Associate privileges at a Trinity Michigan hospital (or equivalent status that allows them to admit and/or treat) or if a PCP practice, are practice patients admitted to a Trinity Michigan hospitalist service? (Y/N)

Yes

Which Trinity Health Hospital?

Is it a PCP practice?

Are practice patients admitted to a Trinity Michigan hospitalist service?

Yes

Please Specify

Diagnostic Testing

Has your practice utilized diagnostic testing or other services at a Trinity Michigan hospital in the past 12 months such that patient care would benefit from this connectivity? (Y/N)

Yes

CIN Parntership

Clinically Integrated Network

Does your practice participate in a Clinically Integrated Network (CIN) with the local Trinity Health Ministry? (Y/N)

Yes

EMR Landscape

Reference Lab

Does the practice own or operate as a reference lab for any other practices? (Y/N)

Please Specify

Draw Stations

Do you have a Quest or LabCorp Draw station within the practice? (Y/N)

Please Specify

External LIS or RIS

Does the practice own or subscribe to an external LIS or RIS? (Y/N)

Please Specify

Radiology or Imaging

Does your practice perform any radiology or imaging studies on-site? (Y/N)

Please Specify

Image Storage Solutions

Do you have a PACS environment or other image storage solution? (Y/N)

Please Specify

Device Integrations

Does your practice have any device integration with your EMR currently? (Y/N)

Please Specify

Radiology Information System

Does the practice own or subscribe to an external Radiology Information System (RIS)? (Y/N)

Please Specify

Materials

Does your practice currently rely on paper for ANY of the following: problems list, meds, allergies, or progress notes? (Y/N)

Please Specify

Electronic Medical Record

Is an Electronic Medical Record (EMR) application is currently being used? If yes, what one? How long has the practice utilized this EMR? (Y/N)

Please Specify

Scheduling Applications

Does your practice currently rely on spreadsheets or an email scheduling application for scheduling visits or managing providers schedules? If no, what system do you currently use for scheduling? (Y/N)

Please Specify

Reminder Calls

Do you have an automated system for patient reminder calls/text reminders? (Y/N)

Please Specify

Trinity Epic Care

Does anyone in your practice have Trinity EPIC Care Link access? (Y/N)

Please Specify

Faxing

Does the practice have an electronic faxing solution? (Y/N)

Please Specify

Practice Operations

Business Entity or Affiliation

Is your practice part of a larger business entity or affiliation of practices that has shared operations (accounting, registration, scheduling, HIM, revenue cycle, finance)? (Y/N)

Please Specify

Do you Outsource The Revenue Cycle

a) Does your practice currently outsource any part of it's revenue cycle (aside from bad debt), such as: coding/charge review, claims, insurance follow-up, cash posting/ reconciliation, denials management and patient statements? (Y/N)

Internal Hiring

b) If you currently outsource, do you plan to hire staff to bring that work internally? (Y/N)

Yes

Please Specify Outsource Vendor

Medical Records

Does your practice outsource the processing of Medical Record Release of Information (ROI)? (Y/N)

Please Specify

Major Changes

Has your practice experienced any major changes in the past 12 months (e.g., sale, merged with another practice, etc)? (Y/N)

Please Specify

Clinical Workflow Challenges

Does your practice have clinical workflow challenges (work arounds for charting, lab send outs, recording Point Of Care results, etc.) (Y/N)

Please Specify

Information Technology Partner

Does your practice have an Information Technology partner? (Y/N)

Contact Name

First Last

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Practice Finances

Balance Sheet Ratio

Does your most recent balance sheet show a Current Ratio of 1.5 or higher? (Y/N) (current assets / current liabilities)

Current Balance Sheet

Accepted file types: pdf, docx, csv, Max. file size: 20 MB.

Revenue Flow

Does your practice have at least 30 days worth of revenue available through cash and/or rolling line of credit? (Y/N)

Bank or Credit Line Statements

Accepted file types: pdf, jpg, png, Max. file size: 20 MB.

Accounts Receivable

Does your practice have Accounts Receivable (A/R) days of 40 or fewer? (Y/N) Calculated as Total Outstanding AR (posted charges) / Average Daily Revenue.

Please Provide Documentation

Accepted file types: pdf, jpg, png, Max. file size: 20 MB.

Revenue Cycle Operations

Claims Submissions

Does the practice currently use a Clearinghouse for claims submission? (Y/N)

Please Specify

Large Volume Payers

Is the practice enrolled for 80% of large volume payers for ERA and EFT? (Y/N)

Please Specify

Guarantor Billing

Is the practice accepting of the use of a single patient statement (Guarantor Billing)? (Y/N)

Yes

Claims Attachment

Does the practice acknowledge that Claims Attachment functionality is not offered? (Y/N)

Yes

Sliding Fee Scale

Does the practice offer a sliding fee scale or discount program? (Y/N)

Yes

Practice Demographics

Existing Alignment

CIN Parntership

EMR Landscape

Practice Operations

Practice Finances

Revenue Cycle Operations

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