0955-0003 GENERIC Submission REC Web Survey 9 7 12 (2)

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0955-0003)

T ITLE OF INFORMATION COLLECTION: Survey to Evaluate the Use of HITRC Tool, Checklist for Capability to Exchange Key Clinical Information, by Regional Extension Centers

PURPOSE: Regional Extension Centers (RECs) assist eligible health care professionals with the implementation of electronic health records systems and in achieving Meaningful Use as defined by the Health Information Technology for Economic and Clinical Health Act of 2009. The Health Information Technology Research Center (HITRC) was developed in 2010 to support the efforts of the RECs. To this end, numerous tools and resources have been developed by the HITRC and made available to the RECs.

With this project, ONC seeks to collect feedback from the RECs on one of the tools developed by the HITRC: the Checklist for Capability to Exchange Key Clinical Information tool. Finalized in 2012, the Checklist was designed to assist RECs in helping eligible professionals use electronic health records in the exchange of key clinical information. The information collected from this survey will help evaluate how useful the tool has been to RECs and eligible professionals, and how the tool may be improved.

DESCRIPTION OF RESPONDENTS: We are targeting 60 RECs based off of a contact list provided by ONC—this list has 1-5 names for each REC. However, we would like to target the most appropriate person who works with eligible professionals and knows HITRC tools at the REC. To get them, we will write an introductory message to the contacts on the REC list conveying this desire. We recognize that there may be other individuals within the organization, aside from those on the contact list, who may be most appropriate respondents to the survey due to their work and experience with eligible professionals. To address this, the survey uses introductory screening questions to establish appropriate eligibility. For those not eligible, a message is provided on the Thank You screen asking them to forward the survey to someone who has experience working with eligible professionals and using HITRC tools.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: Mike Furukawa

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

We estimate that responding to the survey will take, on average, about 10 minutes per person. This includes the time needed for a respondent to examine the tool on the HITRC Web site as well as complete the web survey.

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Regional Extension Center staff	207	10 min	34.5
Totals	207	10 min	34.5

FEDERAL COST: The estimated annual cost to the Federal government is ____$5,000____.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan). If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

We have a list prepared by ONC of 60 RECs, with a total of 207 representatives, who we will target for the survey. Since the number is small (N=207) and we cannot guarantee response, we will not draw a sample. Instead, we intend to survey all of the REC representatives.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[X] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No

Attachment A – Survey on Checklist for Capability to Exchange Key Clinical Information tool

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 0990-0383. The time required to complete this information collection is estimated to average 4 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

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