HIT_Field_Test_Eng_4pt_Web3

HIT_Field_Test_Eng_4pt_Web3.doc

CAHPS Field Test of Proposed Health Information Technology Questions and Methodology

HIT_Field_Test_Eng_4pt_Web3

OMB: 0935-0158

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CAHPS® Clinician & Group Survey


Version: Adult Primary Care Questionnaire 1.0 – HIT Field Test Version (Internet)


Language: English


Response Scale: 4 points




File name: 14329002_Web3

Last updated: November 9, 2009

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

Instructions for Introductory Web Screen(s)


  • Replace the cover of this document with your own front cover. Include a user-friendly title and your own logo.

  • Include this text regarding the confidentiality of survey responses:

Your Privacy is Protected. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied unless you consent to the use of the information for another purpose. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential.

Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the health care you get.

If you want to know more about this study, please call XXX-XXX-XXXX.










































Additional guidance is available in Preparing a Questionnaire Using the CAHPS Clinician & Group Survey: https://www.cahps.ahrq.gov/cahpskit/files/32_CG_Preparing_a_Questionnaire.pdf




Your Doctor

1. Our records show that you got care either online or in person from [FILL DOCTOR NAME] in the last 12 months.

Is that right?

1 Yes

2 No If No, go to #59 on page 10



The questions in this survey booklet will refer to the doctor named in Question 1 as “this doctor.” Please think of that doctor as you answer the survey.


2. Is this the doctor you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

1 Yes

2 No



3. How long have you been going to this doctor?

1 Less than 6 months

2 At least 6 months but less than 1 year

3 At least 1 year but less than 3 years

4 At least 3 years but less than 5 years

5 5 years or more



Your Care From This Doctor in the Last 12 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital.


4. In the last 12 months, how many times did you visit this doctor to get care for yourself?

None If None, go to #10

1 time

2

3

4

5 to 9

10 or more times



5. In the last 12 months, did you phone this doctor’s office to get an appointment for an illness, injury or condition that needed care right away?

1 Yes

2 NoIf No, go to #7



6. In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed?

1 Never

2 Sometimes

3 Usually

4 Always



7. In the last 12 months, did you make any appointments for a check-up or routine care with this doctor?

1 Yes

2 No If No, go to #10



8. In the last 12 months, when you made an appointment for a check-up or routine care with this doctor, how often did you get an appointment as soon as you thought you needed?

1 Never

2 Sometimes

3 Usually

4 Always



9. In the last 12 months, how often was it easy to make an appointment for a check-up or routine care at this doctor’s office?

1 Never

2 Sometimes

3 Usually

4 Always



10. Can you make appointments at this doctor’s office by e-mail or on a website?

1 Yes

2 No If No, go to #13

3 Don’t know If Don’t know, go to #13



11. In the last 12 months, did you use e-mail or a website to make an appointment at this doctor’s office?

1 Yes If Yes, go to #12

2 No

3 Don’t know If Don’t know, go to #13

11a. Why didn’t you use e-mail or a website to make an appointment at this doctor’s office?

_________________________________________________________________________________________________________

Go to #13



12. In the last 12 months, when you used e-mail or a website to get an appointment at this doctor’s office, how often did you get an appointment as soon as you thought you needed?

1 Never

2 Sometimes

3 Usually

4 Always



13. In the last 12 months, did you ever fill out a medical history form on a website before a visit to this doctor?

1 Yes

2 No If No, go to #14



13a. In the last 12 months, how often did this doctor seem informed and up-to-date about your medical history?

1 Never

2 Sometimes

3 Usually

4 Always



14. In the last 12 months, did you phone this doctor’s office with a medical question during regular office hours?

1 Yes

2 No If No, go to #16



15. In the last 12 months, when you phoned this doctor’s office during regular office hours, how often did you get an answer to your medical question that same day?

1 Never

2 Sometimes

3 Usually

4 Always



16. In the last 12 months, did you phone this doctor’s office with a medical question after regular office hours?

1 Yes

2 No If No, go to #18



17. In the last 12 months, when you phoned this doctor’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

1 Never

2 Sometimes

3 Usually

4 Always



18. In the last 12 months, did you e-mail this doctor’s office with a medical question?

1 Yes

2 No If No, go to #21



19. In the last 12 months, when you e-mailed this doctor’s office, how often did you get an answer to your medical question as soon as you needed?

1 Never

2 Sometimes

3 Usually

4 Always



20. In the last 12 months, when you e-mailed this doctor’s office, how often were all of the questions in your e-mail answered?

1 Never

2 Sometimes

3 Usually

4 Always



21. In the last 12 months, did this doctor’s office ever send you an e-mail to remind you about tests or treatment you needed?

1 Yes

2 No If No, go to #22



21a. In the last 12 months, did you make an appointment for any of the tests or treatment mentioned in a reminder e-mail?

1 Yes If Yes, go to #22

2 No



21b. Why didn’t you make an appointment for any of the tests or treatment mentioned in a reminder e-mail?

_________________________________________________________________________________________________________



PROGRAMMING NOTE: IF Q4 (# OF VISITS LAST 12 MOS = NONE), SKIP OVER Q22-35 TO Q36.



Your Visits To This Doctor in the Last 12 Months

22. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this doctor within 15 minutes of your appointment time?

1 Never

2 Sometimes

3 Usually

4 Always



23. In the last 12 months, how often did this doctor explain things in a way that was easy to understand?

1 Never

2 Sometimes

3 Usually

4 Always



24. In the last 12 months, how often did this doctor listen carefully to you?

1 Never

2 Sometimes

3 Usually

4 Always



25. In the last 12 months, did you talk with this doctor about any health problems or concerns?

1 Yes

2 No If No, go to #27



26. In the last 12 months, how often did this doctor give you easy to understand instructions about taking care of these health problems or concerns?

1 Never

2 Sometimes

3 Usually

4 Always



27. In the last 12 months, how often did this doctor seem to know the important information about your medical history?

1 Never

2 Sometimes

3 Usually

4 Always



28. In the last 12 months, how often did this doctor show respect for what you had to say?

1 Never

2 Sometimes

3 Usually

4 Always



29. In the last 12 months, how often did this doctor spend enough time with you?

1 Never

2 Sometimes

3 Usually

4 Always



30. Choices for your treatment or health care can include things like medicine, surgery, or other treatment. In the last 12 months, did this doctor tell you there was more than one choice for your treatment or health care?

1 Yes

2 No If No, go to #33



31. In the last 12 months, did this doctor talk with you about the pros and cons of each choice for your treatment or health care?

1 Yes

2 No



32. In the last 12 months, when there was more than one choice for your treatment or health care, did this doctor ask which choice you thought was best for you?

1 Yes

2 No



33. In the last 12 months, did this doctor order a blood test, x-ray or other test for you?

1 Yes

2 No If No, go to #35



34. In the last 12 months, when this doctor ordered a blood test, x-ray or other test for you, how often did someone from this doctor’s office follow up to give you those results?

1 Never

2 Sometimes

3 Usually

4 Always



35. Using any number from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor possible, what number would you use to rate this doctor?

0Worst doctor possible

1

2

3

4

5

6

7

8

9

10Best doctor possible





Your Prescription Medicines in the Last 12 Months

36. In the last 12 months, did you ever use
e-mail or a website to ask this doctor’s office to refill or renew one of your prescriptions?

1 Yes

2 No



37. In the last 12 months, did you ever use
e-mail or a website to ask this doctor’s office to prescribe a new medicine for you?

1 Yes

2 No



PROGRAMMING NOTE: IF Q4 (# OF VISITS LAST 12 MOS = NONE), SKIP OVER Q38-45 TO Q46.



This Doctor’s Use of Computers or Handheld Devices in the Last 12 Months

38. Doctors may use computers or handheld devices during an office visit to do things like look up your information or order prescription medicines. In the last 12 months, did this doctor use a computer or handheld device during any of your visits?

1 Yes

2 No If No, go to #44



39. During your visits in the last 12 months, did this doctor ever use a computer or handheld device to look up test results or other information about you?

1 Yes

2 No

3 Don’t know



40. During your visits in the last 12 months, did this doctor ever use a computer or handheld device to show you information?

1 Yes

2 No



41. In the last 12 months, did this doctor ever use a computer or a handheld device to order your prescription medicines?

1 Yes

2 No

3 Don’t know



42. During your visits in the last 12 months, was this doctor’s use of a computer or handheld device helpful to you?

1 Yes, definitely

2 Yes, somewhat

3 No



43. During your visits in the last 12 months, did this doctor’s use of a computer or handheld device make it harder or easier for you to talk with him or her?

1 Harder

2 Not harder or easier

3 Easier



Clerks and Receptionists at This Doctor’s Office

44. In the last 12 months, how often were clerks and receptionists at this doctor’s office as helpful as you thought they should be?

1 Never

2 Sometimes

3 Usually

4 Always



45. In the last 12 months, how often did clerks and receptionists at this doctor’s office treat you with courtesy and respect?

1 Never

2 Sometimes

3 Usually

4 Always


Website Information Provided By This Doctor’s Office

46. Does this doctor’s office put your laboratory or other test results on a website for you to see?

1 Yes

2 No If No, go to #51

3 Don’t know If Don’t know, go to #51



47. In the last 12 months did you look for your lab or other test results on the website?

1 Yes If Yes, go to #48

2 No



47a. Why didn’t you look for your lab or other test results on the website?

_________________________________________________________________________________________________________

Go to #51



48. In the last 12 months, how often was it easy to find these lab or other test results on the website?

1 Never

2 Sometimes

3 Usually

4 Always





49. In the last 12 months, how often were these lab or other test results put on the website as soon as you needed them?

1 Never

2 Sometimes

3 Usually

4 Always



50. In the last 12 months, how often were these lab or other test results presented in a way that was easy to understand?

1 Never

2 Sometimes

3 Usually

4 Always



51. Does this doctor’s office put a list of your prescription medicines on a website for you to see?

1 Yes

2 No If No, go to #54

3 Don’t know If Don’t know, go to #54



52. In the last 12 months, did you look at this list of your prescription medicines on the website?

1 Yes If Yes, go to #53

2 No



52a. Why didn’t you look at the list of your prescription medicines on the website?

_________________________________________________________________________________________________________

Go to #54



53. In the last 12 months, how often was the list of prescription medicines up to date?

1 Never

2 Sometimes

3 Usually

4 Always





54. Visit notes sum up what was talked about on a visit to a doctor’s office. Visit notes may be available on paper, on a website or by e-mail. In the last 12 months, did this doctor’s office offer you visit notes?

1 Yes

2 No If No, go to #58

3 Don’t know If Don’t know, go to #58



55. In the last 12 months, how did this doctor’s office offer you the visit notes? Mark one or more.

1 On paper

2 On a website

3 By e-mail

4 Some other way



56. In the last 12 months, did you look at any visit notes from this doctor’s office?

1 Yes If Yes, go to #57

2 No



56a. Why didn’t you look at any visit notes from this doctor’s office?

_________________________________________________________________________________________________________

Go to #58





57. In the last 12 months, how often were the visit notes easy to understand?

1 Never

2 Sometimes

3 Usually

4 Always


58. Health information technology is a way for doctors and patients to share medical information using technology like computers and the Internet.  This survey asked you about using e-mail to make appointments or send questions, seeing your test results on a web site, and other experiences with health information technology.  Are there any other kinds of health information technology we should have asked about in this survey?

_________________________________________________________________________________________________________






About You

59. In general, how would you rate your overall health?

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor



60. A health provider is a doctor, nurse or anyone else you would see for health care. In the past 12 months, have you seen a doctor or other health provider three or more times for the same condition or problem?

1 Yes

2 No If No, go to #62



61. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.

1 Yes

2 No



62. Do you now need or take medicine prescribed by a doctor? Do not include birth control.

1 Yes

2 No If No, go to #64



63. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

1 Yes

2 No



64. What is your age?

1 18 to 24

2 25 to 34

3 35 to 44

4 45 to 54

5 55 to 64

6 65 to 74

7 75 or older



65. Are you male or female?

1 Male

2 Female



66. What is the highest grade or level of school that you have completed?

1 8th grade or less

2 Some high school, but did not graduate

3 High school graduate or GED

4 Some college or 2-year degree

5 4-year college graduate

6 More than 4-year college degree

67. Are you Hispanic or Latino/Latina?

1 Yes

2 No



68. What is your race? Please mark one or more.

1 American Indian or Alaska Native

2 Asian

3 Black or African-American

4 Native Hawaiian or Other Pacific Islander

5 White



69. Did someone help you complete this survey?

1 Yes

2 No End Survey.




70. How did that person help you? Mark all that apply.

1 Read the questions to me

2 Entered the answers I gave

3 Answered the questions for me

4 Translated the questions into my language

5 Helped in some other way

Please explain:





Thank you.



File Typeapplication/msword
File TitleCAHPS® Clinician & Group Survey
AuthorLinda Markovich
Last Modified Byvhabedmcinnk
File Modified2009-11-09
File Created2009-11-09

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