Comprehensive Project Profile The information you provide in this form will allow us to prepare a cost analysis for your project. Please be as accurate as possible so we may provide you with the best possible scenario. The prices you receive in your investment analysis are valid for 30 days from the date of preparation. All information provided is kept confidential and is not shared with any outside source besides agreed IT partners.
Completed by: Date: Please return by fax, mail or email to: ifa systems AG Fax: +49-2234-9336730 Email: info@ifasystems.de Practice/hospital name Telephone Address
Fax
City
State/ZIP
Doctor
Admin.
Contact
_____________________________________________________________________________________
Single location
Single hospital
Group hospital
Single location
Multiple locations
# of locations
# of doctors
If multiple locations, are the sites connected via telephone data lines? Yes No DSL ISDN T1 Other Does the practice/hospital currently use a computer system? Network type
Novell
The workstations are:
Unix PCs
or
NT
Yes
No
Other
Dumb terminals
How many PCs are currently in use? ifa systems AG www.ifasystems.com
Phone: +49-2234-933670 Fax: +49-2234-9336730
How many dumb terminals are currently in use? The computer system is currently used for: Billing/admin Medical records
Outcomes
Other
Name(s)/types of currently used software (HIS etc.) Are there any PCs/terminals in the examination lanes? Yes
No
Total # of patient visits per day (all doctors) Number of active patient files Number of exam lanes (All sites in case of multiple locations) Number of separate screening areas Number of visual field rooms Number of photo rooms (Would you like access to your info in the photo room?)
Y
N
Y
N
Number of laser rooms (Would you like access to your info in the laser room?) Where do you take the medical histories? Front desk Screening room
Exam lane
How is exam data currently recorded? Doctor dictates to scribe Doctor dictates for later transcription Doctor writes in record Other (please specify)
How many letters are dictated/transcribed per week? How many new patient visits do you have per week? Does the HOSPITALC/HOS co-manage? Yes
No
How do you communicate? Send out letters Do you have a website?
# of cases/week Fax letters
Internet & email
Other
If yes, what is the url:
Which ophthalmic specialties are provided in the practice/hospital (e.g. retina, lasik etc.)
ifa systems AG www.ifasystems.com
Phone: +49-2234-933670 Fax: +49-2234-9336730
Please list the quantity, manufacturer and model # of all diagnostic instrumentation utilized by the practice/hospital. Instrument
Qty.
Manufacturer
Model #
Location
Lensmeter Autorefractor Autokeratometer NCT Computer phoropter Perimeter Photo slit lamp Fundus camera HRT/LDT/OIS/ImageNet Endo camera A-Scan B-Scan Corneal topog. Use a separate sheet of paper if you have more instruments than the sheet can accommodate.
Please number the functions/areas/methods desired by priority (1-12) Basic medical records
Video/diagnostic instrument interfaces
Coding assistance
ICD assistance
Digitized photos
Dictation/transcription
Statistical analysis (outcomes)
Quality management
Resource planning/task management
Co-management (web)
Telemedicine
Internet connectivity
ifa systems AG www.ifasystems.com
Phone: +49-2234-933670 Fax: +49-2234-9336730