Conduct Focus Groups to Test Messages and Materials

Form Approved

OMB No. 0990-0376

Exp. Date 07/31/2014

Attachment B1

Interviewer: _______________ Date: _______________ Letter sent: _______________ Reconfirmation Call: _______________

Group:

Physicians Screener for Focus Groups

CALL INTO PRIVATE PRACTICES

RECRUIT GPs/FPs/IMs/Pediatricians ONLY

RECRUIT 8 PER GROUP >>RECRUIT ONLY 1 PER PRACTICE

NEED GOOD MIX BY SMALL AND LARGE PRACTICE

Hello, I’m ___________ with _____________, an independent marketing research firm. We are not selling any product or service. We are conducting a research study among physicians on behalf of the U.S. Department of Health and Human Services and would like to include your views. My questions will only take a few minutes. May I speak with (insert Dr.’s name)?

1. First, do you, or does any member of your household or immediate family work for, or receive any compensation from:

A market research company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

The federal government _____

A company that provides IT support (including systems and software) to medical practices or hospitals _____

For a health insurance provider _____

For a managed care organization _____

As an employee or advocate at an organization that focuses on health

(Such as the American Cancer Society) _____

[IF “YES” TO ANY >> GET SPECIFICS AND HOLD]

2. What is your specialty? _____________________________

MUST BE GP/FP/IM/PED TO QUALIFY

[ATTEMPT MIX, BUT RECRUIT MAX. 2 PEDS]

2A. [ASK IF IM ONLY...]

What percentage of your practice is as a primary care physician?

________________ % [MUST BE AT LEAST 50% TO QUALIFY]

3. How long have you been practicing in your current specialty?

______________ >> [MUST BE AT LEAST 2 YEARS TO QUALIFY] [NEED GOOD MIX]

4. Are you currently in private practice?

Yes _____

TERMINATE >> No _____

4A. What percentage of your time is spent seeing patients in your private practice versus time spent in hospitals, clinics, or in academia?

____________________% >> [MUST BE AT LEAST 50% TO QUALIFY]

[NOTE: MUST BE IN PRIVATE PRACTICE & SPEND AT LEAST 50% OF THEIR TIME SEEING PRIVATE PRACTICE PATIENTS TO QUALIFY. IF WORK ONLY IN A PUBLIC SETTING - IN A HOSPTIAL, CLINIC, OR IN ACADEMIA >> TERMINATE]

4B. What is the name of your practice?

___________________________________ >> [MAX 1 PER PRACTICE]

5. How many doctors, physician’s assistants, and nurse practitioners are in your practice?

# Doctors ___________

# Physician’s Assistants +___________

# Nurse Practitioner +___________

Total = __________

IF TOTAL IS LESS THAN 8 > RECRUIT AS SMALL PRACTICE

IF TOTAL IS 8 OR GREATER > RECRUIT AS LARGE PRACTICE

[NEED GOOD MIX OF SMALL AND LARGE PRACTICES REPRESENTED]

6. Please indicate your planned timing for the adoption and implementation of a complete electronic health record (EHR) or electronic medical record (EMR) system.

Already adopted EHR system more than 6 months ago ___ >>> TERMINATE

Adopted EHR system within past 6 months ___ [RECRUIT for “Converted” Group]

Currently implementing EHR system ___ [RECRUIT for “Converted” Group]

Planning to implement EHR system within 1-3 years ___ [RECRUIT for “Planning” Group]

Planning to implement EHR system within 4+ yrs ___ [RECRUIT for “Not Planning” Group]

Not planning to implement EHR system ___ [RECRUIT for “Not Planning” Group]

7. Please tell me your age. _____________ [NEED MIX]

8. [Record Gender] [ATTEMPT MIX]

Male _____

Female _____

9. Have you ever attended a focus group discussion? By that we mean an informal, round-table discussion, conducted by a professional moderator, in which you were asked your opinions regarding a product, a service, or advertising?

ASK QUESTIONS A-C >> Yes _____

INVITE TO GROUP >> No _____

1. How many of these groups have you attended?

______________________________

2. How long ago was the last one of these groups you attended? [If more than two focus groups in past six months, TERMINATE]

______________________________

3. What was/were the topics discussed? [RECORD]

______________________________

[INVITE TO GROUP]

Thank you for answering my questions. As I mentioned, we are conducting a study on behalf of the US Department of Health and Human Services among physicians regarding electronic health records. Your input is critical to the success of the project.

In order to accomplish our research objective, we would like to invite you to take part in an informal, group discussion to be conducted on [DATE] at [TIME]. The discussion will be lead by a professional moderator and will last 1.5 hours or less. We are confident that you will enjoy the exchange of information and will find it beneficial.

As a token of appreciation for sharing your views, you will receive a [AMOUNT] cash incentive at the time of the discussion. If you prefer, we can donate the [AMOUNT] to a charity of your choice.

We can only invite a select number of physicians to take part. Can we schedule your participation?

[If yes, read…..]

If you need glasses for reading or watching TV, please bring them with you to the discussion.

[Record Group (“Converted”, “Planning”, or “Not Planning”)]

Group/Date/Time:

ID# _______________________________________________________________

NAME: _________________________________________________

PRACTICE NAME: ________________________________________________ [RECRUIT MAX 1 PER]

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) ( )___________________________________

(EVE) ( )___________________________________

(FAX) ( )___________________________________

(CELL) ( )____________________________________

(EMAIL) ___________________________________________

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 0990-0376. The time required to complete this information collection is estimated to average 10 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: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer