Download:
pdf |
pdfOMB Approval No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx
Electronic Health Records Demonstration
Office Systems Survey
April 1, 2009
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.
Prepared by Mathematica Policy Research, Inc.
1
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.
Prepared by Mathematica Policy Research, Inc.
2
SECTION 1 - General Information – Practice
1.1. Date:
1.2. 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
1.4. Location
Address:
1.5.
Location
City:
{MERGE FIELD}
{MERGE FIELD} Add a second line as in IPG web form
1.6.
Location
State
{MERGE FIELD}
1.8. Telephone No.:
1.9. Fax No.:
{MERGE}
1.7. Location
Zip Code:
{MERGE FIELD}
{MERGE FIELD}
{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) __________________________________________________
Prepared by Mathematica Policy Research, Inc.
3
1.15 Is your practice currently participating in any of the following programs? Please check all that apply
Physician Quality Reporting Initiative (PQRI)
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
Prepared by Mathematica Policy Research, Inc.
4
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. 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 2.0b
2.0b. 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
Prepared by Mathematica Policy Research, Inc.
5
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
Yes
2.10. PIN # (Individual Medicare Billing Number) 3
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
Yes
2.10. PIN # (Individual Medicare Billing Number) 3
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
2
3
Please use the following codes to indicate specialty: Cardiology (C); Endocrinology (E); Family Practice (F); Geriatrics (G); Internal Medicine (I); Other
(please specify)
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).
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).
2.12 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).
Prepared by Mathematica Policy Research, Inc.
6
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
Has your practice implemented 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 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
Prepared by Mathematica Policy Research, Inc.
7
3.7
How many of the [FILL IN FROM 2.12] 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 2.12.
3.8
Have you received any technical assistance on the adoption of the EHR system or other health information
technology (HIT)?
Yes
No
Please proceed to question 3.8a
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 has NOT implemented an EHR (that is, you answered “no” to 3.1), please proceed to 3.9b.
3.9a Has your practice at this location implemented 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
Prepared by Mathematica Policy Research, Inc.
8
3.9b Has your practice at this location implemented 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 purchase 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.”)
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
b. Coronary Artery Disease
c. Hypertension
d. Congestive Heart Failure
e. Preventive Care
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
f. Adult Asthma
Yes
No
g. Depression
Yes
No
h. Anticoagulation
Yes
No
i. Other
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 _______________________________
Prepared by Mathematica Policy Research, Inc.
9
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 has NOT implemented an EHR (that is, you answered “no” to 3.1), please proceed to 3.15b.
3.15a Has your practice at this location implemented 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 Has your practice at this location implemented 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 eprescribing system.
Yes
No
3.16 When did the practice purchase 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.”)
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 _________________
Prepared by Mathematica Policy Research, Inc.
10
If this practice location has NOT implemented an EHR, has NOT implemented an electronic patient registry, AND
has NOT implemented 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 4.1.
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
4.1 Please estimate the proportion of…
None
4.1a
4.1b
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
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)
Paper charts that were pulled for scheduled
patient visits over the past month
If response to 4.1a = “None”, please proceed to next section below. For all other responses to 4.1a, please proceed
to question 4.1c
4.1c
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: ___________________________________________________
__________________________________________________________________
Prepared by Mathematica Policy Research, Inc.
11
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 2.12.
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 for each of the following functions (as
opposed to relying on paper charts).
None
Functions
4.1d. Clinical notes for individual patients
Refers to using the electronic system to create, update, store
and display clinical notes.
4.1e. Allergy 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.
4.1f. Problem 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.
4.1g. Patient 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.
4.1h. Patient medical histories
Prepared by Mathematica Policy Research, Inc.
12
PROPORTION OF PATIENTS
1/2 or
1/4 or
Some,
more,
more,
but less
but less
but less
than ¼
than
than 1/2
¾
3/4 or
more
None
Functions
4.1i. 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.
4.1j. Receiving 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.
4.1k. 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.
4.1l. 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.
4.1m Receiving 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.
4.1n. 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.
4.1o. 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]
Prepared by Mathematica Policy Research, Inc.
13
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
None
Functions
4.1p 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.
Prepared by Mathematica Policy Research, Inc.
14
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
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 2.12.
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).
None
Functions
PROPORTION OF PATIENTS
1/2 or
1/4 or
Some,
more,
more,
but less
but less
but less
than ¼
than
than 1/2
¾
3/4 or
more
Laboratory Orders
Items 4.2a -2b, and -2c 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.
4.2a 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.
4.2b Fax laboratory 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
laboratory or ordered directly without using any paper or a
stand-alone fax machine.
4.2c 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.
Prepared by Mathematica Policy Research, Inc.
15
* (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.”)
None
Functions
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
Imaging Orders
Items 4.2d,-2e, and -2f 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.”)
4.2d 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.
4.2e 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.
4.2f 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 4.2g -2h and –2i 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.
4.2g 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.)
Prepared by Mathematica Policy Research, Inc.
16
*(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.”)
4.2h 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.
None
Functions
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
4.2i 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 4.2j -2k, and -2l 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.
4.2j Transfer electronic imaging results (received in nonmachine 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.)
4.2k 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.
4.2l 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
Prepared by Mathematica Policy Research, Inc.
17
(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.”)
manually uploaded or posted into the system.
Referral and Consultation Requests
4.2m Enter requests for referrals to or consultation with
other providers (for example, specialists, subspecialists, 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.
None
Functions
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
Sharing Information with other Providers
4.2n Transmit medication lists or other medical
information to other providers (for example, hospitals,
home health agencies, or other physicians)
4.2o Transmit laboratory results to other providers (for
example, hospitals, home health agencies, or other
physicians)
Results are sent as machine-readable data.
4.2p Transmit imaging results to other providers (for
example, hospitals, home health agencies, or other
physicians)
Results are sent as machine-readable data.
4.2q 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 4.2r -2s,and –2t 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 exclude Schedule II-V drugs
Prepared by Mathematica Policy Research, Inc.
18
(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.”)
4.2r Print prescriptions (new prescriptions and refills) on
a computer printer and fax to pharmacy or hand to
patient
4.2s Fax prescription orders (new prescriptions and
refills) electronically from electronic system
The prescription is faxed without using any paper or a standalone fax machine.
4.2t 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.
Prepared by Mathematica Policy Research, Inc.
19
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 2.12.
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 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).
None
Functions
4.3a 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.
4.3b View graphs of patient height or weight data over
time
4.3c View graphs of patient vital signs data over time
(such as blood pressure or heart rate)
4.3d Flag incomplete or overdue test results
4.3e Highlight out of range test levels
Refers to system comparing test results with guidelines or
provider-determined goals for this patient
Prepared by Mathematica Policy Research, Inc.
20
PROPORTION OF PATIENTS
1/2 or
1/4 or
Some,
more,
more,
but less
but less
but less
than ¼
than
than 1/2
¾
3/4 or
more
4.3f View graphs of laboratory or other test results over
time for individual patients
None
Functions
4.3g Prompt clinicians to order necessary tests, studies,
or other services
4.3h Review and act on reminders at the time of a patient
encounter regarding interventions, screening, or
follow-up office visits recommended by evidencebased practice guidelines
[This question will be asked for each CAD, HF, diabetes,
and preventive diagnosis identified in question 3.13]
4.3i 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.
4.3j 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
Prepared by Mathematica Policy Research, Inc.
21
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
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
Not used during
last year
Report types
4.3k Search for or generate a list of patients requiring a
specific intervention (such as an immunization)
4.3l Search for or generate a list of patients on a specific
medication (or on a specific dose of medication)
4.3m Search for or generate a list of patients who are due
for a lab or other test in a specific time interval
4.3n 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.
Prepared by Mathematica Policy Research, Inc.
22
As needed
basis or at
least once
Regularly for
full practice
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 2.12.
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).
None
Functions
4.4a 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.
4.4b Exchange secure messages with patients
4.4c. Allow patients to view their medical records online
4.4d Allow patients to provide information online to
update their records
4.4e Allow patients to request appointments online
4.4f Allow patients to request referrals online
4.4g 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]
4.4h 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]
Prepared by Mathematica Policy Research, Inc.
23
PROPORTION OF PATIENTS
1/2 or
1/4 or
Some,
more,
more,
but less
but less
but less
than ¼
than
than 1/2
¾
3/4 or
more
None
Functions
4.4i 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]
4.4j 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]
4.4k 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]
4.4l 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.
4.4m 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.
Prepared by Mathematica Policy Research, Inc.
24
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
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 2.12.
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).
None
Functions
4.5a 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.
4.5b Generate new prescriptions (that is, system
prompts for common prescription details including
medication type and name, strength, dosage, and
quantity)
4.5c 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)
4.5d Select individual medication for prescription (for
example, from a drop-down list in the electronic
system)
4.5e Calculate appropriate dose and frequency, or
suggest administration route based on patient
parameters such as age, weight, or functional
limitations
4.5f Screen prescriptions for drug allergies against the
patient's allergy information
4.5g Screen new prescriptions for drug-drug interactions
against the patient's list of current medications
Prepared by Mathematica Policy Research, Inc.
25
PROPORTION OF PATIENTS
1/2 or
1/4 or
Some,
more,
more,
but less
but less
but less
than ¼
than
than 1/2
¾
3/4 or
more
None
Functions
4.5h. 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 Check for drug-disease interaction
Electronic system may either store this information or link to
Internet websites with such information.
Prepared by Mathematica Policy Research, Inc.
26
Some,
but less
than ¼
1/4 or
more,
but less
than 1/2
1/2 or
more,
but less
than
¾
3/4 or
more
SECTION 5 - Data Attestation ARRA Funding Experience
(a)
Yes, it did change the decision to adopt or change the pace of adoption
(b)
No, we were aware of the penalties, but it did not change the decision or pace of
adoption
No, we were not aware of the penalties
(c)
Prepared by Mathematica Policy Research, Inc.
27
Prepared by Mathematica Policy Research, Inc.
28
SECTION 6 -- Data Attestation
WARNING: You will be unable to make changes to your responses once you have completed this section.
65.1 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
65.2 Name: ______________________________________________________
65.3 Title: ________________________________________________________
Signature: (this line is for hard copy questionnaire. Otherwise 65.2 serves as the e-signature)
_________________________________________________________________
65.4 Comments? Please add any comments about the survey here.
Thank you for completing this survey.
Prepared by Mathematica Policy Research, Inc.
29
| File Type | application/pdf |
| Author | research laptop |
| File Modified | 2010-01-19 |
| File Created | 2010-01-19 |