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Electronic Data Exchange Registration Form

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Welcome to the Missouri Department of Health & Senior Services' (DHSS) Electronic Data Exchange Registration Form!

To begin, please answer the following questions about which public health data systems you want to exchange data with. You may have to work with your EHR vendor to answer questions related to your HL7 capabilities.

If you have any questions about the registration form, please email edx@health.mo.gov.

Once you are finished, click "Submit" at the bottom of the survey.

Today's Date

* must provide value

M-D-Y

Entered By DHSS

* must provide value

Yes

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For which public health data systems are you registering?

* must provide value

Immunizations (ShowMeVax)

Electronic Case Reporting (ECR)

Electronic Laboratory Reporting (ELR)

Syndromic Surveillance (SYS)

Does your organization currently administer immunizations?

* must provide value

Yes

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If your organization does not administer vaccinations, you do not need to register for Electronic Data Exchange with ShowMeVax. If you are wanting to request QBP (Query) only interface, please contact us at edx@health.mo.gov.

If you are attempting to sign up for a ShowMeVax account to view or enter vaccinations, please click the this link for the ShowMeVax account registration page.

Is your organization enrolled in Missouri's immunization information system, ShowMeVax?

* must provide value

Yes

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If your organization is not enrolled in ShowMeVax, it will need to be set up in the system before we can implement your HL7 connection. A notification will be sent to the ShowMeVax help desk upon completing of this survey.

Do you wish to register your intent for "Promoting Interoperability" (formerly known as "Meaningful Use")?

If you are using this form to obtain your yearly attestation letters, please click here to email the MOPHIE team.

* must provide value

Yes

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Registration Point of Contact	First Name:
	Last Name:
	Title:
	Phone:
	Ext:
	Email:

Will you be the main point of contact for Electronic Data Exchange (EDX) for your organization?

EDX Point of Contact: Provides project management and coordination on behalf of the organization. Should be high enough in the organizational structure to make decisions independently and enforce changes to workflows or policies. A physician or nurse manager is preferred.

* must provide value

Yes

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Electronic Data Exchange Point of Contact	First Name:
	Last Name:
	Title:
	Phone:
	Ext:
	Email:

Organization Name

For entities with more than one physical location, please provide the name of the overarching organization. For entities with only one physical location, please provide the name of the single location.

* must provide value

Organization Type

* must provide value

Other Organization Type

* must provide value

National Provider Identifier (NPI)

Not sure what your 10-digit NPI number is? Click here to find out.

* must provide value

Clinical Laboratory Improvement Amendments (CLIA) Number

Not sure what your 10-digit CLIA number is? Click here to find out.

* must provide value

Pharmacy License Number

Not sure what your pharmacy's license number is? Click here to find out. When searching, make sure you select "Pharmacy" as the Profession Name. Number will either be 6 or 10 digits long.

* must provide value

Organization Address

* must provide value

Organization City

* must provide value

Organization State

* must provide value

Organization Zip Code

* must provide value

Organization Phone Number

* must provide value

Missouri DHSS requires providers to complete an MOA in order to submit Immunization data to ShowMeVax via Electronic Data Exchange.

Click here to download and fill out the MOA if you have not already done so. Please use the link to the right to upload your completed MOA. Please include your facility name when saving the document.

* must provide value

Upload file

Please download the Electronic Data Exchange Facility Listing template. Once you have completed the template, please return here to upload. Please include your facility name when saving the document.

* must provide value

Upload file

Electronic Health Record (EHR) Vendor, HL7, and Software Information

Please work with your EHR vendor to complete this section.

EHR Vendor Data Exchange Technical Lead*	Responsible for architecting and configuring the interface solution. Also responsible for helping the provider to understand the EHR interface and troubleshoot submissions during testing.
EHR Vendor Primary Point of Contact*	Primary vendor-side contact for the onboarding project. Provides project management and coordination on behalf of the EHR vendor.

*One individual may perform both roles. If this is the case, please enter the information in both roles or the form will not submit.

EHR Vendor Name

* must provide value

EHR Software Name

* must provide value

Version of the Software

* must provide value

EHR Contact List
EHR Vendor Data Exchange Technical Lead	First Name:
	Last Name:
	Title:
	Phone:
	Email:
EHR Vendor Primary Point of Contact	First Name:
	Last Name:
	Title:
	Phone:
	Email:

Does this software meet the requirements for HL7 v2.5.1 messaging?

Note: Missouri DHSS requires providers to submit data for immunizations using HL7 v2.5.1 if they are interested in electronic data exchange.

* must provide value

Yes

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If your organization's EHR is not capable to sending messages in HL7 2.5.1, we are unable to onboard you to submit immunizations to ShowMeVax at this time.

Please reach out to us when your EHR is capable of sending messages in HL7 2.5.1

Does this software utilize SOAP Web Services to transmit data?

Note: Missouri DHSS requires providers to submit data for immunizations via SOAP Web Services using the CDC WSDL.

* must provide value

Yes

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If your organization's EHR cannot utilize SOAP Web Services to transmit date, we are unable to onboard you to submit immunizations to SHowMeVax at this time.

Please reach out to us when your EHR is capable of using SOAP Webservices to transmit data.

Which HL7 interface are you wanting to set up?

* must provide value

Bidirectional Exchange (Vaccine submission and query - VXU/QBP)

Unidirectional Exchange (Vaccine submission only - VXU)

Unidirectional Exchange (Query only - QBP) (approved on a case by case basis)

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Will the interface report directly to ShowMeVax or will it use a centralized reporting hub?

* must provide value

Direct Report (Point-to-Point)

Provider Organization Hub

EHR Vendor Hub

Health Information Exchange (HIE)

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What is your Hub/HIE name?

* must provide value

Certified HealthIT Product List (CHPL) ID

Not sure what your CHPL ID is? Click here to find out.

Note: Be sure to enter the CHPL ID for your EHR vendor's "Electronic Case Reporting" Product.

* must provide value

Health Care Organization Identifier (HCO ID)

If your organization is accredited by The Joint Commission, please enter your HCO ID. Not sure what your HCO ID is? Click here to find out. You can also find your HCO ID in the OID.

Note: Your HCO ID is a max of 6 numerical characters and can be any number between 1 and 999,999

If your organization is not accredited by The Joint Commission, please leave blank.

Does this software meet the requirements for HL7 v2.5.1 messaging?

Note: Missouri DHSS requires providers to submit data for ELR using HL7 v2.5.1 if they are interested in electronic data exchange.

* must provide value

Yes

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What method does your software plan to use to send ELR data?

Note: Missouri DHSS allows providers to send ELR data in HL7 v2.5.1 format through its SFTP or by using SimpleReport.

Missouri DHSS also allows providers to send ELR data in a CSV format through its SFTP, but it is not preferred. Selecting this option indicates that you are able to send ELR data, but not through electronic data exchange.

* must provide value

HL7 v2.5.1 using Secure File Transfer Protocol (SFTP)

HL7 v2.5.1 using SimpleReport

CSV using Secure File Transfer Protocol (SFTP)

MODROP (Online Portal)

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Syndromic Surveillance reporting is defined as, "the reporting of Emergency Department/Emergency Room data."

Do you still wish to proceed with onboarding for Syndromic Surveillance?

Yes

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Can your EHR software transmit data via Secure File Transfer Protocol (SFTP)?

Note: Missouri DHSS prefers providers to use Secure File Transfer Protocol (SFTP) transmit syndromic surveillance data.

Yes

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If your EHR cannot transmit data via SFTP, can your EHR software utilize a VPN Tunnel (TCP connection) to transmit data formatted in HL7 v2.5.1?

Note: Missouri DHSS allows providers to use a VPN tunnel (TCP Connection) to transmit syndromic surveillance data, but this method is not preferred.

* must provide value

Yes

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If you cannot utilize a VPN tunnel, can your EHR software utilize SOAP Web Services (HTTP) to transmit data?

Note: Missouri DHSS allows providers to use SOAP Web Services to send syndromic surveillance data, but it is not preferred.

* must provide value

Yes

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Missouri Department of Health and Senior Services requires the use of either Secure File Transfer Protocol (SFTP) or a VPN tunnel to transport data formatted in HL7 2.5.1 to onboard with Syndromic Surveillance.

Please contact us when your EHR is capable of one of them.

I acknowledge that all the information entered above is accurate at the time of this submission.

* must provide value

Yes

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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.

Electronic Data Exchange Registration Form

If your organization does not administer vaccinations, you do not need to register for Electronic Data Exchange with ShowMeVax. If you are wanting to request QBP (Query) only interface, please contact us at edx@health.mo.gov.

If your organization is not enrolled in ShowMeVax, it will need to be set up in the system before we can implement your HL7 connection. A notification will be sent to the ShowMeVax help desk upon completing of this survey.

Registration Contact

Provide information of the point of contact (POC) completing this registration.

Provide information on the overarching organization of your location.

Facility Information

Because you selected Immunizations, Missouri DHSS requires a signed MOA and completed clinic listing sheet found below. Please provide complete these forms and upload them here in the survey.

Electronic Health Record (EHR) Vendor, HL7, and Software Information

Please work with your EHR vendor to complete this section.

If your organization's EHR is not capable to sending messages in HL7 2.5.1, we are unable to onboard you to submit immunizations to ShowMeVax at this time.

Please reach out to us when your EHR is capable of sending messages in HL7 2.5.1

If your organization's EHR cannot utilize SOAP Web Services to transmit date, we are unable to onboard you to submit immunizations to SHowMeVax at this time.

Please reach out to us when your EHR is capable of using SOAP Webservices to transmit data.

Missouri Department of Health and Senior Services requires the use of either Secure File Transfer Protocol (SFTP) or a VPN tunnel to transport data formatted in HL7 2.5.1 to onboard with Syndromic Surveillance.

Please contact us when your EHR is capable of one of them.

Acknowledgement and Submission

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