Women in Healthcare IT Leadership Awards 2017

Email your entry to HDM Editor in Chief Fred Bazzoli [email protected] The deadline for submissions is February 3, 2017.

Name of Person Filling Out the Nomination: Title: Organization: Address: E-mail address: Phone:

NOMINATION FORM

PART 1 Please select the segment of industry being nominated: o HIT Leader (CIO, CMIO, CSO, VP of IT or other IT title) o Technology Vendor Executive o Industry Thought Leader/Influencer (regulators, provider CEOs, vendors, consultants, academics, researchers, foundations, elected officials)

PART 2 Name of Person Being Nominated: Title: Organization: Address: E-mail address: Phone: Fax: PART 3 (PLEASE ONLY FILL OUT THE SECTION THAT APPLIES TO THE NOMINEE)

If you are nominating an HIT Leader, please answer the following questions (1-8):

1. Number of Hospitals/Physician Practices in the HIT Leader’s Organization: Number of Other Care Delivery Locations: Number of IT Staff (in FTEs): Annual IT Budget (approx.): Years in Current Position/Years in the HIT Industry:

2. Describe the HIT Leader’s job responsibilities/complexity (be as thorough as possible; attach more detail if desired).

3. How has the candidate affected the implementation of healthcare IT in her capacity?

4. Describe how the leader has effected change, and provide details. Describe a project, describe the investment, and provide details on the ROI of the project.

5. Describe the impact the candidate has had on her organization, or within her scope of influence, and why it matters. Please give at least one specific example, detailing the impact and the return to the organization.

6. How has the candidate advanced her institution’s competitive position or stature through its technology environment?

7. Describe a situation in which the candidate was successful in driving positive change. 8. Describe how the HIT Leader has mentored other women in her organization (optional entry).

If you are nominating a Technology Vendor Executive, please answer the following questions (9-14):

9. Name of company/organization: Approximate number of customers in healthcare: Description of products/services: Annual Revenue (optional): Years in Current Position/Years in the Healthcare Industry:

10. Describe how the candidate has encouraged the research and development of IT products/services in her organization.

11. What specific IT initiatives has the candidate been involved in, demonstrating industry involvement and participation for the betterment of HIT and/or care delivery? Please describe at least one such project/initiative in which the candidate had an active role.

12. Describe how the candidate has worked with provider IT executives. Highlight a specific example of a project/initiative on which the candidate worked jointly with an IT executive and results of the collaboration.

13. How has the candidate advanced her company’s or organization’s competitive position or stature through its technology environment?

14. Describe how the Executive has mentored other women in her organization (optional entry). If you are nominating an Industry Thought Leader/Influencer, please answer the following questions (15-20):

15. Organization Information Type of Organization: Role Related to Healthcare IT: Number of Years Working in Health IT or on Health IT-related Issues:

16. Job responsibilities and complexity (be as thorough as possible; attach more detail if desired).

17. Describe how the leader has effected change. Please provide details.

18. Describe the impact the candidate has had on healthcare I.T. and why it matters. Please give at least one specific example.

19. Describe a situation in which the candidate was successful in driving positive change. 20. Describe how the Thought Leader has mentored other women (optional entry).