Regional Extension Center staff

Form Approved

OMB No. 0955-0003

Exp. Date 10/31/2014

ATTACHMENT A: Survey on Checklist for Capability to Exchange Key Clinical Information tool

Q 1. As part of your role at your Regional Extension Center (REC), do you work with Eligible Professionals to help them reach the Meaningful Use objectives for electronic health records (or supervise REC staff who do)?

• Yes (GO TO QUESTION 2)

• No (SKIP TO THANK YOU #1)

Q 2. The Health Information Technology Research Center (HITRC) portal offers tools to assist you in your work with Eligible Professionals to help them satisfy the Meaningful Use objectives. Have you looked at any of the tools on the HITRC portal?

• Yes (SKIP TO QUESTION 4)

• No (GO TO QUESTION 3)

Q 3. Which of the following are reasons why you have not looked at tools on the HITRC portal? (check all that apply)

• I was not aware there were tools available on the HITRC portal

• I have no need for the tools on the HITRC portal

• No Eligible Professionals have asked for any tools

• Eligible Professionals are unlikely to spend enough time with any tool

• In my experience, tools are rarely helpful

• The time that I have available to help Eligible Professionals is too limited

• I have not had time to examine the tools on the HITRC portal

• Other – please specify

(SKIP TO QUESTION 9)

Q 4. Have you ever offered any of the tools available on the HITRC portal to any Eligible Professionals?

• Yes (SKIP TO QUESTION 6)

• No (GO TO QUESTION 5)

Q 5. Which of the follow are reasons why you have not offered any of the tools on the HITRC portal to any Eligible Professionals? (check all that apply)

• I can best help Eligible Professionals without the tools on the HITRC portal

• No Eligible Professionals have asked for any tools

• Eligible Professionals are unlikely to spend enough time with any tool

• In my experience, tools are rarely helpful

• The time that I have available to help Eligible Professionals is too limited

• I intend to offer the tools on the HITRC portal to Eligible Professionals later

• Other – please specify

(SKIP TO QUESTION 8)

Q 6. Have you ever looked at the Checklist for Capability to Exchange Key Clinical Information tool on the HITRC portal, for helping Eligible Professionals with using EHRs to exchange key clinical information? Click to see tool

• Yes (GO TO QUESTION 7)

• No (SKIP TO QUESTION 9)

Q 7. Have you ever offered the Checklist for Capability to Exchange Key Clinical Information to any Eligible Professionals?

• Yes (SKIP TO QUESTION 10)

• No (SKIP TO QUESTION 11)

Q 8. Have you ever looked at the Checklist for Capability to Exchange Key Clinical Information tool on the HITRC portal, for helping Eligible Professionals with using EHRs to exchange key clinical information? Click to see tool

• Yes (SKIP TO QUESTION 11)

• No (GO TO QUESTION 9)

Q 9. The remaining questions pertain to your opinion about the Checklist for Capability to Exchange Key Clinical Information tool for helping Eligible Professionals use EHRs to exchange key clinical information. Please take a few minutes now to examine this tool? Click to see tool

Click when done --> (SKIP TO QUESTION 11)

Q 10. When you offered the Checklist for Capability to Exchange Key Clinical Information tool to Eligible Professionals, did the Eligible Professionals usually go on to meet the Meaningful Use care coordination objectives?

• Yes

• No

• I don’t know

(GO TO QUESTION 11)

Q 11. Please tell us what you think of the Checklist for Capability to Exchange Key Clinical Information tool by answering the following questions. Click to see tool

• How helpful do you think the tool can be for Eligible Professionals in reaching the care coordination objectives for Meaningful Use? (Very helpful, Somewhat helpful, A little helpful, Not at all helpful)

• How difficult would Eligible Professionals find this tool to use? (Very difficult, Somewhat difficult, Not very difficult, Not at all difficult)

• How likely are Eligible Professionals to use this tool? (Very likely, Somewhat likely, Not very likely, Not at all likely)

• How would you describe the tool in terms of its visual appeal? (Very appealing, Somewhat appealing, Not very appealing, Not at all appealing)

• How would you describe the clarity of the tool’s content? (Very clear, Somewhat clear, Not very clear, Not at all clear)

• How complicated would most Eligible Professionals find the tool to be? (Very complicated, Somewhat complicated, Not very complicated, Not at all complicated)

• To what extent does the tool offer information beyond what Eligible Professionals already know? (Very much, Somewhat, A little, Not at all)

• How likely is it that you will offer this tool to Eligible Professionals in the future? (Very likely, Somewhat likely, Not very likely, Not at all likely)

(GO TO THANK YOU #2)

THANK YOU #1. This questionnaire is for REC staff who work with Eligible Professionals and HITRC tools. If there is a more appropriate representative at your REC that fit these criteria we encourage you to forward this survey to them. Thank you for your time.

THANK YOU #2. Thank you for taking the time to complete this survey. Your responses will help us improve the development of this and other tools in the future.

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 0955-0003. 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.