Patients at Primary Care Practices

OMB Approval No: 0990-NEW

Approval Expires: xx/xx/20xx

P atient Perceptions of

Health Care Survey

Draft Instrument

March 5, 2010

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-NEW. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, 200 Independence Ave. SW, Suite 336-E, Washington, DC 20201

ABOUT THIS SURVEY

• This study is being conducted by Mathematica Policy Research, an independent research company on behalf of the Department of Health and Human Services, the Office of the National Coordinator for Health Information Technology.

• The purpose of the study is to learn about patient satisfaction with the delivery of health care in physician practices that are in varying stages of electronic health records adoption and use.

• Practices were randomly selected from among primary care practices in this state.

• The questions in this survey are about you, your health, and how you use health care services. Your participation in this study is voluntary. It will take 15 minutes to complete the questionnaire. You will receive a $10 gift card for completing the survey.

• Most of the questions can be answered by simply checking a box. A few ask you to write in your answer.

• Follow all “GO TO” instructions after marking a box. If no such instruction is provided, please continue to the next question.

• If you do not know an answer, please write “DK” next to the question.

• All of your answers will be treated confidentially to the extent allowable by law. Your answers will not be shared with your doctor, this medical practice or anyone outside of the research study team. Your responses will not change your medical coverage, other health benefits, or your relationship with your health care provider.

If you have questions about this survey or your participation in it, please call Karen Bogen, the study’s survey director, at 1-617-674-8355.

When you are finished, please return your completed survey to the Mathematica representative in the waiting room who gave it to you.

Thank you very much for your time and help with this important study!

A. HEALTH STATUS

T he first section of questions is about your health.

A1. In general, would you say your health is excellent, very good, good, fair, or poor?

MARK ONE ANSWER ONLY

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

A2. Please mark “Yes” if a health care provider has ever told you that you had any of the conditions listed below.

	MARK ONE ANSWER PER ROW
	Yes	No
a. Heart disease, including congestive heart failure, heart attack, angina, or hypertension	1 □	0 □
b. Diabetes	1 □	0 □
c. A stroke	1 □	0 □
d. A mental or psychiatric disorder	1 □	0 □
e. Any kind of cancer	1 □	0 □
f. Arthritis, including rheumatoid arthritis	1 □	0 □
g. Lung conditions or breathing problems such as emphysema, asthma, or chronic obstructive pulmonary disease (COPD)	1 □	0 □
h. Other (Please list any other conditions that a health care provider has said you have.)	1 □	0 □

A3. How would you rate your knowledge about your health and the factors that may affect your health in the future?

MARK ONE ANSWER ONLY

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

A4. How confident are you about filling out a medical form by yourself?

MARK ONE ANSWER ONLY

1 □ Extremely confident

2 □ Quite confident

3 □ Somewhat confident

4 □ A little confident

5 □ Not at all confident

A5. Including today’s visit, how many times did you visit a physician or clinic in the past 12 months? Please include times when you were seen by any health care professional such as a doctor, a nurse or physician’s assistant but exclude visits to the emergency room.

MARK ONE ANSWER ONLY

1 □ 1 time

2 □ 2 to 3 times

3 □ 4 to 5 times

4 □ 6 to 10 times

5 □ More than 10 times

B. TODAY’S VISIT

The next set of questions is about today’s visit to this medical practice. The questions ask about the MAIN health care provider you saw today, which may be a doctor, a nurse practitioner, or a physician’s assistant.

B1. What was the MAJOR purpose of your medical appointment today?

MARK ONE ANSWER ONLY

1 □ A regular check-up, well-person examination, or physical

2 □ Care of a chronic condition (a condition lasting for 3 months or more with no known cure)

3 □ Get help for a specific acute problem or illness (infection, injury, etc.)

4 □ Other purpose – please describe: _________________________________________

B2. Is the health care provider you saw today the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

1 □ Yes

0 □ No

B3. Please mark “Yes” or “No” to indicate if your health care provider did the following things during today’s visit.

	MARK ONE ANSWER PER ROW
	Yes	No
a. Examine your heart and lungs with a stethoscope	1 □	0 □
b. Work with you to set goals for avoiding illness and staying healthy	1 □	0 □
c. Provide materials such as booklets, pamphlets, articles, videotapes, or website links to help you understand your health or chronic condition or recommended treatments	1 □	0 □
d. Explain what to expect with your health or illness in the future	1 □	0 □
e. Explain what to do if problems or symptoms continue, get worse, or come back	1 □	0 □

B4. How satisfied are you with today’s visit overall?

MARK ONE ANSWER ONLY

1 □ Very satisfied

2 □ Somewhat satisfied

3 □ Somewhat dissatisfied

4 □ Very dissatisfied

B5. How satisfied are you with the amount of time your health care provider spent with you at today’s visit?

MARK ONE ANSWER ONLY

1 □ Very satisfied

2 □ Somewhat satisfied

3 □ Somewhat dissatisfied

4 □ Very dissatisfied

B6. Please give one response in each row regarding today’s visit.

	MARK ONE ANSWER PER ROW
	Excellent	Very Good	Good	Fair	Poor
a. How would you rate the quality of care you received in today’s visit overall?	1 □	2 □	3 □	4 □	5 □
b. How would you rate the technical skills of your health care provider (thoroughness, carefulness, competence) during today’s visit?	1 □	2 □	3 □	4 □	5 □
c. How would you rate the personal manner of your health care provider (courtesy, respect, sensitivity, kindness) during today’s visit?	1 □	2 □	3 □	4 □	5 □
d. How would you rate your health care provider’s explanation of health information in terms of how easy it was to understand?	1 □	2 □	3 □	4 □	5 □
e. How would you rate the attention that your health care provider gave you during today’s office visit (for example, not getting easily distracted by telephone calls or other patients’ needs)?	1 □	2 □	3 □	4 □	5 □

B7. How would you rate your health care provider’s knowledge about your current health problems?

MARK ONE ANSWER ONLY

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

B8. At today’s visit, did you feel that you were given the time to ask all, some, or none of the health-related questions you had?

MARK ONE ANSWER ONLY

1 □ All

2 □ Some

3 □ None

B9. Health care providers may use computers or handheld devices during an office visit to do things like look up your information or order prescription medicines. Did the main health care provider you saw today use a computer or handheld device during your visit?

MARK ONE ANSWER ONLY

1 □ Yes GO TO QUESTION B12, PAGE 7

0 □ No

B10. How many minutes did your main health care provider spend with you during today’s visit? (Do not include time spent waiting or with other staff.)

MARK ONE ANSWER ONLY

1 □ Less than 5 minutes

2 □ 5 to 15 minutes

3 □ 16 to 30 minutes

4 □ 31 to 45 minutes

5 □ 46 to 60 minutes

6 □ More than 60 minutes

B11. How much of the total visit time today did your main health care provider spend directly interacting with your chart and records, that is time spent looking through the file, trying to find information, or writing notes?

MARK ONE ANSWER ONLY

1 □ All of the time

2 □ Most of the time

3 □ Some of the time GO TO SECTION C, QUESTION C1, PAGE 10

4 □ A little of the time

5 □ None of the time

B12. Please indicate “Yes” or “No” for each of the following statements about today’s visit with your main health care provider:

	MARK ONE ANSWER PER ROW
	Yes	No
a. At today’s visit, did the main health care provider enter notes about your health into a computer or handheld device while you were present?	1 □	0 □
b. At today’s visit, did the main health care provider use a computer or handheld device to show you information?	1 □	0 □
c. At today’s visit, did the main health care provider use a computer or handheld device to look up test results or other information about you?	1 □	0 □
d. At today’s visit, did the main health care provider use a computer or a handheld device to order your prescription medicines?	1 □	0 □
e. At today’s visit, did the main health care provider use a computer or a handheld device to print out health related materials to give to you?	1 □	0 □
f. At today’s visit, did the main health care provider tell you that he or she would be using the computer during your exam or discussion?	1 □	0 □
g. At today’s visit, did the main health care provider explain what he or she was doing on the computer while doing it?	1 □	0 □
h. At today’s visit, did the main health care provider tell you when he or she was logging off your patient record on the computer?	1 □	0 □

B13. How many minutes did your main health care provider spend with you during today’s visit? (Do not include time spent waiting or with other staff.)

MARK ONE ANSWER ONLY

1 □ Less than 5 minutes

2 □ 5 to 15 minutes

3 □ 16 to 30 minutes

4 □ 31 to 45 minutes

5 □ 46 to 60 minutes

6 □ More than 60 minutes

B14. How much of the total visit time today did your main health care provider spend directly interacting with the computer, that is time spent working with the mouse, keyboard or looking at the computer screen?

MARK ONE ANSWER ONLY

1 □ All of the time

2 □ Most of the time

3 □ Some of the time

4 □ A little of the time

5 □ None of the time

B15. Please indicate how strongly you agree or disagree with each of the following statements about today’s visit with your health care provider.

	MARK ONE ANSWER PER ROW
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. The use of the computer in the exam room improved the quality of care I received from my health care provider.	1 □	2 □	3 □	4 □	5 □
b. Because of the computer, the health care provider spent less time looking at me than I liked during the visit.	1 □	2 □	3 □	4 □	5 □
c. Because of the computer, the health care provider spent less time talking with me than I liked during the visit.	1 □	2 □	3 □	4 □	5 □
d. Because of the computer, I felt that my health care provider was more aware of my medical history.	1 □	2 □	3 □	4 □	5 □
e. The use of the computer in the exam room made the visit with my health care provider feel less personal.	1 □	2 □	3 □	4 □	5 □

B16. Would you say that the health care provider’s use of a computer or handheld device at today’s visit was helpful or unhelpful to you overall?

MARK ONE ANSWER ONLY

1 □ Very helpful

2 □ Somewhat helpful

3 □ Neither helpful nor unhelpful

4 □ Somewhat unhelpful

5 □ Very unhelpful

B17. Would you say that the health care provider’s use of a computer or handheld device at today’s visit made it harder or easier for you to talk with him or her?

MARK ONE ANSWER ONLY

1 □ Much harder

2 □ Somewhat harder

3 □ Neither harder nor easier

4 □ Somewhat easier

5 □ Much easier

B18. Please indicate whether your health care provider’s use of a computer at today’s visit had a positive effect, negative effect, or no effect on the following aspects of your interaction with the provider. What effect did the computer have on.

	MARK ONE ANSWER PER ROW
	Very positive	Somewhat positive	No effect	Somewhat negative	Very negative
a. Your ability to describe your concerns to your health care provider?	1 □	2 □	3 □	4 □	5 □
b. The quality of the face-to-face communication with your health care provider?	1 □	2 □	3 □	4 □	5 □
c. Your health care provider's willingness to listen?	1 □	2 □	3 □	4 □	5 □
d. The length of time spent listening to your concerns?	1 □	2 □	3 □	4 □	5 □

.

C. SINCE LAST YEAR

C1. Thinking about all the health care providers you may have seen at this medical practice, for how many years have you been a patient of any provider at this medical practice?

MARK ONE ANSWER ONLY

1 □ 1-2 years

2 □ 3-5 years

3 □ 6-10 years

4 □ More than 10 years

C2. Including today’s visit, how many times have you seen a health care provider at this medical practice in the past 12 months?

MARK ONE ANSWER ONLY

1 □ 1 visit

2 □ 2-3 visits

3 □ 4-5 visits

4 □ 6-10 visits

5 □ More than 10 visits

C3. The next question is about possible changes that may have occurred at this medical practice. Comparing your visit today to a visit you made to this practice 12 or more months ago, please indicate whether each of the following items has gotten better, gotten worse, or stayed the same.

	MARK ONE ANSWER PER ROW
	Gotten Better	Gotten Worse	Stayed the Same
a. The quality of the care you have received from this medical practice.	1 □	2 □	3 □
b. The technical skills of your health care provider (thoroughness, carefulness, competence).	1 □	2 □	3 □
c. The personal manner of your health care provider (courtesy, respect, sensitivity, kindness).	1 □	2 □	3 □
d. The health care provider’s explanation of health information in terms of how easy it was to understand.	1 □	2 □	3 □
e. The attention that your health care provider gives you during your office visit (for example, not getting easily distracted by telephone calls or other patients’ needs).	1 □	2 □	3 □
f. Your health care provider’s knowledge about your health problems.	1 □	2 □	3 □
g. Your health care provider’s communication with other doctors or health care professionals about your medical care.	1 □	2 □	3 □

C4. Comparing your visit today to a visit you made to this practice 12 or more months ago, do you feel that the amount of time your health care provider spends with you during the office visit has increased, decreased, or stayed the same?

MARK ONE ANSWER ONLY

1 □ Increased

2 □ Decreased

3 □ Stayed the same

C5. During the past 12 months, did you ever communicate by e-mail with a health care provider at this medical practice to fill or refill a prescription?

MARK ONE ANSWER ONLY

1 □ Yes

0 □ No

C6. During the past 12 months, did you ever communicate by e-mail with a health care provider at this medical practice to ask a question about your health or get medical advice?

MARK ONE ANSWER ONLY

1 □ Yes

0 □ No

D. CARE COORDINATION

The next questions are about how your health care providers share information about your care.

D1. During the past 12 months, was there ever a time when you thought one of your health care providers within this medical practice did not talk to your other health care providers within this practice enough about your care?

MARK ONE ANSWER ONLY

1 □ Yes

0 □ No

n □ Have only one doctor in this practice or no communication needed

D2. During the past 12 months, was there ever a time when you thought your health care provider from this medical practice did not talk to your health care providers outside this practice enough about your care?

MARK ONE ANSWER ONLY

1 □ Yes

0 □ No

n □ Have only one doctor or no communication needed

D3. If you were referred to a specialist during the past 12 months, did the specialist have the information he or she needed from your medical records?

MARK ONE ANSWER ONLY

1 □ Yes

0 □ No

n □ Not referred to a specialist

	MARK ONE ANSWER PER ROW
	Yes	No	NA (no tests or procedures)
a. A doctor at this practice was unaware of tests or procedures I received elsewhere	1 □	0 □	n □
b. A doctor at another practice was unaware of tests or procedures I received here	1 □	0 □	n □

D4. During the past 12 months, have any of your health care providers ever been unaware of test results or diagnostic procedures that another provider had ordered?

E. BACKGROUND

These last questions are about you and your background.

E1. What kind of health insurance do you have?

MARK ALL THAT APPLY

1 □ Private health insurance (through a current or former employer or union, or bought on your own, by you or a spouse or family member)

2 □ Medicare (the government program for persons 65 years old and older or persons with disabilities)

3 □ Medicaid or some other government assistance program for persons with low income

4 □ TRICARE, VA, Champ-VA, or other military health care

5 □ Indian Health Service

6 □ I am not covered by health insurance

E2. How confident are you that your medical records and personal health information at this practice remain confidential?

MARK ONE ANSWER ONLY

1 □ Very confident

2 □ Somewhat confident

3 □ Not too confident

4 □ Not at all confident

E3. How old are you?

MARK ONE ANSWER ONLY

1 □ 18 to 24

2 □ 25 to 34

3 □ 35 to 44

4 □ 45 to 54

5 □ 55 to 64

6 □ 65 to 74

7 □ 75 or older

E4. Are you male or female?

1 □ Male

2 □ Female

E5. Are you of Hispanic or Latino/Latina origin?

1 □ Yes

0 □ No

E6. What is your race? Please mark one or more categories.

MARK ALL THAT APPLY

1 □ American Indian or Alaska Native

2 □ Asian

3 □ Black or African-American

4 □ Native Hawaiian or Other Pacific Islander

5 □ White

E7. What is the highest grade or year of school you have completed?

MARK ONE ANSWER ONLY

1 □ Did not complete high school or GED

2 □ High school diploma or GED

3 □ Some college or vocational school after high school

4 □ 4-year college degree (Bachelor’s Degree)

5 □ Graduate or professional degree (e.g., MA, MBA, Ph.D., JD, MD)

6 □ Other type of degree (Please specify)

E8. Is English your primary spoken language?

1 □ Yes GO TO QUESTION E10, PAGE 15

0 □ No

E9. What is your primary spoken language?

E10. What is your current marital status?

MARK ONE ANSWER ONLY

1 □ Married/living as married

2 □ Separated

3 □ Divorced

4 □ Widowed

5 □ Never married

E11. How many people live in your household including yourself?

| | | PEOPLE IN HOUSEHOLD

E12. Which of the following best describes your current employment status?

MARK ONE ANSWER ONLY

1 □ Working full-time

2 □ Working part-time

3 □ Not working, but not retired

4 □ Retired

E13. Counting everyone in your household, what was your total household income in 2009? Please include wages, benefits, earnings, and all other sources of income.

MARK ONE ANSWER ONLY

1 □ Less than $10,000

2 □ $10,000 or more but less than $30,000

3 □ $30,000 or more but less than $50,000

4 □ $50,000 or more but less than $75,000

5 □ $75,000 or more but less than $100,000

6 □ $100,000 or more

E14. Did someone help you complete this survey?

1 □ Yes

0 □ No GO TO END

E15. How did that person help you?

MARK ALL THAT APPLY

1 □ Read the questions to me

2 □ Wrote down the answers I gave

3 □ Answered the questions for me

4 □ Translated the questions into my language

5 □ Helped in some other way (Please specify) ____________________________________

THANK YOU VERY MUCH FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

PLEASE HAND YOUR COMPLETED SURVEY TO THE MATHEMATICA REPRESENTATIVE IN THE WAITING ROOM.