CMS-10264 Supporting Statement A Revised.CLEAN

The Centers of Medicare & Medicaid Services (CMS) of the Department of Health and Human Services (HHS) is requesting Office of Management and Budget (OMB) approval to survey Medicare beneficiaries, specifically Medicare Advantage and/or Part D Drug Plan (MA/PDP) beneficiaries, about their experiences with a pilot Registration Summary and Medication History Personal Health Record (PHR). CMS, in conjunction with the Agency for Healthcare Research and Quality (AHRQ), has contracted with the National Opinion Research Center (NORC) at the University of Chicago to conduct this assessment. The study will help HHS better understand Medicare beneficiaries’ experiences using PHRs, their opinions of PHRs in general, and the perceived effects of its usage on their health information management and healthcare as a whole. Analyzing the experiences of this pilot population will expand understanding of how PHRs could be used to meet the needs of Medicare beneficiaries.

Initally, CMS worked to determine its role regarding PHRs and Medicare beneficiaries by soliciting industry opinion from a variety of entities. Responses from a 2005 Request for Information (RFI) soliciting public feedback on CMS’ role with regard to PHRs suggested that CMS should make Medicare data available, focus on privacy and security, and not build its own PHR. In 2006, the American Health Information Community (AHIC) Consumer Empowerment Workgroup (CEWG) made a recommendation to CMS to pilot programs that measure the value of a Registration Summary and Medication History PHR for patients with chronic conditions and their clinicians. In 2007, CMS initiated two contracts to regarding Medicare Fee-for-service (FFS) and MA/PDP beneficiaries’ use of PHRs. In the Medicare MA/PDP PHR study, CMS decided to work with commercial health plans serving MA/PDP Plan beneficiaries that offer PHRs.

Seven health plans that offer their members free access to their own internet-based PHRs volunteered to participate in this pilot. Their PHRs offer a variety of functions and include content such as basic demographics, medication history, diagnoses, and procedures. Some plans had offered the PHR to their members for an extended period prior to the study, while others have only recently offered availability.

To meet the goals of the CEWG, funds were provided to AHRQ to secure a contract with NORC to evaluate the use and usefulness of these PHRs for Medicare MA/PDP beneficiaries. To meet the goals for the Medicare MA/PDP PHR evaluation, NORC had been tasked with: conducting meetings with beneficiaries to obtain qualitative feedback on their opinions of PHRs; analyzing PHR utilization data provided by the health plans to CMS; and, conducting a survey to gather information on PHR users experiences with and opinions of the applications.

NORC conducted 10 informal meetings with fewer than 9 beneficiaries each. Five meetings were conducted with beneficiaries who were users of the PHRs that were part of this pilot, and five meetings were conducted with beneficiaries who were eligible to use PHRs under this pilot but were non-users. The beneficiaries were asked about their healthcare priorities, how they manage their health information, their opinions of PHRs, and their usage of technology. Users also talked about their reasons for use, what features they used and any effects they see from using the PHR. Non-users were asked why they did not use the PHR. Customized agendas tailored to meet the functionalities of each health plan’s PHR were developed for each meeting.

An additional aspect of this project is quantitative analysis of Medicare MA/PDP beneficiaries’ aggregate utilization of the PHRs. The participating health plans send monthly data on utilization of their PHRs to CMS. The monthly summaries provided to CMS included totals of: Medicare MA/PDP plan members; PHR registrants; new PHR registrants; repeat PHR users; users with chronic conditions; and users accessing Rx portion. NORC has held conference calls with health plan representatives to obtain information on the content and features of their PHRs, their utilization data collection procedures, and their PHR marketing/outreach efforts.

This survey will add an important component to CMS’ investigation into beneficiaries’ interactions with PHRs. This evaluation will involve a short voluntary survey of 2,160 Medicare MA/PDP beneficiaries who have registered for a PHR through their health plan. The following sections of this document provide a detailed justification for the proposed data collection to be conducted, in accordance with OMB requirements.

B. Justification

1. Need and Legal Basis

In 2004, President George W. Bush announced that all citizens would have access to interoperable electronic health records by 2014. The use of health information technology has demonstrated improvements in the effectiveness, efficiency, and quality of healthcare delivery, improvements in patient safety, and improvements in the functioning of the health care system. This survey aims to contribute to the progress of this health information technology initiative by evaluating the Medicare MA/PDP beneficiaries’ perceptions of PHRs.

PHRs may provide benefits for patients such as improvement in overall health, better patient-provider communication, improved quality of care, and reduction in unnecessary tests and medication errors. Public opinion polls show that people generally favor the usage of PHRs. A 2004 Harris Interactive poll showed that 84% of respondents thought it would be a good idea to have a PHR.^ⁱ PHR users generally demonstrate the greatest appreciation for access to test results and further ability for provider-patient communication.^ⁱⁱ An extensive literature review on PHRs concluded that, while there is strong support for PHRs, until they provide demonstrable value to users and improvements in healthcare, adoption will remain low.^ⁱⁱⁱ Tang et al. (2008) note the value in improving our understanding of which groups percieve PHRs to be useful; which features they utilize; and, whether/how their healthcare, health-related behaviors, and overall health change consequent to usage. Understanding this would enhance our existing knowledge base and move the industry in the right direction when developing future PHR applications.^{^iv} As detailed in Section B-16, our evaluation will include analyses of beneficiaries’ perceptions of PHR functionalities, experiences with registration, and sub-group analyses per categories such as usage frequency, health status, demographics, and health plan.

As prior work on PHR adoption and attitudes of the elderly suggests, Kaebler et al. (2008) found that those with chronic conditions could potentially benefit the most from using PHRs.^{^v} A 2003 online survey conducted by the Markle Foundation found that those with chronic illnesses and those caring for the elderly reported the highest need and most urgent interest in PHRs.^{^vi} However, there are many barriers to adoption of PHRs for this population. Lober et al. (2006) found that limited access to computers, computer anxiety, low literacy and health literacy levels, vision or hearing difficulties, memory problems, and physical disabilities were among the top barriers to adoption of PHRs for low-income, elderly and chronically ill patients.^{^vii}

2. Information Users

CMS, in conjunction with AHRQ and NORC, will administer a new information collection. CMS anticipates that the information obtained through this survey could contribute to improvements in PHRs and inform Medicare’s efforts to understand benefits associated with PHR usage. The survey data will be analyzed to better understand how MA/PDP beneficiaries that use PHRs feel about the user-friendliness, usefulness, and benefit of their PHRs.

The information will be collected through administration of a brief paper Self Administered Questionnaire (SAQ) that will be mailed to repeat users of the PHR who are Medicare MA/PDP Plan members. Each of the health plans involved in the demonstration has signed a contractual Business Associate (BA) agreement with NORC so that NORC may obtain address data of beneficiaries. Although the health plans will provide contact information, none of the information obtained from individuals completing the survey will be shared with the health plans. Individual responses will be aggregated in order to better understand Medicare MA/PDP users’ perceptions of the tools and functions.

3. Use of Information Technology

The information collection will not be administered electronically for a number of reasons. Many of the health plans involved are unable to obtain email address information for beneficiaries, making an electronic format difficult to administer. A large majority of Medicare beneficiaries have reported mailed, paper-based SAQs as the easiest for them to complete. Furthermore, a mailed survey gives beneficiaries the opportunity to hand off the survey to caregivers for completion if assistance is necessary, which will ensure the accuracy of the data. Signatures will not be required for this survey.

Although the survey will not be administered electronically, the use of information technology will be incorporated into the methodology in other ways. For example, in order to reduce data entry burden and enhance the use of information technology, the SAQ data will be scanned into a programmable data entry system to minimize data entry errors. An additional 10 percent of the data will be double entered and adjudicated to ensure accuracy and completeness.

The voluntary survey will be mailed to beneficiaries as an SAQ. In addition, prior to receiving a questionnaire, respondents receive a professionally drafted letter signed by NORC and the health plan outlining the importance of the study and requesting their participation. To maximize response, NORC will also conduct telephone prompting to remind beneficiaries to complete and return (by mail or fax) the SAQ or to allow them to complete the SAQ over the telephone. Although we anticipate the respondents will prefer to complete the survey on paper, beneficiaries who prefer to complete the survey on the computer will be emailed a .pdf version of the survey that they will be able to return by email.

4. Duplication of Efforts

NORC performed an extensive review of the literature on PHRs in January 2008. The information obtained from this review indicated that little research has closely investigated the use and perceptions of PHRs, particularly with this population. Lober et al. (2006) investigated the barriers to adoption of PHRs in a low-income, elderly and chronically ill population. This particular evaluation was administered through focus groups with a small number (38) of participants living in one retirement community, and survey data was not collected.^{^viii} Kim et al. (2007) have used usage log data from that study to analyze utilization trends of that group.^{^ix}

Although a few health plans have collected data on user satisfaction with their own PHR tools and most health plans collect aggregate data on frequency of use of particular functions (Kaiser Permanente, HIP USA, etc.), none to date have specifically investigated Medicare beneficiary users’ perceptions around the user-friendliness and usefulness of the functions of these tools.

The present study seeks to collect data from roughly 2,160 Medicare beneficiaries distributed widely across the United States using seven different PHRs. It is the first evaluation of Medicare MA/PDP beneficiaries’ opinions of the user-friendliness and usefulness of PHRs. No other projects assessing Medicare MA/PDP beneficiaries’ experiences with commercial PHRs are known to be funded by either the federal government or private entities prior to the development of this study. No other survey of this type has been identified.

5. Small Businesses

The survey will not being targeting small businesses and will have minimal effect on small entities. Completion of the survey will require minimal time (no more than 30 minutes) out of a respondent’s workday. Our expectation of the completion time is based on an internal timing test completed by NORC. Since only a small percentage of Medicare beneficiaries receive work-related compensation, the burden will be very small to this group.

6. Less Frequent Collection

This survey will be conducted only once. The questionnaire data will provide CMS with information on how Medicare MA/PDP beneficiaries perceived their PHRs. The survey data will provide CMS with a deeper understanding of which beneficiaries choose to use PHRs, the challenges beneficiaries faced in using PHRs, and the overall perceptions of usefulness they found in its usage. These findings can inform development of PHRs to improve the usefulness of these tools for the larger population of Medicare beneficiaries that do not currently have access to them.

7. Special Circumstances

This request is consistent with the general information collection guidelines of 5 CFR 1320.5(d)(2). There are no special circumstances associated with this project.

8. Federal Register/Outside Consultation

CMS has consulted with subject matter and survey design experts at NORC, AHRQ, and CMS in designing the survey and methodology. Additionally, CMS has established a PHR Expert Panel comprised of twelve prominent leaders in PHR administration, design, and evaluation. All twelve members of this panel provided extensive feedback on the design of the data collection instrument that included advising on the clarity of instructions and content, order of questions, disclosure and reporting format and the data elements that will be reported on. CMS will continue to consult with the panel through monthly meetings to obtain the most up to date information on PHR initiatives and activities and receive continued feedback on the methodology and progress of the evaluation.

The sixty-day Federal Register notice published on May 30th, 2008 is included as Attachment 1.

The PHR Expert Panel members are listed below in Exhibit A.

Exhibit A. PHR Expert Panel Members

Personal Health Records Expert Panel
Name	Title	Organization
Archelle Georgiou	Independent Consultant	N/A
Brad Hesse	Branch Chief	National Cancer Institute
Don Mon	Vice President for Practice Leadership	American Health Information Management Association
Ed Fotsch	CEO	Medem
Leslie Harris	President & CEO	Center for Democracy and Technology
Lori Nichols	Director	Whatcom Health Information Network
Michelle Dougherty	Manager of Practice Leadership	American Health Information Management Association
Patricia Brennan	National Program Director	Robert Wood Johnson Foundation, Project HealthDesign
Paul Kaplan	Chief Medical Officer	Blue Cross and Blue Shield of DE
Rob Tennant	Senior Policy Advisor	Medical Group Management Association
Steve McPhillamy	Partner	Insight Product Development
Steve Ross	Assistant Professor	University of Colorado Health Sciences Center
William Bernstein	Partner	Manatt, Phelps & Phillips

9. Payments/Gifts to Respondents

Participation in the survey is entirely voluntary for beneficiaries. Given the significant efforts to reduce burden on respondents, compensation will not be provided as a part of this information collection.

10. Confidentiality

The privacy of all study participants will be protected. Personal identification information (i.e., beneficiary number or social security number) will not be collected in the surveys. Instead, NORC will assign a subject identification number which will be used in place of the participant’s name on the questionnaire. Data files and reports delivered to CMS will contain subject identification numbers only and no personal identification information. Additionally, all aggregated data will be de-identified. Individual participants will not be identified in any report, publication, or presentation of this study or its results.

NORC will not store the participants’ names or other personal identifiers in the same computer file as their questionnaire data. Any paper copies of questionnaires will be stored in locked cabinets separate from the study administration materials. Electronic data will be stored in a password protected data file and only authorized project staff will have access to the data. At the conclusion of the study, all hard copy materials will be destroyed and electronic files will be deleted as requested or archived in password protected files.

All patient-level data are protected from public dissemination in accordance with the Privacy Act of 1974. Data will be treated in a private matter to the extent allowed by Federal law. There are, however, a number of instances when we might be legally required to disclose participant information. For example, we might be required to disclose the information in response to a Freedom of Information Act request, a Federal court order, or a congressional committee request or subpoena.

NORC has created a generic Business Associate (BA) agreement to account for sharing of participant data, and NORC has shared this with each of the health plans. The generic mockup is included as Attachment 2. However, several plans have requested to use their own BA agreement. NORC has executed BA agreements with each of the seven plans to account for the sharing of patient information.

11. Sensitive Questions

Personal Health Information will be collected in order to aggregate the perceptions of beneficiaries with chronic conditions versus generally healthy beneficiaries regarding the utility of the PHR. CMS considers the collection of this information necessary in order to understand how a PHR can be most useful to those with chronic conditions, as well as to understand the effect of PHR usage on beneficiaries’ health and use of the healthcare system. The Personal Health Information collected will be chronic conditions status and the nature of their health care visits.

The cover letter inviting beneficiaries to participate in the study clearly states that the study is voluntary and does not affect their healthcare benefits. Additionally, the letter explains that information obtained from survey responses will not be attached to personally identifiable information, and will be kept private, unless otherwise compelled by law. Examples of situations that would legally require CMS to share personally identifiable information are included in the authorizing legislation referenced in the letter. Personally identifiable information will be destroyed upon completion of the study. Respondents are provided with contact information for a NORC representative they can call with any questions regarding the use of their information in the survey.

12. Burden Estimates (Hours & Wages)

In Exhibit B, we provide an estimate of the collection burden on participants for this effort. The hours burden for survey participants is based upon results of time testing conducted by NORC, which indicate approximately 30 minutes will be required to complete the survey. Study participants will take part in survey data collection one time only. We also include an estimate of cost burden to respondents for participating in the informal discussions. The maximum expected time of one and a half hours was used to calculate the burden. Roughly 8 beneficiaries participated in each meeting, with a total of 80 beneficiaries participating in one of ten meetings. The estimated total hour burden is 120 hours.

Additionally, we provide an estimate of cost burden to health plans for reading and executing the BA agreements that NORC designed. The time estimate for the health plans is based upon an approximate 15 minutes to read the document and another 15 minutes to review, make any changes, and execute the document. Average time to read the BA is based on the average amount of time it takes an American adult to proofread text, which is estimated at 180 to 200 words per minute.^{^x} Given that the health plans may prefer to use their own BAs, the numbers provided are rough estimates based on NORC’s generic BA. This is included in Exhibit C below.

Exhibit B. Estimate of Cost Burden to Respondents

Item	Number of Respondents	Responses per Respondent	Average Respondent Hours	Estimated Total Hour Burden	Median Hourly Wage Rate^*	Total Hour Cost**
Survey: Adults over 65 years of age	2160	1	.5	1080	$15.13	$16,340.40
Discussions: Adults over 65 years of age	80	1	1.5	120	$15.13	$1,815.60

*“2007 Current Population Survey”, Extracted March 19, 2008. Extracted February 10, 2008 from http://www.census.gov/hhes/www/cpstc/cps_table_creator.html).

**The national percentage of those aged 65 and older who work in 2006 (real earnings) is 18.9% (Employee Benefit Research Institute, EBRI Education and Research Fund Newsletter. December 2007, 28 (12).) While on paper the total imputed costs are expected to be $18,156.00, we anticipate that the total imputed costs will be significantly less given the high percentage of adults over 65 who are not working. If only 18.9% of the sample has real earnings, the total imputed costs would be $3,431.49.

Total burden (hours): 1200

Total imputed costs: $18,156.00

Exhibit C. Estimate of Cost Burden to Health Plan Administrators

Item	Number of Respondents	Responses per Respondent	Average Respondent Hours per BA	Estimated Total Hour Burden	Median Hourly Wage Rate^*	Total Hour Cost
Effort to read and execute BA agreement	7	1	.5	3.5	$28.40	$99.40

*Estimated based on median usual weekly earnings of full-time wage and salary workers by occupation, Medical and Health Service Managers, “2007 Current Population Survey”, U.S. Department of Labor, Bureau of Labor Statistics. Extracted March 19, 2008. ftp://ftp.bls.gov/pub/special.requests/lf/aat39.txt

Total burden (hours): 3.5

Total imputed costs: $99.40

13. Capital Costs

Data collection for this study will not result in any additional capital, start-up, maintenance, or purchase costs to respondents or record keepers. Therefore, there is no burden to respondents other than that discussed in the previous section (B.12).

14. Cost to Federal Government

Estimated Annual Costs to the Federal Government

The total cost to the government for developing and implementing the survey, analyzing the data and report production, and associated personnel costs is estimated to total at $200,000 over a period of rough 12 months.

15. Changes to Burden

This is a new collection of data. No changes to the burden are anticipated.

16. Publication/Tabulation Dates

The data from this study will be compiled in a report that will be made publicly available on the AHRQ website and the CMS website. In order to present a coherent plan, this section presents an overview of the study purpose and main research questions, the limitations of this study and how they will be addressed, a review of the data sources, the planned statistical analyses, and the time schedule for completing the project, including publication of the results.

Purpose and Main Research Questions

To conduct the evaluation of the CMS PHR Pilot for Medicare Advantage & Part D Enrollees, CMS worked with seven health plans to evaluate Medicare MA/PDP beneficiaries experiences with the health plans’ PHRs. The data collected from the survey of Medicare beneficiaries that use PHRs can be used to inform the development of future PHRs by analyzing the beneficiaries’ responses. The survey will cover four main areas of inquiry: (1) the experience of registering for use of the PHR, (2) use and perceived ease of use, (3) perceived benefits of using the PHR and (4) beneficiary characteristics. This will include evaluations of:

Which functionalities are most used and perceived to be most user-friendly and useful
Experiences with, easiness of and reasons for registration
Differences in perceived benefits of using the PHR per sub-groups, including:
- Whether frequent or casual user
- Health status/existence of chronic condition
- Demographics (age, gender, race, ethnicity)
- Health plan (to investigate marginal effects of outreach, user-interface, and/or feature assortment offered)

Limitations and Strategies for Addressing Them

As noted above, the population for this study is MA/PDP beneficiaries that would choose to use a PHR, and this population is not representative of Medicare beneficiaries as a whole. Findings are relevant to those beneficiaries that are computer literate MA/PDP beneficiaries, those with family or friends that serve as proxies and aid them with the PHR and those that have access to the Internet. CMS believes that this population is important to survey in order to understand factors associated with use of PHRs. Additionally, this study evaluates the experiences of beneficiaries’ using the pilot PHRs. There are many different types of PHRs offered by health plans, vendors and providers and the results of this survey may not inform the experience of beneficiaries who are using other PHRs than those involved in the pilot.

While the survey would ideally provide opportunity for a comparison between users and non-users of PHRs, given the scope of the evaluation, an extensive examination of non-users would be prohibitive as the non-users would not be able to answer the survey questions. There are always limitations associated with survey work resulting from difficulty achieving high response rate and assuring validity and reliability of survey questions. Therefore, this survey has been designed to assess perceived use and usefulness of the PHR for users. As noted above, NORC has a solid track record of maximizing response rate using the TDM method. In addition, we have reviewed validated instruments and crafted items using best practices to maximize validity and reliability of results.

How Limitations are addressed

The analytical results will acknowledge that the analysis was conducted on data from MA/PDP beneficiaries that use PHRs
This study is complementary to qualitative discussions with grantees and utilization data collected from health plans
Beneficiaries provided detailed examples of their difficulties with computer access, the user-friendliness of PHRs, and suggestions for their improvement during discussions
The project team will call those that do not respond to the mailed survey as a reminder and opportunity to complete via telephone
Although limited in the applicability of the results, this study:
- Expands the very limited knowledge base regarding PHR use and user-friendliness
- Expands the limited understanding of how the elderly relate to technology
- Will aid CMS in determining their role regarding PHRs and beneficiaries for future projects

Data Sources

This section provides an overview of the survey instrument and details the data collection methodology. The project team will utilize a mixed-mode approach (mail and telephone) to conduct a survey of participating Medicare beneficiaries that will assess their experience with and attitudes toward the demonstration and PHRs in general.

This assessment includes one mailed self-administered questionnaire (SAQ), which will be sent to registered Medicare beneficiaries from each of the seven health plans involved in the pilot. Each individual will receive a pre-notice letter which will explain the information that will be asked of them in the survey and their rights as a participant, and offer contact information for questions. One week following the mailing of the pre-notice letter, beneficiaries will receive the one-time survey and be asked to complete it, expected to take approximately 30 minutes. Results will be summarized within and across the different health plans’ PHRs. To facilitate return of the surveys and ensure high response rates, NORC is providing respondents with pre-addressed and stamped envelopes.

Two weeks following the initial mailing, NORC will telephone respondents who have not yet returned the questionnaire. Two weeks following the initial telephone call, NORC will telephone all respondents who still have not returned the questionnaire a second time. Questionnaires that were lost or misplaced will be mailed at this time, and NORC will offer completion of the survey by telephone as an alternate option to increase response rate. Additionally, NORC will offer completion of the survey in electronic format and return of the survey by email for beneficiaries who prefer this option.

NORC researchers are highly trained in not only project-specific details but also the larger goals of social science research. Trainings cover the fundamentals of data collection, including implementation of sample designs, approach to respondents, administration of questionnaires (neutral probing techniques, accurate recording of responses, following skip patterns, etc.), and protection of respondent privacy. In addition to receiving basic training on the fundamentals of administering surveys, NORC researchers take part in project-specific training, tailored to meet the needs of each study’s data collection method. To inform ongoing training efforts, NORC supervisory staff continuously reviews production data and project-specific reports to gauge progress, quality, and identify issues related to individual researcher or production center staff.

The survey instrument has been developed prior to submitting this OMB clearance package. The SAQ consists of general domains highlighted in Exhibit D. The survey is comprised of closed-ended questions with response types designed on Likert scales of 1-5. The questions ask beneficiaries to assess their frequency of use, level of difficulty in signing up for and using the PHR and its various functions, and level of agreement with a number of statements regarding perceptions of user-friendliness and usefulness of the tool and its functions. Additional questions include closed-ended questions regarding overall health, and closed-ended questions with yes or no response types.

Exhibit D. Medicare Beneficiary Survey Domains

Question Domain	Overview
Registration Experience	Capture information on knowledge of the demonstration, how heard about it, and factors that affect the decision to register
Use and Perceived User-friendliness	Capture information on how frequently Medicare beneficiaries’ use the tool, what features and functions are used the most and least frequently, and beneficiaries perceptions regarding how easy or difficult the PHR and its functions may be to use
Perceived Usefulness	Capture beneficiary attitudes and perceptions regarding how useful the PHR and its functions are for them
Beneficiary Characteristics	Capture demographic data (such as age, gender, health status) to be used to analyze survey data

The survey is included as Attachment 3.

Tabulations and Statistical Analysis

This section details the tabulations and statistical analyses that will be conducted for this study. This study will use both univariate and, where possible, multivariate techniques to analyze the data.

Data analysis will focus on identifying results of the established key research questions. In addition to answering this core set of questions, the analysis will also compare the groups and determine the extent to which certain characteristics of the organization seem to be related to the extent of awareness, the extent of use, the nature of use, and the kinds of barriers experienced.

Both descriptive and inferential statistics, such as the standard t-test, chi-square test, and multiple comparison procedures will be utilized in the analysis. Standard errors will also be provided for these estimates. Non-parametric statistical techniques may also be used to analyze the data, including the chi-square test for cross tabulations, the Wilcoxon rank-sum (Mann-Whitney) two-sample test, and the Komolgorov-Smirnov test for equality of distributions. Non-sampling errors arising from unit and item non-response will be dealt with through weighting and imputation where appropriate. The time schedule and publication plan is described in Exhibit E.

Time Schedule and Publication Plan

Exhibit E. Timetable for Data Collection, Analysis, and Publication

Activity	Expected Date of Completion
Survey sent to respondents	1-4 months following OMB approval
Data preparation	4 months following OMB approval
Analyze Findings	5 months following OMB approval
Prepare Draft Reports	6-7 months following OMB approval
Final Report	7-8 months following OMB approval

17. Expiration Date

NORC anticipates a single administration of the SAQ during the calendar year of 2009.

CMS would like to display the expiration date.

18. Certification Statement

This information collection does not request any exceptions to the certificate statement.

i Harris Interactive (2004) “Two in Five Adults Keep Personal or Family Health Records and Almost Everybody Thinks This is a Good Idea” Health Care News 4(13)

ii Tang, P., Ash, J., Bates, D., Overhage, M., Sands, D. (2006) “Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption” Journal of the American Medical Informatics Association 13(2). p. 121-6

iii Kaelber, D., Ashish, J., Johnston, D., Middleton, B., Bates, D., (2008) “A Research Agenda for Personal Health Records (PHRs)” Journal of the American Medical Informatics Association 12(6). p. 729-36

iv Tang, P., Ash, J., Bates, D., Overhage, M., Sands, D. (2006) “Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption” Journal of the American Medical Informatics Association 13(2). p. 121-6

v Kaelber, D., Ashish, J., Johnston, D., Middleton, B., Bates, D., (2008) “A Research Agenda for Personal Health Records (PHRs)” Journal of the American Medical Informatics Association 12(6). p. 729-36

vi D. Lansky, "A National Agenda for Personal Health Records? How Will We Really Empower Consumers in the Next Decade?,” (Connecting for Health presentation, 2006).

vii p. 514-8

viii . p. 514-8

ix Kim, E., Stolyar, A., Lober, W., Herbaugh, A., Shinstrom, S., Zierler, B., Soh, C., Kim, Y., (2006) “Usage Patterns of a Personal Health Records by Elderly and Disabled Users” AMIA Annual Symposium Proceedings. p. 409-13

x Bailey, R.W. and Bailey, L.M. (1999), Reading speeds using RSVP, User Interface Update - 1999.

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