Assessing the Feasibility of Disseminating Effective Health Care Products through a Shared Electronic Medical Record Serving Member Organizations of a Health Information Exchange

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #4 Survey of Clinicians	Form	New	Available
Form Form #3 Interviews with Patients	Form	New	Available
Form Form #2 Interviews with Support Staff	Form	New	Available
Form Form #1 Interviews with Clinicians	Form	New	Available
Supporting Statement Part B -- Assessing the Feasibility of Disseminating ECH Products Through EMR 5-25-2012.docx	Supporting Statement B	Uploaded 2012-05-25	Available
Attachment E -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2012-01-30	Available
Attachment F -- Description of Clinics.docx	Supplementary Document	Uploaded 2012-01-30	Available
Supporting Statement Part A -- Assessing the Feasibility of Disseminating ECH Products Through EMR 5-25-2012.docx	Supporting Statement A	Uploaded 2012-05-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200997	Survey of Clinicians	Form	New
200996	Interviews with Patients	Form	New
200995	Interviews with Support Staff	Form	New
200994	Interviews with Clinicians	Form	New

ICR Details

OMB Control No: 0935-0192	ICR Reference No: 201202-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Assessing the Feasibility of Disseminating Effective Health Care Products through a Shared Electronic Medical Record Serving Member Organizations of a Health Information Exchange
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/01/2012
	Date Received in OIRA: 02/02/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	24 Months From Approved
Responses	400	0	0
Time Burden (Hours)	133	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The collections proposed under this clearance include activities to assess the feasibility of disseminating materials developed by the Eisenberg Center - Baylor College of Medicine through the use of an electronic medical record (EMR) shared by a network of clinical care providers that are part of a Health Information Exchange (HIE) operating in multiple sites in several states.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 70726	11/15/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4041	01/26/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Interviews with Patients	Form #3	Interview Guide for Patients
Survey of Clinicians	Form #4	Questionnaire for Clinicians
Interviews with Clinicians	Form #1	Interview Guide for Clinicians
Interviews with Support Staff	Form #2	Interview Guide for Support Staff

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400	0	0	400	0	0
Annual Time Burden (Hours)	133	0	0	133	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

---

Annual Cost to Federal Government: $217,451

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/02/2012

---