ICN Data Request Form

ImproveCareNow Registry Request Form
Thank you for your interest in improving the ImproveCareNow Outcomes Registry! Please fill out the form below and submit it to info@improvecarenow.org. Our staff will review the form, share with the ICN Data Operations Committee, and follow up with you within two weeks regarding next steps and any relevant status updates.
Name:*
Role:*
Care Center/Organization:*
Email:*
example@example.com
Sponsor (if applicable):
Strategic Domain Impacted:*

Diversity, Equity, and InclusionOutcomesPatient and Family EngagementInnovation and TechnologyCost of CareSustainabilityOther

If this is a request for a new measure or data element(s), please use this section
Data element(s) being requested:
Is this needed to support a new measure?

YesNo
If yes, please provide additional details:
Is This needed to support... ?

Automated PVP functionAutomated PM functionNew funded researchLearning Lab ActivitiesOther
Please provide additional details:
Additional benefit to the network?
What potential burden will this measure become in order to collect and report the data?
How will this measure impact centers' QI initiatives?
How will this measure impact centers' outcomes?
Please attach any relevant materials for reference, if applicable:

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If this is a request for a registry enhancement, please use this section
Registry enhancement(s) being requested:
Benefit to network:
Would this enhancement help you provide better care to patients?

YesNo
If yes, please provide additional details:
Would this enhancement improve data accuracy?

YesNo
If yes, please provide additional details:
Would this enhancement save youtime?

YesNo
If yes, please provide an estimate
What potential burden will this enhancement become in order to collect and report the data?
How will this enhancement impact centers’ QI initiatives?
How will this enhancement impact centers’ outcomes?
Please attach any relevant materials for reference, if applicable:

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ImproveCareNow Registry Request Form