Form #3 Form #3 Obesity questionnaire -- Yale

 

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

sthma Management and Obesity Prevention

Clinical Decision Support System Usability and User Satisfaction Survey

We are conducting a study to help us assess the usefulness of the Asthma Assessment Form and Obesity Prevention Form in the Electronic Medical Record. We are asking you to complete a brief survey that should take less than 10 minutes of your time. Your participation in this survey is completely voluntary and your answers will be anonymous. Thank you for helping us improve the design of clinical decision support tools for electronic health records.

Asthma Management

We are interested in understanding how you utilize the Electronic Medical Record for your patients with asthma. For each question below, indicate how often the statement is true.
		Never	Sometimes	Often	Usually	Always
a.	I begin to document the history in Centricity during the patient visit.
b.	I begin to document the exam findings in Centricity during the patient visit.
c.	I begin to document my assessment in Centricity during the patient visit.
d.	I begin to document my plan in Centricity during the patient visit.
e.	I print an asthma action plan and give it to the patient, if the patient has asthma on the problem list.
f.	I print an asthma action plan and give it to the patient, if the patient is having asthma symptoms.
g.	I have used the asthma management forms of the Centricity system.
h.	I complete the asthma management forms during the patient visit.

The following questions are about your beliefs about guidelines and decision support systems. A decision support system compares patient characteristics with a knowledge base and then guides a health provider by offering patient-specific and situation-specific advice.
		Never	Sometimes	Often	Usually	Always
a.	I am familiar with the recommendations for management of chronic asthma in the 2007 guidelines from the NIH/NHLBI.
b.	I agree with the recommendations for chronic asthma management in the 2007 guidelines from the NIH/NHLBI.
c.	I believe that reliance on practice guidelines leads to “cookbook medicine.”
d.	I know what a clinical decision support system is.
e.	I believe that clinical decision support systems have the capacity for improving patient care.

3. We are interested in your opinion of the asthma assessment forms in Centricity. Indicate the extent to which you agree or disagree with the following statements:
		Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
a.	The asthma management forms help me take better care of patients.
b.	The asthma management forms are not worth the time they take to use.
c.	The asthma management forms have useful reminders about something I might have forgotten to do.
d.	The asthma management forms are a useful tool to teach me about appropriate care for asthma.
e.	The way the asthma management forms were designed fits efficiently into my workflow.
f.	I needed to learn a lot of things before I could get going with the asthma management forms.
g.	The asthma management forms were designed in a way that minimizes data input.
h.	The asthma management forms offer a good note.
i.	The asthma management forms have too much inconsistency with the NIH/NHLBI guidelines.
j.	I would recommend the asthma management form to a colleague.
k.	The asthma management forms were cumbersome to use.

4. How satisfied are you with the way the asthma forms perform the following functions?
		Very Dissatisfied	Dissatisfied	Neutral	Satisfied	Very Satisfied
a.	Helping me assess asthma severity.
b.	Helping me assess asthma control.
c.	Helping me to choose appropriate therapies.
d.	Generating the asthma action plan.
e.	Creating progress notes
f.	Generating relevant reminders about specialty (allergy and pulmonology) referrals
g.	Entering prescriptions.

5. Do you have any other comments you would like to make regarding the asthma forms?

***If you do not provide primary care to patients at risk for obesity, please end the survey here***

Obesity Prevention

We are interested in understanding how you utilize the Electronic Medical Record for your patients at risk for obesity. For each question below, indicate how often the statement is true.
			Never	Sometimes	Often	Usually	Always
	a.	I begin to document the history in Centricity during the patient visit.
	b.	I begin to document the exam findings in Centricity during the patient visit.
	c.	I begin to document my assessment in Centricity during the patient visit.
	d.	I begin to document my plan in Centricity during the patient visit.
	e.	I have used the obesity prevention forms of the Centricity system.
	f.	I complete the obesity prevention forms during the patient visit.

3. We are interested in your opinion of the obesity assessment forms in Centricity. Indicate the extent to which you agree or disagree with the following statements:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

a.

The obesity prevention forms help me take better care of patients.

b.

The obesity prevention forms are not worth the time they take to use.

c.

The obesity prevention forms have useful reminders about something I might have forgotten to do.

d.

The obesity prevention forms are a useful tool to teach me about appropriate prevention of obesity.

e.

The way the obesity prevention forms were designed fits efficiently into my workflow.

f.

I needed to learn a lot of things before I could get going with the obesity prevention forms.

g.

The obesity prevention forms were designed in a way that minimizes data input.

h.

The obesity prevention forms offer a good note.

i.

The obesity prevention forms have too much inconsistency with the AMA/CDC guidelines.

j.

I would recommend the obesity prevention form to a colleague.

k.

The obesity prevention forms were cumbersome to use.

	5. How satisfied are you with the way the obesity forms perform the following functions?
				Very Dissatisfied		Dissatisfied		Neutral		Satisfied		Very Satisfied
a.		Helping me assess risk for overweight and obesity.
b.		Helping me to choose appropriate therapies.
c.		Helping me to choose an appropriate plan.
d.		Entering orders.
e.		Creating progress notes
f.		Guiding my counseling.

6. Do you have any other comments you would like to make regarding the obesity forms?

DEMOGRAPHICS AND BACKGROUND INFORMATION

1. How skilled are you in using the Centricity system?

Novice
Average User
Expert

2. In general, not just in terms of the Centricity system, how would you rate yourself as a computer user?

Novice
Average User
Expert

3. What is your profession?

MD/DO
Nurse Practitioner
Physician Assistant
APN/ARNP		Specify:
Other

4. At what level of training are you? 5. What is your age?

Resident
Fellow
Attending
Not applicable

25-34
35-44
45-54
55-64
65 or older

Thank you for completing this survey!

Public reporting burden for this collection of information is estimated to average 6 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.