Attachment H -- Consent Form

Consent to be Interviewed

Sponsorship and purpose of this research

This research is sponsored by Agency for Healthcare Research and Quality (AHRQ), an agency within the U.S. Department of Health and Human Services. The purpose of this research is to better identify and understand the barriers health care professionals face in meeting criteria to receive Medicaid incentive payments for using electronic health record systems, or EHRs. In July 2010, the Centers for Medicare and Medicaid Services released its final rule regarding the definitions of “meaningful use” of EHRs (45 CFR Part 170, July 13, 2010). These rules detail the eligibility criteria for receiving Federal monetary incentives for EHR adoption and use in health care practices.

Voluntariness

Participation is entirely voluntary and will not have any effect on your eligibility for Medicaid payments of any kind. You are under no obligation to answer any particular questions posed during the focus group. You may leave the group at any time. Your participation will have no effect on any reimbursements due to you for services rendered for Medicare or Medicaid. Nothing you say will have any effect on your eligibility to receive incentive payments for adoption and use of EHR systems in your practice.

Study size and procedures

Nationally, this study will include up to 90 health care professionals including physicians, dentists, physician assistants, licensed nurse practitioners, and certified nurse midwives. There will be up to 13 sessions. Some will be held in person, while others will be held via “virtual” conference calls. Each focus group will include between 7 to 10 participants if conducted in person, or between 3 to 5 if conducted in a “virtual” session. Participants were first selected from among a list of health care professionals who treat Medicaid patients, or through professional societies in your State. During the recruiting process, participants who said they met criteria for being eligible for receiving Federal incentives were asked to participate. Participants in the various medical professions (above) were recruited to provide a balance of types of licensure and their self-reported eligibility to participate in the incentive program. This eligibility was largely based on the proportion of their patients who are enrolled in Medicaid.

During the focus group, a moderator will lead the discussion by posing questions and asking follow up questions. Participants will offer their knowledge, attitudes, and behaviors regarding EHR usage, the incentives, and perceptions of uses by other providers such as pharmacies and other specialists. The focus group session should last approximately 2 hours.

Participants will be asked to respect each other’s privacy by not disclosing anything discussed in the focus group session. Participants will not be asked to refer to themselves by full name or the name of their practice. Sessions will be audio- and/or video- recorded. These recordings are kept for the purpose of ensuring accuracy. No one other than the research staff will see or hear the tapes. The tapes will be destroyed after the study’s findings are released.

Compensation

Participants will not be compensated at their hourly rate. Rather a gift ($200) is being offered at the completion of the focus group session as a token of appreciation.

Procedures for protecting confidentiality

Participants are being asked to agree not to discuss what they say or hear during the focus group session. This is to respect the privacy of each member. During the sessions, participants are being asked to use only their first names. Recordings of the sessions are being kept for the purpose of ensuring accuracy. No one other than the research staff will see or hear the tapes. The tapes will be destroyed after the study’s findings are released. By using only first names it becomes more difficult to identify any particular participant in the event a recording is lost or stolen. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c).

Potential risks or discomforts

There is a risk that someone in the focus group might recognize you. There is a risk that the audio or video tapes could be lost or stolen. There is also a potential that signed documents might be lost or stolen. We are taking steps to secure these risks by (a) requiring that participants agree not to discuss the focus group’s proceedings, (b) recording only first names of participants on the recordings, (c) temporarily storing written items and tapes in lockable brief cases and permanently storing them in lockable desks and file cabinets. We will destroy the tapes and documents at the earliest opportunity upon completion of our reporting. We will not contact participants after the completion of this session. For “virtual” focus group participants, the only contact after the discussion will be to deliver a token of appreciation.

There is the potential that some of the questions will cause some discomfort, though this we believe is a minimal risk.

Additional information

For additional information you may contact Dr. Sean O. Hogan, from RTI International. He is leading the data collection activities for this study. He can be reached at (800) 334-8571, ext. 2-5265, or email at [email protected]. If you have questions about your rights as a research subject, you may contact RTI International’s Office of Research Protection at 1-866-214-2043.

Statement of understanding

By signing this document I am stating that I have read (or have had read to me) this informed consent statement. By signing this document I attest that I understand the contents of this document.

Signature: _________________________________________ Date: _______________