Survey among Patients / Consumers
Draft Questionnaire
Sample to include:
250 U.S. diabetes patients
250 U.S. cardiovascular disease patients
250 U.S. cancer patients/cancer survivors
500 U.S. adults ages 65+
250 U.S. caregivers (those who provide care and/or make health care decisions for at least one adult – e.g., parent, spouse, etc.)
500 U.S. parents of child(ren) under age 18, who are in the household; parent must be primary decision maker for child’s health care
Screeners
Screening questions as necessary to define segments outlined above
Diabetes Patients
Has a physician or other health care provider diagnosed you with diabetes?
Yes
No [TERMINATE]
Which type of diabetes do you have?
Type 1
Type 2
How long have you been diagnosed with diabetes?
Less than one year
1-3 years
4-5 years
More than 5 years
Cardiovascular Disease Patients
Has a physician or other health care provider diagnosed you with heart disease or hypertension? This may include coronary heart disease, heart failure, congenital heart disease, stroke, hypertension, heart valve disease, or atrial fibrillation.
Yes
No [TERMINATE]
How long have you been diagnosed with heart disease or hypertension?
Less than one year
1-3 years
4-5 years
More than 5 years
Cancer Survivors/Patients
Has a physician or other health care provider ever diagnosed you with any of the following types of cancer: prostate, breast, colon, lymphoma (Hodgkins or non-Hodgkins), non-melanoma skin cancer, or thyroid cancer?
Yes
No [TERMINATE]
Which type of cancer do you have?
Prostate
Breast
Colon
Lymphoma
Non-melanoma skin cancer
Thyroid
How long ago was your diagnosis?
Less than one year
1-3 years
4-5 years
More than 5 years
Are you currently in remission?
Yes
No
Seniors/Medicare Beneficiaries
[Confirm age 65+]
Are you eligible for or do you currently receive Medicare benefits?
Yes
No [TERMINATE]
Caregivers
Do you provide care for a friend or family member who has been diagnosed with a chronic health condition such as diabetes, heart disease, high blood pressure, atrial fibrillation, stroke, cancer, asthma, Alzheimer’s, or arthritis? Providing care may include helping the patient make decisions about treatments and other aspects of health care. It may also include helping the patient take medications and follow doctor’s instructions for treatment.
Yes
No [TERMINATE]
Moms
Are you the mother of a child or children under age 18, who live(s) in your household?
Yes
No [TERMINATE]
Demographics
Standard demographics provided by Ipsos:
Gender
Age
Education
Race / Hispanic ethnicity
Employment status
Marital status
Household size / number of children
Household income
Additional regional information
ADD language preference and rural/urban designation, if possible [check with Ipsos]
QUESTIONNAIRE FOR DIABETES PATIENTS, CARDIOVASCULAR DISEASE PATIENTS, CANCER PATIENTS/CANCER SURVIVORS, SENIORS/MEDICARE BENEFICIARIES
Topic: Experience and Satisfaction with Health System
How many different health care providers have you visited in the past 12 months? (e.g., such as family physician, dentist, eye doctor, cardiologist or other specialist, nurse, midwife, nurse practitioner, etc.) Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None [SKIP to Q3]
Altogether, how many total visits did you make to health care providers in the past 12 months? Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None
How would you rate your health compared to the average person your age?
Excellent
Very good
Good
Fair
Poor
Have you obtained information from any of the following sources in the past 12 months to help you make decisions about health care? [RANDOMIZE AND READ LIST]
|
Yes |
No |
|
Health insurance company |
|
|
|
Health-related Internet site |
|
|
|
Online patient support group or social media forum |
|
|
|
Doctor |
|
|
|
Nurse or other health provider |
|
|
|
Pharmacist |
|
|
|
Place of worship |
|
|
|
Friends or relatives |
|
|
|
Prescription drug company |
|
|
|
Television or radio |
|
|
|
Newspapers or magazines |
|
|
|
Other: please describe |
|
|
|
Topic: Use of Internet for Health Information
How often do you use the Internet through a computer or mobile phone? Please select the single best response.
Through a computer (e.g., desktop, laptop or tablet computer)
Through a mobile phone
Several times a day
Several times a week
Several times a month
Several times a year
Less frequently than several times a year
Never
If NEVER to both technologies: Do you not use the Internet because you do not want to use it, because it is difficult to use, or because you don’t have access?
Do not want to use the Internet
Difficult to use the Internet
Don’t have access to the Internet
Within the past 12 months, have you…
|
Yes |
No |
Searched online for information about a disease or medical condition? |
|
|
Participated in an online support group for a disease or medical condition? |
|
|
Looked at any of your medical test results online? |
|
|
Looked at your medical record online? |
|
|
Sent or received an email message from your health care provider? |
|
|
Sent or received a text message from your health care provider? |
|
|
Renewed a prescription online? |
|
|
Topic: Experience with EHRs and other Forms of Health IT
A “health app” is a program on a cell phone, mobile device or computer that can help you manage your health. Examples of health apps include calorie counters, sleep monitors, heart monitors, exercise trackers, and tools to help you manage your medications.
|
Yes |
No |
Do you currently use a health app? |
|
|
Have you ever used a health app? |
|
|
[If yes to either]: How many health apps have you used or tried in the past year?
1-2
3-5
5 or more
[If yes to either]: Please briefly describe the health app you have used the most [open-ended].
How effective was this health app in helping you manage your health and/or health care?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
If there was a health app that could help you gather all your health records and/or your family’s health records so you could have them in one place – such as on your mobile phone, home computer, tablet or laptop – how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
If there was a health app that could help you share your health records and/or your family’s health records with others you trust (e.g., doctors, other care providers or family), if they need it while providing care, how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
As far as you know, is your health care provider required by law to let you view and get a copy of your medical record?
Yes
No
Not sure
Have you heard of Blue Button?
Yes
No
Not sure
[If yes] – Please describe what Blue Button is. [open end]
Blue Button is a way for patients to get easy, secure online access to view their own personal health information online such as their insurance claims and medical records. Using Blue Button, patients can download their personal health information in a text file or PDF that can be read, printed or saved on any computer.
|
Yes |
No |
Have you used Blue Button to download your medical record? |
|
|
Do you know of any friends or family members who have used Blue Button? |
|
|
[If yes to used]: How effective was this Blue Button in helping you manage your health/health care?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
[If no to used]: Based on the description of Blue Button, do you think you’d use it if it were available to you?
Yes
No
Some doctors and health care organizations use computers or mobile devices to record their patients’ medical and health information. These electronic health records – or ‘EHRs’ – contain notes from your doctor or other medical personnel about your visits, diagnoses, test results, prescriptions, lifestyle and other elements of your medical history. As far as you know, do any of your health care providers maintain your medical record in an electronic system?
Yes
No
Not sure
Topic: Attitudes about EHRs and Health IT
Would you prefer that your health care providers use electronic, computer-based medical records or paper-based records?
Strongly prefer electronic
Somewhat prefer electronic
Neutral – no preference
Somewhat prefer paper
Strongly prefer paper
If your health care provider made your medical records and personal health information (such as medications and doctor’s instructions) available to you online, how likely would you be to go online to view those records and information?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
[If not at all/not too likely]: Which of the following are reasons you would be unlikely to access your medical records online? Please select all that apply. [RANDOMIZE]
Concerned about cost
Don’t have access to a computer
Don’t have access to my medical records online
Don’t have time
Don’t understand medical terms
Concerned about the privacy or security of my medical records
Don’t know how to access it
Not comfortable with technology
Would rather have my doctor keep track of my health care
Not interested
Afraid to know what’s in my record
Other: Please describe [open end]
The following are benefits and features associated with electronic or computer-based medical records and other forms of health information technology. Please indicate how useful you think each would be to you in your health care.
Extremely useful
Very useful
Somewhat useful
Not too useful
Not at all useful
Send and refill prescriptions electronically
Receive electronic reminders to take medications
Receive electronic reminders for appointments, preventive screenings and tests
Communicate with health providers through secure email or secure text messaging
View lab and test results online
Have access to your health information during an emergency
Have a summary of each visit with your health care provider
Send medical information from a device that helps you monitor indicators of your health (such as blood glucose, weight, heart rate or other indicators)
Share your health information with other people—doctors or family caregivers-- you trust
Withhold sensitive health information from selected health care providers (such as mental health information, HIV status, substance abuse or other sensitive health information)
Add or change information in your medical record
Correct inaccurate information in your medical record
Use tools that can help you and your doctor make decisions together about your health care
Manage or keep track of your family’s medical records
Monitor and manage health-related expenses
Keep track and manage medications in one list
Keep track of immunizations
QUESTIONNAIRE FOR CAREGIVERS
Topic: Experience and Satisfaction with Health System
Thinking about the person for whom you provide care, how many different health care providers has this person visited in the past 12 months? (e.g., such as family physician, dentist, eye doctor, cardiologist or other specialist, nurse, midwife, nurse practitioner, etc.) Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None [SKIP to Q3]
Altogether, how many total visits did this person make to health care providers in the past 12 months? Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None
How would you rate the health of the person for whom you provide care compared to the average person his or her age?
Excellent
Very good
Good
Fair
Poor
Have you obtained information from any of the following sources in the past 12 months to help the person for whom you provide care? [RANDOMIZE AND READ LIST]
|
Yes |
No |
|
Health insurance company |
|
|
|
Health-related Internet site |
|
|
|
Online patient support group or social media forum |
|
|
|
Doctor |
|
|
|
Nurse or other health provider |
|
|
|
Pharmacist |
|
|
|
Place of worship |
|
|
|
Friends or relatives |
|
|
|
Prescription drug company |
|
|
|
Television or radio |
|
|
|
Newspapers or magazines |
|
|
|
Other: please describe |
|
|
|
Topic: Use of Internet for Health Information
How often do you use the Internet through a computer or mobile phone? Please select the single best response.
Through a computer (e.g., desktop, laptop or tablet computer)
Through a mobile phone
Several times a day
Several times a week
Several times a month
Several times a year
Less frequently than several times a year
Never
If NEVER to both technologies: Do you not use the Internet because you do not want to use it, because it is difficult to use, or because you don’t have access?
Do not want to use the Internet
Difficult to use the Internet
Don’t have access to the Internet
Within the past 12 months, have you done any of the following activities on behalf of the person for whom you provide care?
|
Yes |
No |
Searched online for information about a disease or medical condition? |
|
|
Participated in an online support group for a disease or medical condition? |
|
|
Looked at any medical test results online? |
|
|
Looked at a medical record online? |
|
|
Sent or received an email message from a health care provider? |
|
|
Sent or received a text message from a health care provider? |
|
|
Renewed a prescription online? |
|
|
Topic: Experience with EHRs and other Forms of Health IT
A “health app” is a program on a cell phone, mobile device or computer that can help you manage your health. Examples of health apps include calorie counters, sleep monitors, heart monitors, exercise trackers, and tools to help you manage your medications.
|
Yes |
No |
Do you currently use a health app to help the person for whom you provide care? |
|
|
Have you ever used a health app to help the person for whom you provide care? |
|
|
[If yes to either]: How many health apps have you used or tried in the past year?
1-2
3-5
5 or more
[If yes to either]: Please briefly describe the health app you have used the most [open-ended].
How effective was this health app in helping you manage the health of the person in your care?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
If there was a health app that could help you gather all the health records of the person for whom you provide care so you could have them in one place – such as on your mobile phone, home computer, tablet or laptop – how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
If there was a health app that could help you share the health records of the person for whom you provide care with others you trust (e.g., doctors, other care providers or family), if they need it while providing care, how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
As far as you know, is your health care provider required by law to let you view and get a copy of your medical record?
Yes
No
Not sure
Have you heard of Blue Button?
Yes
No
Not sure
[If yes] – Please describe what Blue Button is. [open end]
Blue Button is a way for patients to get easy, secure online access to view their own personal health information online such as their insurance claims and medical records. Using Blue Button, patients can download their personal health information in a text file or PDF that can be read, printed or saved on any computer.
|
Yes |
No |
Have you ever used Blue Button to download a medical record? |
|
|
Do you know of any friends or family members who have used Blue Button? |
|
|
[If yes to used]: How effective was this Blue Button in helping you manage health care?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
[If no to used]: Based on the description of Blue Button, do you think you’d use it if it were available to you?
Yes
No
Some doctors and health care organizations use computers or mobile devices to record their patients’ medical and health information. These electronic health records – or ‘EHRs’ – contain notes from your doctor or other medical personnel about your visits, diagnoses, test results, prescriptions, lifestyle and other elements of your medical history. As far as you know, do any health care providers maintain the medical record of the person whom you provide care in an electronic system?
Yes
No
Not sure
Topic: Attitudes about EHRs and Health IT
Would you prefer that health care providers use electronic, computer-based medical records or paper-based records?
Strongly prefer electronic
Somewhat prefer electronic
Neutral – no preference
Somewhat prefer paper
Strongly prefer paper
If a health care provider made the medical records of the person for whom you provide care available to you online, how likely would you be to go online to view those records and information?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
[If not at all/not too likely]: Which of the following are reasons you would be unlikely to access medical records online? Please select all that apply. [RANDOMIZE]
Concerned about cost
Don’t have access to a computer
Don’t have access to my medical records online
Don’t have time
Don’t understand medical terms
Concerned about the privacy or security of medical records
Don’t know how to access it
Not comfortable with technology
Would rather have my doctor keep track of health care
Not interested
Afraid to know what’s in the record
Other: Please describe [open end]
The following are benefits and features associated with electronic or computer-based medical records and other forms of health information technology. Please indicate how useful you think each would be as you help the person for whom you provide care.
Extremely useful
Very useful
Somewhat useful
Not too useful
Not at all useful
Send and refill prescriptions electronically
Receive electronic reminders to take medications
Receive electronic reminders for appointments, preventive screenings and tests
Communicate with health providers through secure email or secure text messaging
View lab and test results online
Have access to health information during an emergency
Have a summary of each visit with a health care provider
Send medical information from a device that helps you monitor indicators of health (such as blood glucose, weight, heart rate or other indicators)
Share health information with other people—doctors or family caregivers-- you trust
Withhold sensitive health information from selected health care providers (such as mental health information, HIV status, substance abuse or other sensitive health information)
Add or change information in a medical record
Correct inaccurate information in a medical record
Use tools that can help you and a doctor make decisions together about health care
Manage or keep track of medical records
Monitor and manage health-related expenses
Keep track and manage medications in one list
Keep track of immunizations
QUESTIONNAIRE FOR MOTHERS
Topic: Experience and Satisfaction with Health System
How many different health care providers have you taken your child(ren) to in the past 12 months? (e.g., such as family physician, dentist, eye doctor, cardiologist or other specialist, nurse, midwife, nurse practitioner, etc.) Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None [SKIP to Q3]
Altogether, how many total visits to health care providers have you taken your child(ren) to in the past 12 months? Please select one response.
1 to 2
3 to 5
6 to 9
10 or more
None
Have you obtained information from any of the following sources in the past 12 months regarding your child(ren)’s health or health care? [RANDOMIZE AND READ LIST]
|
Yes |
No |
|
Health insurance company |
|
|
|
Health-related Internet site |
|
|
|
Online patient support group or social media forum |
|
|
|
Doctor |
|
|
|
Nurse or other health provider |
|
|
|
Pharmacist |
|
|
|
Place of worship |
|
|
|
Friends or relatives |
|
|
|
Prescription drug company |
|
|
|
Television or radio |
|
|
|
Newspapers or magazines |
|
|
|
Other: please describe |
|
|
|
Topic: Use of Internet for Health Information
How often do you use the Internet through a computer or mobile phone? Please select the single best response.
Through a computer (e.g., desktop, laptop or tablet computer)
Through a mobile phone
Several times a day
Several times a week
Several times a month
Several times a year
Less frequently than several times a year
Never
If NEVER to both technologies: Do you not use the Internet because you do not want to use it, because it is difficult to use, or because you don’t have access?
Do not want to use the Internet
Difficult to use the Internet
Don’t have access to the Internet
Within the past 12 months, have you done any of the following activities for your child(ren)’s health or health care?
|
Yes |
No |
Searched online for information about a disease or medical condition? |
|
|
Participated in an online support group for a disease or medical condition? |
|
|
Looked at any medical test results online? |
|
|
Looked at a medical record online? |
|
|
Sent or received an email message from a health care provider? |
|
|
Sent or received a text message from a health care provider? |
|
|
Renewed a prescription online? |
|
|
Topic: Experience with EHRs and other Forms of Health IT
A “health app” is a program on a cell phone, mobile device or computer that can help you manage your health. Examples of health apps include calorie counters, sleep monitors, heart monitors, exercise trackers, and tools to help you manage your medications.
|
Yes |
No |
Do you currently use a health app to help you manage the health or health care of your child(ren)? |
|
|
Have you ever used a health app to help you manage the health or health care of your child(ren)? |
|
|
[If yes to either]: How many health apps have you used or tried in the past year?
1-2
3-5
5 or more
[If yes to either]: Please briefly describe the health app you have used the most [open-ended].
How effective was this health app in helping you manage the health or health care of your child(ren)?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
If there was a health app that could help you gather all of your child(ren)’s health records so you could have them in one place – such as on your mobile phone, home computer, tablet or laptop – how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
If there was a health app that could help you share your child(ren)’s health records with others you trust (e.g., doctors, other care providers or family), if they need it while providing care, how likely would you be to use it?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
As far as you know, is your health care provider required by law to let you view and get a copy of your medical record?
Yes
No
Not sure
Have you heard of Blue Button?
Yes
No
Not sure
[If yes] – Please describe what Blue Button is. [open end]
Blue Button is a way for patients to get easy, secure online access to view their own personal health information online such as their insurance claims and medical records. Using Blue Button, patients can download their personal health information in a text file or PDF that can be read, printed or saved on any computer.
|
Yes |
No |
Have you ever used Blue Button to download a medical record? |
|
|
Do you know of any friends or family members who have used Blue Button? |
|
|
[If yes to used]: How effective was this Blue Button in helping you manage health care?
Extremely effective
Very effective
Somewhat effective
Not too effective
Not at all effective
[If no to used]: Based on the description of Blue Button, do you think you’d use it if it were available to you?
Yes
No
Some doctors and health care organizations use computers or mobile devices to record their patients’ medical and health information. These electronic health records – or ‘EHRs’ – contain notes from your doctor or other medical personnel about your visits, diagnoses, test results, prescriptions, lifestyle and other elements of your medical history. As far as you know, do any health care providers maintain your child(ren)’s health records in an electronic system?
Yes
No
Not sure
Topic: Attitudes about EHRs and Health IT
Would you prefer that health care providers use electronic, computer-based medical records or paper-based records?
Strongly prefer electronic
Somewhat prefer electronic
Neutral – no preference
Somewhat prefer paper
Strongly prefer paper
If a health care provider made your child(ren)’s health records available to you online, how likely would you be to go online to view those records and information?
Extremely likely
Very likely
Somewhat likely
Not too likely
Not at all likely
[If not at all/not too likely]: Which of the following are reasons you would be unlikely to access your child(ren)’s health records online? Please select all that apply. [RANDOMIZE]
Concerned about cost
Don’t have access to a computer
Don’t have access to my medical records online
Don’t have time
Don’t understand medical terms
Concerned about the privacy or security of medical records
Don’t know how to access it
Not comfortable with technology
Would rather have my doctor keep track of health care
Not interested
Afraid to know what’s in the record
Other: Please describe [open end]
The following are benefits and features associated with electronic or computer-based medical records and other forms of health information technology. Please indicate how useful you think each would be as you manage your child(ren)’s health and health care.
Extremely useful
Very useful
Somewhat useful
Not too useful
Not at all useful
Send and refill prescriptions electronically
Receive electronic reminders to take medications
Receive electronic reminders for appointments, preventive screenings and tests
Communicate with health providers through secure email or secure text messaging
View lab and test results online
Have access to health information during an emergency
Have a summary of each visit with a health care provider
Send medical information from a device that helps you monitor indicators of health (such as blood glucose, weight, heart rate or other indicators)
Share health information with other people—doctors or family caregivers-- you trust
Withhold sensitive health information from selected health care providers (such as mental health information, HIV status, substance abuse or other sensitive health information)
Add or change information in a medical record
Correct inaccurate information in a medical record
Use tools that can help you and a doctor make decisions together about your child(ren)’s health care
Manage or keep track of your child(ren)’s medical records
Monitor and manage health-related expenses
Keep track and manage medications in one list
Keep track of immunizations
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ketchum |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |