Form #2 Form #2 Pre-Visit Questionnaire

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

TTACHMENT B

Pre-Visit Questionnaire

This is a short questionnaire in preparation for our site visit. In the questionnaire we ask you questions about the socio-technical characteristics of your practice. Socio-technical characteristics include patient or provider characteristics, physical environment and layout, technical training and support, functionality and usability of health IT technologies, worker roles and communication flows.

Please try to answer all of the questions. Your responses will be kept confidential to the extent permitted by law, including Section 944(c) of the Public Health Service Act.  42 U.S.C. 299c-3(c).  That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied.

We appreciate the time you are taking to complete this questionnaire and hope that the information will help us better understand how new technology influences people.

Instructions

To answer the questions, check the appropriate box on the scale. For example:

	Never		It varies			Always
Overall, health IT saves me time.	1	2		4	5	6	7

Some questions will require answers similar to the scale above, while other questions will require different responses. Please try to be as accurate as possible.

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the questionnaire. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

1. Name of the physician practice: ___________________________________________________

General Information on Practice

2. Which of the following best describes the type of practice that characterizes your group practice:

₁ Multi-specialty

₂ Single specialty

₃ Primary care

₄ Integrated Health System

₅ Independent Physician Association (IPA)

2. How long has the practice existed? ___ years

3. How many people work in the practice?

How many physicians work in the practice?	___ physicians
How many mid-level providers (Physician Assistants and Nurse Practitioners) work in the practice?	___ mid-level providers
How many nurses work in the practice?	___ nurses
How many staff (e.g., receptionist) work in the practice?	___ practice staff

4. Does the practice have IT support? ₁ Yes ₂ No

a) If yes, in the practice? ₁ Yes ₂ No

b) If yes, how many IT support staff work in the practice? ______ IT support staff

5. What is the practice size (How many patients do you have?) ______ patients

6. Has there been in increase or decrease in the number if patients in the last 5 years?

₁ Decrease in patients

₂ Remained stable

₃ Increase in patients

7. Who is the owner of the practice?

₁ Physicians

₂ Hospital

₃ Other (insurance, MCO, university, medical school)

8. Have you recently become part of a larger organization? ₁ Yes ₂ No

Information on health information technology (health IT, such as EHR, e-prescribing, patient portal, e-forms) in the practice

9. Which of the following health IT systems have you implemented in your practice, in what year, and what is the vendor?

Health IT	Yes	Year imple- mented	Vendor
Electronic Health Record (EHR)/ Electronic Medical Record (EMR) (such as Allscripts, EPIC, EHS, Greenway)	1	_______	___________
e-prescribing	1	_______	___________
Computerized provider order entry (CPOE)	1	_______	___________
Patient portal (sometimes referred to as [electronic] personal health records or PHRs; allows patients to view portions of their medical records [e.g., laboratory test results] and supports other health-related tasks such as making appointments or requesting medication refills. Some patient portal applications exist as stand-alone Web sites; other portal applications are integrated into an existing EHR system)	1	_______	___________
Secure messaging with patients (use of secure e-mail between patients and clinicians, typically using the secure messaging functionality in the EHR and/or patient portal)	1	_______	___________
e-forms (surveys that are administered using computerized media [e.g., tablets, laptops] to collect information from patients using pre-formatted forms before or during patient visits)	1	_______	___________
Health information exchange (HIE)	1	_______	___________
Internet connection with laboratory facilities	1	_______	___________

Information about health IT implementation

10. Who at the practice was responsible for the implementation of the health IT system at your practice?

______________________________________________________________________________________________

11. Before implementing your health IT system, did you prepare for it by finding information about this particular [health IT] implementation? If you did, do you remember what kind of information was most helpful and who provided it?

Please use this box to briefly describe the information. During the interview in the practice, we will ask to provide more detail.

12. Did the practice use resources or guides on how to implement health IT or study the workflow in your practice such as the AHRQ Workflow Assessment for Health IT toolkit (Workflow toolkit) when implementing the health IT system?

₁ Yes

₂ No

a) If yes, do you remember what tools?

Please use this box to briefly describe the information. During the interview in the practice, we will ask to provide more detail

b) Were these tools helpful? ₁ Yes ₂ No

c) Did you create any Workflow Process Maps (a Workflow Process Map is a diagram that shows the temporal sequencing of tasks in relation to other components in an organization [person, organization, environment, and tools and technologies]) when implementing the health IT? ₁ Yes ₂ No

d) If yes, do you have any documentation that shows results of how you studied your work and workflow to prepare for health IT implementation (for example workflow process maps) that you can share with us? ₁ Yes ₂ No

Relationship practice and hospital

13. Does your practice belong to a larger organization such as an integrated healthcare system? ₁ Yes ₂ No (skip to question 14)

If yes, does the larger organization you are part of, provide you with support for:

a) Health IT implementation ₁ Yes ₂ No

b) Redesigning your workflows ₁ Yes ₂ No

c) Health IT support (e.g., help desk) ₁ Yes ₂ No

ppoith health IT implementation

14. Did the practice receive support when you were implementing your health IT system? ₁ Yes ₂ No

a) If yes, from whom?

₁ Vendor

₁ Regional Extension Center (REC) [Wisconsin Health Information Technology Extension Center (WHITEC)/ Alabama Regional Extension Center (ALREC)]

₃ Quality Improvement Organization (QIO) [A QIO is an association of practicing doctors and other health care experts, who work to improve the quality of health care in communities across America. QIQ monitors appropriateness, effectiveness, and quality of care provided to Medicare patients. They work under the U.S. Centers for Medicare and Medicaid Services (CMS) and are represented nationally by the American Health Quality Association.]

₄ Other…

Health IT and Practice Redesign

15. Was the health IT implemented as part of a practice redesign effort?  ₁ Yes ₂ No

Health IT satisfaction

16. How satisfied are you with the following health IT?

	Very dissatisfied	Dissatisfied	Neither	Satisfied	Very satisfied	Not Applicable
Electronic Health Record (EHR)/Electronic Medical Record (EMR)	1	2	3	4	5	6
e-Prescribing	1	2	3	4	5	6
Computerized Provider Order Entry (CPOE)	1	2	3	4	5	6
Patient Portal	1	2	3	4	5	6
Secure messaging	1	2	3	4	5	6
e-forms	1	2	3	4	5	6
Health Information Exchange (HIE)	1	2	3	4	5	6
Internet connection with labs	1	2	3	4	5	6

Thank you for your participation!