Hartford HealthCare Epic On-Site Assessment Form

Please fill out the following Hartford HealthCare Epic On-Site Assessment Form:

 

Company Demographics

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Legal Practice Name:

Specialty:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Number of Midlevels or Other Providers:

Number of Physicians:

First Name

Last Name

Practice Contact Role:

Contact Phone Number:

Contact Email Address:

General Inventory

Number of Desktops:

If any of these are "backup desktops," how many?

Number of Laptops:

If any of these are "backup laptops" how many?

Number of PCs:

Number of Macs:

Number of Tablets (iPads, Chromebooks, Microsoft Surfaces, etc.)::

Number of Printers:

Number of Scanners:

Number of Multifunction Printers (MFPs):

Does the office fax/scan from the MFPs?Fax OnlyFax and ScanScan Only

Does the practice fax via telephone lines?YesNo

How many fax numbers does the practice employ?

IT Environment

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Does the practice have their own IT staff?

YesNo

If Yes, Number of IT staff:

IT Manager Name:

If No, Name of IT firm:

Firm Contact Name:

IT Phone Number:

IT Email:

Name of Current Practice Management/Billing System:

Name of Current EMR:

Name of Other System in Use:

Will Stay After Epic?

YesNo

Name of Other System in Use:

Will Stay After Epic?

YesNo

Name of Other System in Use:

Will Stay After Epic?

YesNo

Name of Other System in Use:

Will Stay After Epic?

YesNo

Is there broadband internet access at each site?

YesNo

Network Type:

WiredWirelessBoth

Are all locations networked?

YesNo

Are there any networked medical devices?

YesNo

If Yes, what are the devices?

Are there any mobile devices used in the practice (i.e. smartphone, tablet):

YesNo

If Yes, what are the devices?

Do you plan on using this application on a laptop?

YesNo

Do you plan on using the laptops on your wireless network?

YesNo

Do you have adequate chargers and spare batteries for laptops and portable devices?

YesNo

Internal Infrastructure

Are all rooms hard-wired for network access?YesNoPartial

If partial, please explain:

Are there any workgroup switches in use in the office?YesNo

If yes, please describe location and indicate make(s), model(s), and speed here:

Verify Network Infrastructure

External IP Address:

Primary ISP download/upload speed (e.g., 100 Mbps down/35 up, etc.):

Connection type?CableDSLFiberSatellite4G/5G

Secondary/Backup ISP:

Connection type?CableDSLFiberSatellite4G/5G

Internal (LAN) subnet used (CIDR):

Location of network equipment:

Router make and model:

Firewall(s) make and model:

Switch(es) make and model:

Does the office have an Uninterruptable Power Supply (UPS) attached to the network infrastructure?YesNo

Make and model of UPS:

Additional Information:

Wireless Information

Total Number of Wireless Access Points (WAPs):

Make, model, and location(s) WAP(s):

Office/Private WiFi:YesNoN/A

SSID(s):

Encryption type:RadiusWPA2 PersonalWPA2 EnterpriseWPAWEPOpen

Guest/Patient WiFi:YesNoN/A

Guest SSID(s):

Encryption type:RadiusWPA2 PersonalWPA2 EnterpriseWPAWEPOpen

Number of visible SSIDs:

Demarcation Area

Location of demarcation point:

Is this a secure area?YesNo

Do you see any potential environmental hazards?YesNo

Details:

Phone System

System Type:VOIPAnalogDigital

Are computers connected to the network via the phones?YesNo

Malware Protection

Antivirus software:

Is A/V software managed?YesNo

Workstation Summary

Do any computers NOT have at least 4 GB RAM?YesNo

Indicate machine name(s) here of any that do not:

Do any desktop computers NOT have a 24” monitor?YesNo

Indicate machine name(s) here of any that do not:

Do any computers NOT have at least a 7th generation Intel i5 processor?YesNo

Indicate machine name(s) here of any that do not:

Do any computers NOT have GPU with resolution of 1920x1080?YesNo

Indicate machine name(s) here of any that do not:

Are there any all-in-one desktops?YesNo

How many?

What version of Citrix Workspace is installed?

Printer/MFP List

Printer Information Needed for Each Device

Scanner List

Scanner Information Needed for Each Device

Miscellaneous

How does the group take pictures of the patients?

Device Count:

Make:

Model:

Does the practice schedule telemed sessions?YesNo

Telemed Application:

Are there historically any issues with power or Internet connectivity in the building?YesNo

Additional details:

Any concerns/sensitivities the office has that should be noted?

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