Evaluation of the Medicare Care Management Performance Demonstration (Office System Survey)

OMB Approval No.: xxxx-xxxx

E

xpiration Date: xx/xx/xxxx

Electronic Health Records Demonstration

Office Systems Survey

April 1November 7,, 20098

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 0938-NEW. The time required to complete this information collection is estimated to average 0.48 hours or 29 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: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Thank you for participating in the Centers for Medicare & Medicaid Services (CMS) Office Systems Survey (OSS). This survey is being conducted as part of the Electronic Health Records Demonstration (EHRD) and its evaluation. The goal of this demonstration is to unite technology and clinical practice in the physician office setting. The evaluation of the EHRD will help CMS develop additional programs that can assist physicians in moving toward the common goal of improving care. This is a unique opportunity for your practice to contribute to a large-scale effort to improve the quality of ambulatory health care.

The survey asks about three types of health information technology (HIT) that you may be using in your practice to help manage your patients’ health needs. The survey will first ask if your practice is currently using or is in the process of obtaining:

• An Electronic Health Record (EHR) system

• A stand-alone electronic patient registry

• A stand-alone electronic prescribing system

The survey will then collect information about the functions of the systems you currently using.

Please complete all sections of the survey unless directed within it to skip a section. If you are not aware of how all the providers in the practice are using the functions asked about in the survey, please consult with them prior to answering the questions.

Again, we thank you for taking the time to fill out this important survey.

SECTION 1 - General Information -– Practice

{MERGE} FIELDS INDICATE DATA THAT WILL BE FILLED IN BASED ON RESPONSE TO THE DEMONSTRATION APPLICATION OR A PREVIOUS OSS.

1. Date:

2. EHRD Assigned Practice ID Number: {MERGE FIELD}

Please review your practice information below for accuracy. Please make corrections where necessary.

1.3. Legal Name of Practice					{MERGE FIELD}
1.4. Location Address:			{MERGE FIELD} Add a second line as in IPG web form
1.5. Location City:	{MERGE FIELD}					1.6. Location State	{MERGE}	1.7. Location Zip Code:	{MERGE FIELD}
1.8. Telephone No.:				{MERGE FIELD}
1.9. Fax No.:		{MERGE FIELD}
1.10. E-mail Address:					{MERGE FIELD}
1.11. Federal Tax ID for this practice:					{MERGE FIELD}

1.12. Please check here if all of the above information is correct.

1.13. Is your practice affiliated with an Independent Practice Association (IPA), Physician Hospital Organization (PHO) or other medical group?

Yes Please proceed to question 1.14

No Please proceed to question 1.15

1.14. Please indicate which type(s) of organization(s) your practice is affiliated with: {MERGE FIELD FROM PRIOR OSS RESPONSE; NOT COLLECTED ON APPLICATION}

IPA (please specify) ___________________________________________________

PHO (please specify) __________________________________________________

Community health center (please specify) __________________________________

Academic medical center (please specify) __________________________________

Owned by a hospital, hospital system or integrated delivery system

(please specify) _______________________________________________________

Owned by a larger medical group (please specify)_____________________________

Other (please specify) __________________________________________________

1.15 Is your practice currently participating in any of the following programs? Please check all that apply

	Physician Quality Reporting Initiative (PQRI)
	Better Quality Information
	Bridges to Excellence (BTE)
	Doctors Office Quality Information Technology (DOQIT) Warehouse submissions
	State or regional public reporting group
	Other private sector electronic health records (EHR) demonstrations or initiatives (please name, and include the sponsoring insurer or employer):
	Other federal quality improvement initiatives including pay-for-performance (please name):
	State or other publicly funded quality improvement initiatives including pay-for-performance or Medicaid IT initiatives (please name):
	Private quality improvement initiatives including pay-for-performance (please name):
	Other similar programs (please name):
	None of the above
	Do not know

SECTION 2 – Provider Profile

The following information comes from [your practice’s EHRD application form/AFTER YEAR 1 THIS WILL READ: the most recent practice information you provided for the EHR demonstration]. Please review the information below for accuracy and make corrections or additions where necessary.

Please note that provider identifiers are being requested in this survey to ensure that the correct information is associated with the practice. The information you provide will be used by CMS internally, only for the purposes of the EHRD and its evaluation. This information will not be shared or disseminated outside of the project staff.

2.0a. What is the total number of providers currently working at this practice in this location? (Please include all primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives, including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration. Please exclude residents and fellows.) _________________

2.0ab. The number of providers currently participating in the demonstration is____ [MERGE FIELD] ___________.

Is that correct?

Yes Please proceed to instructions in bold below

No Please proceed to question 2.0bc

2.0bc. What is the correct number of participating providers? ____________

Please verify the information below for each primary care provider participating in the demonstration who works at this practice location. (By primary care providers we mean: primary care physicians, specialty physicians practicing primary care, and physician assistants and nurse practitioners practicing primary care who bill Medicare independently, as enumerated in 2.0b or c).

Please note at the bottom of each box whether a previously mentioned provider has left the practice and the date of that departure, or a new provider has joined the practice and is participating in the demonstration and the date the provider joined the practice.

** ALL FIELDS BELOW WILL BE POPULATED WITH DATA FROM THE APPLICATION FORM, LAST OSS, OR MOST RECENT DATA FROM ARC – WHICHEVER IS MOST RECENT.

THE WEB PROGRAM WILL INCLUDE ENOUGH BOXES TO CAPTURE ALL THE LOCATION’S PARTICIPATING PROVIDERS’ INFORMATION

2.1. First Name 2.2. MI 2.3. Last Name

2.4. Individual (NPI) National Provider Identification Number

2.5. Credentials (MD, DO, NP, PA) 2.6. Specialty ¹ 2.8. Language(s) spoken (other than English)

2.7. If other, please specify

2.9. Provider’s Primary Practice Location (Y/N) ² 2.10. PIN # (Individual Medicare Billing Number) ³

Yes No

2.11. Please check here if all of the above is correct. 

Please check here if any information was incorrect, and make necessary corrections 

Please check here if this provider left the practice in the last year  Date of departure ______________

Please check here if this provider is new to the practice in the last year  Date joined practice_____________

2.1. First Name 2.2. MI 2.3. Last Name

2.4. Individual (NPI) National Provider Identification Number

2.5. Credentials (MD, DO, NP, PA) 2.6. Specialty ¹ 2.8. Language(s) spoken (other than English)

2.7. If other, please specify

2.9. Provider’s Primary Practice Location (Y/N) ² 2.10. PIN # (Individual Medicare Billing Number) ³

Yes No

2.11. Please check here if all the information is correct. 

Please check here if any information was incorrect, and make necessary corrections 

Please check here if this provider left the practice in the last year  Date of departure ______________

Please check here if this provider is new to the practice in the last year  Date joined practice_____________

[ADDITIONAL BOXES WILL BE AVAILABLE AS NEEDED]

Footnotes:

1 Please use the following codes to indicate specialty: Cardiology (C); Endocrinology (E); Family Practice (F); Geriatrics (G); Internal Medicine (I); Other (please specify)

2 Please indicate whether the provider listed primarily practices at this office location (that is, sees 50% or more of his or her patients primarily at this location).

3 Please provide the Individual Medicare Billing Number (PIN) that is assigned by the Medicare Carrier in your state for use by this provider at this practice location only. (HCFA 1500 form field 24K or 33).

2.120a. What is the total number of providers currently working at this practice in this location? (Please include all primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives, including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration. Please exclude residents and fellows.) _________________

NOTE THAT THE REMAINDER OF THE SURVEY PERTAINS TO THE TOTAL NUMBER OF PROVIDERS (NOT JUST THOSE PARTICIPATING IN THE DEMONSTRATION) AND TO ALL PATIENTS SEEN BY THOSE PROVIDERS (NOT JUST THOSE ON MEDICARE).

SECTION 3 - Use or Planned Use of Electronic Health Records, an Electronic Patient Registry, or an Electronic Prescribing system

A. Electronic Health Records

An Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. This record may include patient demographics (for example, age or sex), diagnoses, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and imaging reports.

An EHR system has the capability of generating a complete record of a clinical patient encounter, as well as supporting other care-related activities, such as evidence-based decision support, quality management, and outcomes reporting. (The EHR covers all conditions that the patient might have, as distinct from a registry that covers a specific disease or a limited set of diseases). A practice management or billing system is not an EHR system.

Implementation of specific functions within an EHR system may vary based on the goals set by a practice and could include: entering progress notes; providing decision support within the patient encounter; and utilizing computerized physician order entry for laboratory tests and prescriptions.

This subsection (A) asks about the use (or planned use) of an EHR system in this practice location. (Subsection B will ask about electronic patient registries, and Subsection C will ask about electronic prescribing.)

3.1	DoesHas your practice currently haveimplemented an EHR in this location? (By “implemented” we mean an EHR has been purchased, installed, and tested, and is currently being used.)
	Yes Proceed to question 3.3
	No Proceed to question 3.2
3.2	When do you plan to implement an EHR at this practice location? 0-6 months 7-12 months 13-24 months other _______________________________
	If you answered No to question 3.1, please proceed to Subsection B, Electronic Patient Registry
If you answered Yes to 3.1, please answer questions 3.3-3.6.
3.3	When did the practice acquire (that is, install)purchase the current EHR from the vendor? ____________________(mm/dd/yy)
3.4	What is the vendor name, product name, and version of the EHR system you currently have at this practice location?
3.5	Is the EHR system certified, or has it ever been certified, by the Certification Commission for Healthcare Information Technology (CCHIT)? (www.cchit.org) Yes Please proceed to question 3.5a No Please proceed to question 3.6
3.5a	In what year was the EHR system certified? (If more than one year, indicate the most recent year.) _____________(yyyy) Don’t know
3.6	Are you currently using the system in this practice location? (By “use” we mean use for purposes related to patient care. If the system is used solely for practice management or billing, please respond “no.”)
	Yes
	No Please proceed to question 3.8

3.7 How many of the [FILL IN FROM 2.120a] providers in this practice location currently use the practice’s EHR system? ________ (By “use” we mean using for any purpose or functions.)

The total number of providers includes primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a.

3.8 Have you received any technical assistance on the adoption of the EHR system or other health information technology (HIT)?

Yes Please proceed to question 3.8a

No Please proceed to Subsection B, Electronic Patient Registry

3.8a IF YES: Where did you receive this technical assistance from? Please check all that apply.

	DOQ-IT University
	Quality Improvement Organization (QIO)
	Health Information Technology Adoption or e-health Initiative
	EHR vendor (please specify):
	Private consultant
	Larger organization that owns this practice
	Other (please name):

B. Electronic Patient Registry

For purposes of this survey, an electronic patient registry is defined as an electronic system, either a component of an EHR or a stand-alone system that is designed to: identify patients with specific diagnoses or medications; identify patients overdue for specific therapies; facilitate prompt ordering of specific laboratory tests or recommended drugs; and facilitate prompt communication with patients requiring follow-up. A stand-alone registry is a separate electronic system from an EHR system. (It may also be referred to as a patient e-registry.)

For example, a practice may use a registry for its diabetes patients to document care at visits, and to create reports that indicate which patients are due for certain blood tests, or are not meeting specific treatment goals for diabetes. A registry may also be used to ensure all suggested preventive screenings take place.

These next questions ask about the use of electronic registries in your practice.

If this practice location hasdoes NOT currently implementedhave an EHR (that is, you answered “no” to 3.1), please proceed to 3.9b.

3.9a HasDoes your this practice at this location implementeduse an EHR (rather than a stand-alone patient registry) to perform registry functions, such as tracking patients who have a specific chronic illness, or receive preventive care (that is, immunizations, mammography and other cancer screening) for at least one condition? (By “implemented” we mean an EHR has been purchased, installed, and tested, and is currently being used.)

Yes Please proceed to Question 3.13

No Please proceed to Question 3.9b

3.9b Has yourDoes this practice at this location implementedhave a stand-alone patient registry to track patients who have a specific chronic illness, or receive preventive care (that is, immunizations, mammography and other cancer screening) for at least one condition? (By “implemented” we mean an EHR has been purchased, installed, and tested, and is currently being used.)

Yes Please proceed to Question 3.9c

No Please proceed to Question 3.14

3.9c Is this stand-alone patient registry linked with your EHR system? That is, do you electronically update the registry from the EHR system?

An electronic update may include regularly running a program to transfer data from the EHR to the registry.

Yes

No

3.10 When did the practice purchaseacquire (that is, install) the current stand-alone patient registry from the vendor?

________________________(mm/dd/yy)

3.11 What is the vendor name, product name, and version of the stand-alone patient registry that you currently have at this practice location?

3.12 Are you currently using the stand-alone patient registry system at this practice location? (By “use” we mean use for purposes related to patient care. If the system is used solely for practice management or billing, please respond “no.”) (By “use” we mean using for any purpose or functions.)

Yes Please proceed to question 3.13

No Please proceed to Subsection C, Electronic prescribing

3.13 For which of the following conditions is your EHR system (or stand-alone patient registry) being used to manage patient care?

By “manage patient care” we mean using the electronic system to help improve care for patients with a specific diagnosis or condition. This often occurs, for example, through the use of electronic clinical reminders or other informational or decision supports within the EHR or registry, or by the EHR or registry’s making it possible to do targeted outreach to patients with the condition.

a. Diabetes Yes No f. Adult Asthma Yes No

b. Coronary Artery Disease Yes No g. Depression Yes No

c. Hypertension Yes No h. Anticoagulation Yes No

d. Congestive Heart Failure Yes No i. Other Yes No

e. Preventive Care Yes No If other, please specify: _________________

__________________________________

If you answered no to question 3.9b, please answer question 3.14. All others please proceed to Subsection C, Electronic Prescribing System

3.14 When do you plan to implement a patient registry system, either within an EHR or as a stand-alone system, at this practice location? Do not plan to implement one 0-6 months 7-12 months 13-24 months

other _______________________________

C. Electronic Prescribing System

Electronic prescribing tools are designed to generate prescriptions and to conduct other functions related to medication prescribing. They may either be components of an EHR or stand-alone system and sometimes include hand-held devices.

The next series of questions ask to what extent your practice uses an electronic prescribing tool and whether that tool is a stand-alone or part of your EHR.

If this practice location hasdoes NOT currently implementedhave an EHR (that is, you answered “no” to 3.1), please proceed to 3.15b.

3.15a Has Does your practice at this location implementeduse an EHR to generate prescriptions? (By “implemented” we mean an EHR has been purchased, installed, and tested, and is currently being used.)

Yes Please proceed to Section 4, Electronic System Functions

No Please proceed to Question 3.15b

3.15b HasDoes your practice at this location implementedhave a stand-alone electronic prescribing system to generate prescriptions? (By “implemented” we mean an EHR has been purchased, installed, and tested, and is currently being used.)

Yes Please proceed to Question 3.15c

No Please proceed to Question 3.19

3.15c Is this stand-alone prescription system linked with your EHR system? That is, do you electronically update the prescription system from the EHR system?

An electronic update may include regularly running a program to transfer data from the EHR to the e-prescribing system.

Yes

No

3.16 When did the practice purchaseacquire (that is, install) the current stand-alone prescribing system? _________________ (mm/dd/yy)

3.17 What is the vendor name, product name, and version of the stand-alone prescribing system you currently have at this practice location?

_____________________________________________________

_____________________________________________________

3.18 Are you currently using the stand-alone prescribing system at this practice location? (By “use” we mean use for purposes related to patient care. If the system is used solely for practice management or billing, please respond “no.”) (By “use” we mean using for any purpose or functions.)

Yes Please proceed to Section 4, Electronic System Functions

No Please proceed to Section 4, Electronic System Functions

If you answered no to question 3.15b, please answer question 3.19. All others please proceed to section 4

3.19 When do you plan to implement an electronic prescribing system, either within an EHR or a free-standing system? Do not plan to implement one 0-6 months 7-12 months 13-24 months

other _________________

If this practice location hasdoes NOT currently implementedhave an EHR, hasdoes NOT implementeduse an electronic patient registry, AND hasdoes NOT implementeduse an electronic prescribing system (that is, you answered “no” to 3.1 AND 3.9b AND 3.15b), please proceed to Section 5. All others please continue to Section 4, question 4.10.

SECTION 4 – Electronic Health Record, Patient Registry, and Prescribing System Functions

An EHR system has the capability of generating a complete record of a clinical patient encounter, as well as supporting other care-related activities, such as evidence-based decision support, quality management, and outcomes reporting. An EHR system can have many functions such as: entering progress notes; providing decision support within the patient encounter; and utilizing computerized physician order entry for laboratory and prescriptions. Electronic patient registries and electronic prescribing systems may perform some of these functions.

Domain 1. Completeness of Information

PROPORTION OF PAPER RECORDS/CHARTS

4.10 Please estimate the proportion of…		None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.10a	Paper records that have been transitioned to the EHR system. By “transitioned” we mean either scanned documents in full into the EHR or keyed in data items by hand (such as patient demographics, medical history, blood pressure readings, test results)
4.10b	Paper charts that awere pulled for scheduled patient visits over the past month

If response to 4.10a =is “None”0, please proceed to next section below. For all other responses to 4.10a, please proceed to question 4.10c

4.10c What method did you predominantly use to transition your paper records to the EHR system? Was it to scan documents in full into the system, key in the data items by hand, a combination of both, or some other method?

Scan documents in full

Key in data items by hand

Combination of scanning and keying in items

Other, please specify: ___________________________________________________

__________________________________________________________________

Domain 1. Completeness of Information (Cont.)

*

This section asks about the extent to which your practice uses an EHR system, electronic patient registry, or electronic prescribing system for maintaining different types of patient data. When responding please refer to patients seen over the past month by ALL providers in this practice location, or by other office staff acting on behalf of those providers. When the item is about using a function for a subset of patients – such as those needing imaging studies – please refer to the proportion of relevant patients. By “all providers” we mean all the primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives in this practice location (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a.

Please estimate the proportion of patients for which providers (or others acting on their behalf) at this practice location use the EHR, electronic patient registry, or electronic prescribing system to performfor each of the following functions (as opposed to relying on paper charts).

PROPORTION OF PATIENTS

Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.1Aad. Maintain cClinical notes for individual patients Refers to using the electronic system to create, update, store and display clinical notes.
4.1eAd. Maintain aAllergy lists for individual patients Refers to using the electronic system to create, update, store and display a list of medications or other agents (food, environmental) to which patient has a known allergy or adverse reaction.
4.1fAe. Maintain pProblem or diagnosis lists for individual patients Refers to using the electronic system to create, update, store and display a list of problems or diagnoses for a patient.
4.1gAf. Enter or maintain pPatient demographics (for example, age or sex) Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the system.
4.1hAg. Maintain pPatient medical historiesy
4.1iCa. Recording (or entering) laboratory orders into electronic system Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the system. Includes orders for lab tests conducted by external providers and the practice itself.
4.1jCf1. Receivinge laboratory results by fax or mail and scanning paper versions into electronic system Refers to converting the image or text from paper into a digital image or text that is saved in the electronic system. Includes results from lab tests conducted by external providers and the practice itself.
4.1kCl. Reviewing laboratory test results electronically Refers to (1) system tracking that results have been received and (2) physician examining screens with displays of results stored in the system.
4.1lCb. Recording (or entering) imaging orders into electronic system Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the system. Includes orders for imaging conducted by external providers and the practice itself.
4.1mCf2. Receivinge imaging results by fax or mail and scanning paper versions into electronic system Refers to converting the image or text from paper into a digital image or text that is saved in the electronic system. Includes results from imaging conducted by external providers and the practice itself.
4.1nCm. Reviewing imaging results electronically Refers to (1) system tracking that results have been received and (2) physician examining screens with displays of results stored in the system.
4.1oDd. Recording that instructions or educational information were given to patient [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.1p2Aa. Recording (or entering) prescription medications (new prescriptions and refills) into electronic system Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the system.

Domain 2: Communication of Care Outside the Practice

*

This section asks about the extent to which your practice uses an EHR system, electronic patient registry, or electronic prescribing system for communication with providers outside the practice. Providers outside the practice include those that are part of a larger organization or network with which the practice is affiliated. When responding, please refer to all patients seen over the past month with certain conditions by ALL providers in this practice location, or by other office staff acting on behalf of those providers. By “all providers” we mean all the primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives in this practice location (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a.

Please estimate the proportion of patients for which providers (or others acting on their behalf) at this practice location use the EHR, electronic patient registry, or electronic prescribing system to perform each of the following functions (as opposed to relying on paper charts).

PROPORTION OF PATIENTS

Functions	None 0	Some, but less than ¼ 1		1/4 or more, but less than 1/2 2		1/2 or more, but less than ¾ 3		3/4 or more 4
Laboratory Orders
Items 4.2a1C -2bc1, and -2cd1 and –e1 form a hierarchy of laboratory ordering functions, ordered by degree of technological sophistication. Your responses to the three questions should represent the experience of all patients in your practice at this location who needed laboratory work over the past month. If the range of proportions given for these three questions sum to more than 1, a pop up box will appear that asks you to review your responses for accuracy and make any corrections as needed.	* (If responses to the three items below sum to more than 1, a pop up box will appear that says, “The range of proportions that you responded to these three items sum to more than 1. Please review your responses for accuracy and revise any as needed.”)
4.2a1Cc1. Print and fax laboratory orders to facilities outside the practice Order is first printed and then sent over a telephone line using a stand-alone fax machine.
4.2b1Cd1. Fax laboratory orders electronically from system, or order electronically through a portal maintained by the laboratoryfacilities outside the practice Order is generated electronically, using a macro or template, and faxed directly through the electronic system to the laboratory or ordered directly without using any paper or a stand-alone fax machine.
4.2c1Ce1. Transmit laboratory orders electronically directly from system to facilities outside the practice that have the capability to receive such transmissions Order is sent as machine-readable data.
Functions	None 0		Some, but less than ¼ 1		1/4 or more, but less than 1/2 2		1/2 or more, but less than ¾ 3		3/4 or more 4
Imaging Orders
Items 4.2d1C,-c2e2, and -2f-d2 and –e2 form a hierarchy of imaging ordering functions, ordered by degree of technological sophistication. Your responses to the three questions should represent the experience of all patients in your practice at this location who needed imaging over the past month. If the range of proportions given for these three questions sum to more than 1, a pop up box will appear that asks you to review your responses for accuracy and make any corrections as needed.	*(If responses to the three items below sum to more than 1, a pop up box will appear that says, “The range of proportions that you responded to these three items sum to more than 1. Please review your responses for accuracy and revise any as needed.”)
4.2d1Cc2. Print and fax imaging orders to facilities outside the practice Order is first printed and then sent over a telephone line using a stand-alone fax machine.
4.2e1Cd2. Fax imaging orders electronically from system, or order electronically through a portal maintained by facilities outside the practice Order is generated electronically, using a macro or template, and faxed directly through the electronic system to the imaging facility without using any paper or a stand-alone fax machine.
4.2f1Ce2. Transmit imaging orders electronically directly from system to facilities outside the practice that have the capability to receive such transmissions Order is sent as machine-readable data.
Laboratory Results
Items 4.2g1C -2hg1, -h1 and –2ii1 form a hierarchy of inputting laboratory results into an EHR system, ordered by degree of technological sophistication. Your responses to the three questions should represent the experience of all patients in your practice at this location who received laboratory results over the past month. If the range of proportions given for these three questions sum to more than 1, a pop up box will appear that asks you to review your responses for accuracy and make any corrections as needed.	*(If responses to the three items below sum to more than 1, a pop up box will appear that says, “The range of proportions that you responded to these three items sum to more than 1. Please review your responses for accuracy and revise any as needed.”)
4.2g1Ch1. Transfer electronic laboratory results (received in non-machine readable form, such as an e-fax) directly into system Refers to saving or attaching an electronic submission, such as an e-fax, that is not electronically searchable in the EHR system. (An e-fax is a transmission of the image of a document directly from a computer or multi-purpose printer without the use of stand-alone fax equipment to generate the paper-based image.)
4.2h1Cg1. Enter laboratory results manually into electronic system in a searchable field (whether received by fax, mail or phone) Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the electronic system and is searchable.
Functions	None 0	Some, but less than ¼ 1		1/4 or more, but less than 1/2 2		1/2 or more, but less than ¾ 3		3/4 or more 4
4.2i1Ci1. Receive electronically transmitted laboratory results directly into system from facilities that have the capability to send such transmissions Results are received electronically and do not need to be manually uploaded or posted into the system.
Imaging Results
Items 4.2j1C -2kg2, -h2 and – and -2li2 form a hierarchy of inputting imaging results into an EHR system, ordered by degree of technological sophistication. Your responses to the three questions should represent the experience of all patients in your practice at this location who received imaging results over the past month. If the range of proportions given for these three questions sum to more than 1, a pop up box will appear that asks you to review your responses for accuracy and make any corrections as needed.	(If responses to the three items below sum to more than 1, a pop up box will appear that says, “The range of proportions that you responded to these three items sum to more than 1. Please review your responses for accuracy and revise any as needed.”)
4.2j1Ch2. Transfer electronic imaging results (received in non-machine readable form, such as an e-fax) directly into system Refers to saving or attaching an electronic submission, such as an e-fax, that is not electronically searchable into the EHR system. (An e-fax is a transmission of the image of a document directly from a computer or multi-purpose printer without the use of stand-alone fax equipment to generate the paper-based image.)
4.2k1Cg2. Enter imaging results manually into electronic system in a searchable field (whether received by fax, mail or phone) Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the electronic system and is searchable.
4.2l1Ci2. Receive electronically transmitted imaging results directly into system from facilities that have the capability to send such transmissions Results are received electronically and do not need to be manually uploaded or posted into the system.
Referral and Consultation Requests
4.2m1Dh. Enter requests for referrals to or consultation with other providers (for example, specialists, sub-specialists, physical therapy, speech therapy, nutritionists) Refers to recording physician or patient requests for referral/ consultation, scheduling the referral/ consultation, and tracking results of referral/ consultation.
Functions	None 0	Some, but less than ¼ 1		1/4 or more, but less than 1/2 2		1/2 or more, but less than ¾ 3		3/4 or more 4
Sharing Information with other Providers
4.2n1.D.i. Transmit medication lists or other medical information to other providers (for example, hospitals, home health agencies, or other physicians)
4.2o1Dj1. Transmit laboratory results to other providers (for example, hospitals, home health agencies, or other physicians) Results are sent as machine-readable data.
4.2p1Dj2. Transmit imaging results to other providers (for example, hospitals, home health agencies, or other physicians) Results are sent as machine-readable data.
4.2q3e. Receive electronically transmitted reports directly into system, such as discharge summaries, from hospitals or other facilities that have the capability to send such transmissions
Prescription Orders
Items 4.2rA -2s-d, -e and –2tf form a hierarchy of sending prescriptions, ordered by degree of technological sophistication. Your responses to the three questions should represent the experience of all patients in your practice at this location over the past month. If the range of proportions given for these three questions sum to more than 1, a pop up box will appear that asks you to review your responses for accuracy and make any corrections as needed. Note that these questions excludeEXCLUDE Schedule II-V drugs	(If responses to the three items below sum to more than 1, a pop up box will appear that says, “The range of proportions that you responded to these three items sum to more than 1. Please review your responses for accuracy and revise any as needed.”)
4.2rAd. Print prescriptions (new prescriptions and refills) on a computer printer and fax to pharmacy or hand to patient
4.2sAe. Fax prescription orders (new prescriptions and refills) electronically from electronic system The prescription is faxed without using any paper or a stand-alone fax machine.
4.2tAf. Transmit prescription orders (new prescriptions and refills) electronically directly from system to pharmacies that have the capability to receive such transmissions The prescription is sent and received without relying on a stand-alone fax machine at either the provider’s office or the pharmacy.
4.3e. Electronic receipt of reports, such as discharge summaries, from hospitals that have the capability to send such transmissions

Domain 3: Clinical Decision Support

*

This section asks about the extent to which your practice uses an EHR system, electronic patient registry, or electronic prescribing system for clinical decision support. When responding please refer to patients seen over the past month by ALL providers in this practice location, or by other office staff acting on behalf of those providers. By “all providers” we mean all the primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives in this practice location (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a. Please complete all questions in the survey unless directed within it to skip a section. If you are not aware of how all the providers in the practice are using the functions asked about in this section, please consult with them prior to answering the questions..Please

Please estimate the proportion of patients for which providers (or others acting on their behalf) at this practice location use the EHR, electronic patient registry, or electronic prescribing system to perform each of the following functions (as opposed to relying on paper charts).

PROPORTION OF PATIENTS

Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.3a1Ab. Enter information from clinical notes into documentation templates Documentation templates are preset formats that determine what information will be displayed on each page and how it will be displayed. Templates usually allow information to be displayed as discrete data elements (that is, each element of data is stored in its own field or box.) For example, the clinical notes page can have separate boxes for entry of notes or data about a patient’s height, weight, blood pressure, or other vital signs. Methods of entry include direct keyboard entry (typing); entering notes/data using templates, forms or drop-down menus; or dictation with the voice transcribed manually or via voice recognition into text that is later integrated into the system.
4.3b1Aj. View graphs of patient height or weight data over time
4.3c1Ak. View graphs of patient vital signs data over time (such as blood pressure or heart rate)
4.3d1Ck. Flag incomplete or overdue test results
4.3e1Cn. Highlight out of range test levels Refers to system comparing test results with guidelines or provider-determined goals for this patient
4.3f1Co. View graphs of laboratory or other test results over time for individual patients
Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.3g1Cp. Prompt clinicians to order necessary tests, studies, or other services
4.3h1Da. Review and act on reminders at the time of a patient encounter regarding interventions, screening, or follow-up office visits recommended by evidence-based practice guidelines [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.3i2Ba. Reference information on medications being prescribed Electronic system displays information about medications stored in its e-prescribing module/ subsystem or offers providers links to Internet websites with such information.
4.3j2Bd. Reference guidelines and evidence-based recommendations when prescribing medication for a patient Electronic system links to published diagnosis-specific guidelines or recommendations that includes appropriate medications for that diagnosis

Domain 3: Clinical Decision Support (Cont.)

*

The next section asks about the extent to which your practice uses an EHR system (or an electronic patient registry or electronic prescribing system) for clinical decision support. When responding please refer to this practice location’s experience over the past year. If you are not aware of how all the providers in the practice are using the functions asked about in this section, please consult with them prior to answering the questions.

For each type of report, please note the extent to which this practice location used the EHR, electronic patient registry or electronic prescribing system (as opposed to reviewing paper charts) to generate reports.

Extent of Use During Last Year

Report types	0=Not used during last year	1=As needed basis or at least once	2=Regularly for full practice
4.3ka Search for or generate a list of patients requiring a specific intervention (such as an immunization)
4.3lb Search for or generate a list of patients on a specific medication (or on a specific dose of medication)
4.3mc Search for or generate a list of patients who are due for a lab or other test in a specific time interval
4.3nd Search for or generate a list of patients who fit a set of criteria, such as age, diagnosis and clinical indicator value. For example, age less than 76, diagnosed with diabetes, and has an HbA1c greater than 9 percent.

Domain 4: Use of the System to Increase Patient Engagement/Adherence

*

This section asks about the extent to which your practice uses an EHR system, electronic patient registry, or electronic prescribing system for increasing patient engagement and adherence to their care plans. When responding please refer to patients seen over the past month by ALL providers in this practice location, or by other office staff acting on behalf of those providers. By “all providers” we mean all the primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives in this practice location (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a.

Please estimate the proportion of patients for which providers (or others acting on their behalf) at this practice location use the EHR, electronic patient registry, or electronic prescribing system to perform each of the following functions (as opposed to relying on paper charts).

PROPORTION OF PATIENTS

Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.4a1Ah. Manage telephone calls Refers to bringing up a patient’s record whenever the patient calls or is called by the office and noting reason for the call.
4.4b1Ba. Exchange secure messages with patients
4.4c1Bb. Allow patients to view their medical records online
4.4d1Bc. Allow patients to provide information online to update their records
4.4e1Bd. Allow patients to request appointments online
4.4f1Be. Allow patients to request referrals online
4.4g1Db. Produce hard copy or electronic reminders for patients about needed tests, studies, or other services (for example, immunizations) [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.4h1Dc. Generate written or electronic educational information to help patients understand their condition or medication [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.4i1De. Create written care plans (personalized to patient’s condition or age/gender for preventive care) to help guide patients in self-management [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.4j1Df. Prompt provider to review patient self-management plan (or patient-specific preventive care plan) with the patient during a visit [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.4k1Dg. Modify self-management plan (or patient specific preventive care plan) as needed following a patient visit [This question will be asked for each CAD, HF, diabetes, and preventive diagnosis identified in question 3.13]
4.4l2Bb. Identify generic or less expensive brand alternatives at the time of prescription entry Electronic system includes formularies that identify generic or less expensive alternatives to selected medication or offers providers links to Internet websites with such information.
4.4m2Bc. Reference drug formularies of the patient's health plans/ pharmacy benefit manager to recommend preferred drugs at time of prescribing Preferred drugs refer to medicines that receive maximum coverage under the patient’s health plan.

Domain 5: Medication Safety

*

The next section asks about the extent to which your practice uses an EHR system, electronic patient registry, or electronic prescribing system for a variety of functions related to medication safety. When responding please refer to patients seen over the past month by ALL providers in this practice location, or by other office staff acting on behalf of those providers. By “all providers” we mean all the primary care physicians, specialty physicians, physician assistants, nurse practitioners, and nurse midwives in this practice location (including those who are participating in the demonstration, as well as those who are not eligible for or not participating in the demonstration) as enumerated in 2.120a.

Please estimate the proportion of patients for which providers (or others acting on their behalf) at this practice location use the EHR, electronic patient registry system, or electronic prescribing system to perform each of the following functions (as opposed to relying on paper charts).

PROPORTION OF PATIENTS

Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.5a1Ac. Maintain medication list for individual patients Refers to using the electronic system to create, update, store and display a list of all medications (prescription and non-prescription) that the patient is taking.
4.5b2Ab. Generate new prescriptions (that is, system prompts for common prescription details including medication type and name, strength, dosage, and quantity)
4.52Ac. Generate prescription refills (that is, system allows provider to reorder a prior prescription by revising original details associated with it, rather than requiring re-entry)
4.5d2Be. Select individual medication for prescription (for example, from a drop-down list in the electronic system)
4.5e2Bf. Calculate appropriate dose and frequency, or suggest administration route based on patient parameters such as age, weight, or functional limitations
4.5f2Bg. Screen prescriptions for drug allergies against the patient's allergy information
4.5g2Bh. Screen new prescriptions for drug‑­drug interactions against the patient's list of current medications
Functions	None 0	Some, but less than ¼ 1	1/4 or more, but less than 1/2 2	1/2 or more, but less than ¾ 3	3/4 or more 4
4.5h2Bi. Check for drug-laboratory interaction Such as to alert provider that patient is due for a certain laboratory or other diagnostic study to monitor for therapeutic or adverse effects of the medication or to alert provider that patient is at increased risk for adverse effects. Electronic system may either store this information or link to Internet websites with such information.
4.5i 2Bj Check for drug-disease interaction Electronic system may either store this information or link to Internet websites with such information.

SECTION 5 - Data Attestation

WARNING: You will be unable to make changes to your responses once you have completed this section.

5.1 I have reviewed the data submitted in this survey and agree that it is a correct assessment of this practice. I understand and acknowledge that my survey responses are accurate to the best of my knowledge and may be subject to validation. (Practices that knowingly make false attestations could lose any incentive payments that were made based on false data).

Agree Disagree

5.2 Name:

5.3 Title:

Signature: (this line is for hard copy questionnaire. Otherwise 5.21 serves as the e-signature)

_________________________________________________________________

5SECTION 6 – Attestation

6.1 I understand and acknowledge that my survey responses are accurate to the best of my knowledge and may be subject to validation, and that I have read and agreed to the data attestation above.

Agree Disagree

6.42 Comments? Please add any comments about the survey here.

Thank you for completing this survey.

30

Prepared by Mathematica Policy Research, Inc.