National Test Bed Pilot Survey

Form Approved

OMB No. 0955-0005

Exp. Date 7/31/2014

National Bed Engagement Survey

1. What type of organization do you represent?

   • Vendor organization

   • Provider organization

   • Other (please specify):

2. Is your organization interested in participating in the proposed National Test Bed?

   • Yes

   • Not at this time due to the following concerns:

3. What advice do you have that might help this effort be successful?

4. What are the necessary characteristics of the organization that would be ideal to convene the National Test Bed?

5. What motivations and incentives would be necessary to allow you and your organization to prioritize the type of work to complete the pilot project described in the attachment?

6. What type of assistance do you think your organization would be willing to provide to the National Test Bed?

7. What would be necessary to allow you and your organization to prioritize the work as described in the attachment?

8. Does your organization have the capability to complete the pilot project as described in the attachment?

   • Yes

   • Not at this time due to the following concerns:

9. As a follow-up to Question 8, would your organization be able to implement the pilot project as described in the attachment within 6 months?

10. How long do you think it would take for your organization to complete the pilot project described in the attachment?

    • About an hour

    • Several hours

    • Several days

    • Several weeks

    • Several months

    • Other (please specify your predicated time):

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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 0955-0005. The time required to complete this information collection is estimated to average two (2) hours 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

11. How many similar measure-specific projects, as described in the National Test Bed document attached, could you organization complete per year?

    • 0

    • 1 to 2

    • 3 to 4

    • 5 to 6

    • 6 to 7

    • More than 7 projects per year

12. What types of employees would be needed to complete the pilot project described in the attachment?

13. What kind of authorization would be needed at your company in order to share the results with a measure developer if you completed the pilot project described in the attachment

14. What roadblocks do you anticipate that might prevent you from being able to complete the pilot project described in the attachment?

15. What could we change about the pilot project described in the attachment to make it easier or more efficient for you to complete?

16. Would your organization be more or less interested in sharing future functionality information if you also received a de-identified report of other vendor plans as a result of your sharing this information?

    • More interested

    • Less interested

    • Please describe why your organization would be more or less interested in sharing future functionality information:

17. As part of our analysis of measure feasibility, we are interested in hearing about future functionality planned in your product. We see this as one of the benefits of working directly with EHR vendors. Please describe your level of willingness to share this information on a confidential basis.

18. What types of organizations (name specific organizations, if applicable) would you trust to keep this future functionality information confidential (i.e., de-identified)?

19. What additional information should we be asking as part of the pilot project described in the attachment?

20. Contact information:

    • Name (First and Last)

    • Organization name

    • Email address

    • Phone number

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