Form CMS-10273 Office System Survey Validation Form

OMB Approval No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx

Electronic Health Records Demonstration
Office Systems Survey
Validation Form
November 7, 2008

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 1.38 hours or 83 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, N2-14-26,
Baltimore, MD 21244-1850.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Thank you for participating in the validation of the Centers for Medicare & Medicaid Services (CMS) Office
Systems Survey (OSS). This validation is being conducted as part of the Electronic Health Records
Demonstration (EHRD) and its evaluation. The goal of this evaluation 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.
This form asks about the use of your Electronic Health Record (EHR) system to document clinical notes,
laboratory results and orders, imaging results and orders, and prescription medication orders. To document
each response, please print and send a screen shot (with all patient identifying information removed) from your
computer.
Please complete all sections of this form.
Again, we thank you for taking the time to fill out this important form.

Prepared by Mathematica Policy Research, Inc.

1

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

1.

Select three dates in the last two weeks on which more than five patients were seen at the practice.
Verify that, for each date, there is an electronic clinical note for 75 percent or more of every patient seen
in the office by a physician.
a.

Month/Day/Year:

|

|

|/|

|

|/|

|

|

|

|

… Yes

… No

b.

Month/Day/Year:

|

|

|/|

|

|/|

|

|

|

|

… Yes

… No

c.

Month/Day/Year:

|

|

|/|

|

|/|

|

|

|

|

… Yes

… No

2.

During the last two weeks, on the first day more than five patients were seen at the practice, select three
patients who had laboratory results reported to the practice.

2a.

For how many of these patients is the laboratory result received electronically in the practice’s system?
Patients

2b.

How were the laboratory results received by the electronic system?
Patient 1

Patient 2

Patient 3

a.

Fax………………………………………………….

b.

Mail………………………………………………….

c.

Scanned…………………………………………….

d.

Entered manually (keyboard entry)……………...

e.

Transferred directly (e-fax)……………………….

f.

Directly (electronically)……………………………

2c.

Are the laboratory orders for these three patients documented?

2ci.

2d.

Yes

Please proceed to Question 2ci

No

Please proceed to Question 2d

How many orders are documented?

Orders

For how many of these patients was the laboratory order sent electronically?
Patients

Prepared by Mathematica Policy Research, Inc.

2

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

2e.

How were the laboratory orders sent?
Patient 1

Patient 2

Patient 3

a.

Fax…………………………………………………..

b.

Mail………………………………………………….

c.

Scanned…………………………………………….

d.

Printed and faxed………………………………….

e.

Faxed electronically……………………………….

f.

Directly (electronically)……………………………

3.

During the last two weeks, on the first day more than five patients were seen at the practice, select three
patients who had imaging results reported to the practice.

3a.

For how many of these patients is the imaging result received electronically in the practice’s system?
Patients

3b.

How were the imaging results received by the electronic system?
Patient 1

Patient 2

Patient 3

a.

Fax…………………………………………………..

b.

Mail………………………………………………….

c.

Scanned…………………………………………….

d.

Entered manually (keyboard entry)……………..

e.

Transferred directly (e-fax)……………………….

f.

Directly (electronically)……………………………

3c.

Are the imaging orders for these patients documented?

3ci.
3d.

Yes

Please proceed to Question 3ci

No

Please proceed to Question 3d

How many orders are documented?

Orders

For how many of these patients was the imaging order sent electronically?
Patients

Prepared by Mathematica Policy Research, Inc.

3

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

3e.

How were the imaging orders sent?
Patient 1

Patient 2

Patient 3

a.

Fax…………………………………………………..

b.

Mail………………………………………………….

c.

Scanned…………………………………………….

d.

Printed and faxed………………………………….

e.

Faxed electronically……………………………….

f.

Directly (electronically)……………………………

4.

During the last two weeks, on the first day more than five patients were seen at the practice, select three
patients for whom a physician in the practice refilled prescription medications.

4a.

For how many of these patients was the order electronically documented in the system?
Patients

4b.

How were prescription orders sent?
Patient 1

Patient 2

Patient 3

a. Printed and faxed to pharmacy or handed to
patient…………………………………………………….
b. Faxed electronically……………………………….

c.

Directly (electronically)…………………………....

Prepared by Mathematica Policy Research, Inc.

4

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

5.

For validation purposes, please provide the last four digits of each patient’s social security number.
Last Four Digits of Social Security Number

Patient
1
2
3
4
5
6
7
8
9
6a.

Please print a patient de-identified screen shot to document each of your responses to questions 1
through 4 above.
To print a de-identified screen shot:
PC users: Click the PrintScreen key on your keyboard. Then click Start -> Programs -> Accessories ->
Paint. In the Paint program, select Edit – Paste and then File – SaveAs to save the screen image to a file.
Mac users: Mac Command key-Shift-3 captures the whole screen and saves a file to your desktop.
Print out the image and manually black out (or cross out) all patient identifying information.

6b.

Please fax all printed screen shots to Mathematica Policy Research at 609-799-0005, attention Martha
Kovac.

6c.

I have printed a screen shot to document each of the responses to questions 1 through 4 and faxed
them to Mathematica Policy Research. All patient information is de-identified.
1

… Agree

2

… Disagree

7.

I understand and acknowledge that my survey responses are accurate to the best of my knowledge
and may be subject to verification.
1

… Agree

2

… Disagree

Prepared by Mathematica Policy Research, Inc.

5

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

8a.

Name: ____________________________________

8b.

Title:

8c.

Phone number: _____________________________

____________________________________

(we will only call you if we have questions about your responses).
Thank you for completing this form.

Prepared by Mathematica Policy Research, Inc.

6

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to
receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.