Physicians Form C Shortened Survey Administered on Paper

Form Approved

OMB No. 0955-

Exp. Date XX/XX/20XX

Form C Shortened Survey Administered on Paper for Non-Responders of Telephone Survey

This survey seeks to understand challenges with adopting and using EHRs and the help that practices that provide primary care services, like yours, have received to meet those challenges. The survey should be completed by the person most familiar with EHR selection, implementation, and use in your practice. This may be you, another clinician, practice manager, nurse, Information Technology staff, or another employee.

It should take you about 10 minutes to answer these questions. All the information you provide will be kept confidential.

Please answer each question as best you can by placing a check mark or an X to the left of the answer you choose. Sometimes you will be asked to skip a question. When this happens, an arrow to the right of the answer choice will tell you what question to skip to.

For example:

____ Yes  Go to Question 3

____ No  Go to Question 3

1. Does this practice use an electronic health record (EHR) or electronic medical record (EMR) system? Do not include billing record systems.

1. ____ Yes  Go to Question 2

2. ____ No  End survey. Thank you for your time, no other action is required

from you at this point. Please return this survey in the enclosed envelope.

3. ____ Uncertain  End survey. Thank you for your time, no other action is

required from you at this point. Please return this survey in the enclosed envelope.

2. Did your practice transition from using paper charts to an EHR?

1. ____ Yes, we transitioned from paper charts to using an EHR

2. ____ No, this practice opened with an EHR

3. ____ Uncertain

3. In which year did you install your current EHR?

1. ___ __ __ __ (YYYY)

2. ____ Uncertain

Meaningful use is a way to optimize health care and use technology to improve patient care and is defined by standards set by the Department of Health and Human Services. Certified EHRs meet these established standards and other criteria for structured data. Certified EHR technology gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.

4. Is your current EHR system certified to meet meaningful use as defined by the Department of Health and Human Services?

1. ____ Yes  Go to Question 5

2. ____ No  Go to Question 6

3. ____ Uncertain  Go to Question 6

5. To meet the meaningful use certification standards, did you have to: (Select only one response.)

1. ____ Upgrade our EHR software  Go to Question 7

2. ____ Install a different EHR system  Go to Question 7

3. ____ Neither upgrade our EHR system nor install a different EHR system  Go to

Question 7

4. ____ Uncertain  Go to Question 7

6. To meet the meaningful use certification standards, do you plan: (Select only one response.)

1. ____ To upgrade our EHR software to a new version  Go to Question 7

2. ____ To install an entirely new EHR system  Go to Question 7

3. ____ Neither to upgrade our EHR system nor install a different EHR system  Go

to Question 7

4. ____ Uncertain  Go to Question 7

7. Medicare and Medicaid offer incentive programs to providers that demonstrate “meaningful use of their EHR system.” Have you applied for the Medicare incentive program?

1. ____ Yes  Go to Question 9

2. ____ No  Go to Question 8

3. ____ Uncertain  Go to Question 8

8. Have you applied for the Medicaid incentive program?

1. ____ Yes  Go to Question 9

2. ____ No  Go to Question 12

3. ____ Uncertain  Go to Question 12

9. In what year did you first apply for an EHR incentive program? (Select only one response.)

1. ____ 2011

2. ____ 2012

3. ____ 2013

4. ____ 2014

5. ____ Uncertain

10. How easy or difficult was it for you to use the online system to attest to the meaningful use criteria?

1. ____ Extremely easy  Go to Question 14

2. ____ Somewhat easy  Go to Question 14

3. ____ Somewhat difficult  Go to Question 11

4. ____ Extremely difficult  Go to Question 11

5. ____ Uncertain  Go to Question 14

11. Did you receive help or assistance to address this difficulty?

1. ____ Yes  Go to Question 14

2. ____ No  Go to Question 14

12. Do you intend to apply for an EHR incentive program?

1. ____ Yes, I intend to apply  Go to Question 14

2. ____ No, I do not intend to apply  Go to Question 13

3. ____ Uncertain if I will apply  Go to Question 13

13. Which of the following are reasons you have for not applying for an EHR incentive program? (Circle only one response for each item.)

Yes

No

1. Not qualified as an “eligible provider”? Y N

2. Do not see enough Medicaid patients? Y N

3. Do not see enough Medicare patients? Y N

4. The process to apply is difficult? Y N

5. Not familiar with the incentive program(s)? Y N

6. Unsure that incentives will actually be paid? Y N

7. My EHR system does not exchange health information

electronically with other providers (e.g., EHR systems “don’t

talk to each other”)? Y N

8. Not prepared to implement electronic prescribing? Y N

9. Other? Y N

14. Please indicate whether you agree or disagree with the following statements about your practice’s EHR. (Circle only one response for each item.)

Strongly Strongly

agree Agree Disagree disagree Uncertain

1. Your EHR provides financial benefits

for your practice. SA A D SD U

2. Overall, your practice functioned

more efficiently with an EHR system SA A D SD U

3. Your EHR helps your practice to

deliver better patient care SA A D SD U

15. Overall, how satisfied or dissatisfied are you with your EHR system?

1. ____ Very satisfied

2. ____ Satisfied

3. ____ Dissatisfied

4. ____ Very dissatisfied

16. How likely are you to recommend your EHR system to others?

    1. ____ 10 (Extremely likely)

    2. ____ 9

    3. ____ 8

    4. ____ 7

    5. ____ 6

    6. ____ 5

    7. ____ 4

    8. ____ 3

    9. ____ 2

    10. ____ 1

    11. ____ 0 (Not at all likely)

17. The following are some issues that some practices face during the transition from using paper records to electronic health records or when upgrading from a previous EHR system to a new version of the same software. Please indicate how difficult or easy each issue was for your practice using the scale of “Extremely difficult,” “Somewhat difficult,” “Neither difficult nor easy,” “Somewhat easy,” or “Extremely easy”. (Circle only one response for each item.)

Extremely Somewhat Somewhat Extremely

difficult difficult Neither easy easy

1. Assess your practice’s hardware

requirements? ED SD N SE EE

2. Assess your practice’s software

requirements, including Internet

connectivity? ED SD N SE EE

3. Select your current EHR system ED SD N SE EE

4. Negotiate a contract for your current

EHR with a vendor or company? ED SD N SE EE

5. Design or redesign your practice’s

workflow to accommodate your

current EHR system? ED SD N SE EE

6. Implement the workflow design or

redesign that accommodates your

current EHR system? ED SD N SE EE

7. Initially train staff to use your current

EHR system? ED SD N SE EE

8. Protect the privacy and security of

electronic health information? ED SD N SE EE

18. Please indicate if you have received help from any of the following organizations with adopting and implementing your current EHR system. (Circle only one response for each item.)

Yes

No

1. EHR vendor or the company that sold you your EHR? Y N

2. Local Regional Extension Center or affiliate? Y N

3. Professional association (e.g., the American Association of

Family Physicians)? Y N

4. Local hospital or health system? Y N

5. Payer/Insurance company? Y N

6. Other? Y N

19. Please indicate if your practice currently participates in any of the following care transformation programs. (Circle only one response for each item.)

Yes

No

1. Patient-Centered Medical Home (PCMH) arrangement Y N

2. Pay-for-Performance or bundled payment arrangement

in which you can receive financial bonuses based on your

performance Y N

3. Accountable Care Organization or other similar arrangement

by which you may share savings with insurers (including

private insurance, Medicare, Medicaid, and other public

options) Y N

20. What is your main job function or role? (Select only one response.)

1. ____ Physician

2. ____ Nurse practitioner, certified nurse midwife, physician’s assistant

3. ____ Nurse

4. ____ Medical assistant

5. ____ Other clinical staff

6. ____ Practice/office manager

7. ____ IT staff

8. ____ Billing specialist

9. ____ Executive Staff (CEO, COO, CFO, etc.)

10. ____ Other administrative/non-clinical staff

11. ____ Other. Please specify: ___________________________

21. Is this practice or clinic a single- or multi-specialty (group) practice?

1. ____ Single

2. ____ Multi-specialty

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 0955-xxxx . The time required to complete this information collection is estimated to average 10 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: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer