Consumer Survey: Year 2, September 6, 2013 version
First, let’s talk about your visits to health care providers. By health care providers, we mean primary care physicians, specialists, mental health professionals, physician assistants, nurses, clinics, and hospitals.
A. Topic: Experience with Health Care System
i. Health Seeking Behavior – Health Care Usage
First, how many different health care providers have you visited in the last 12 months?
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 a health care provider in the last 12 months?
1 to 2
3 to 5
6 to 9
10 or more
None
B. Topic: Health Status
Now I would like to find out more about your health.
In general, how would you rate your overall health now?
Excellent
Very good
Good
Fair
Poor
Are you being treated for any chronic disease or medical condition such as high blood pressure, diabetes, heart or lung disease, or arthritis?
YES
NO
ii. Gaps in Information/Coordination
[SKIP TO Q6 IF Q1=NONE]
Now let’s talk about the coordination of your medical care and sharing of your medical record with health care providers. A medical record is information that your health care provider keeps about your health care, such as notes from your visits, a list of drugs that you take or lab test results.
In the past 12 months, when getting care for a medical problem, was there a time when you:
a. Had to bring an X-ray, MRI, or other type of test result with you to the appointment?
YES NO
b. Had to wait for test results longer than you thought reasonable?
YES NO
c. Had to redo a test or procedure because the earlier test results were not available?
YES NO
d. Had to provide your medical history again because your chart could not be found?
YES NO
e. Had to tell a health care provider about your medical history because they had not gotten your records from another health care provider?
YES NO
f. Were given online access to any part of your medical record by any of your health care providers?
YES NO
Within the past 12 months, have you asked for copies of your medical record from any of your health care providers?
YES
NO [SKIP TO Q9]
How difficult was it to receive the medical record you requested?
Very difficult
Somewhat difficult
Not very difficult
Not difficult at all
Or did you not get the medical record you requested [SKIP TO Q9]
What was the format of the copy of the medical record you received, paper or electronic?
RECEIVED AN ELECTRONIC COPY
RECEIVED A PAPER COPY
RECEIVED BOTH
Overall, how satisfied are you with the quality of the health care you have received from any of your health care providers?
Very satisfied
Somewhat Satisfied
Not very satisfied
Not satisfied at all
During the past 12 months, has a clinical laboratory given you direct access to any test results, such as blood test results, in either paper or electronic format?
YES
NO
Caregiving
Are you currently caring for or making health care decisions for a child, a spouse, a parent, or other family member?
YES
NO
C. Topic: Prior Experience and Exposure to IT and Health IT – Computer/Internet Access and Use
The next questions are about your use of the internet and familiarity with electronic medical records. Electronic medical records are created, stored and viewed on computers.
How often do you access the Internet?
Every day
Most days
Some days
Rarely
Never
[ASK ONLY IF Q12 = NEVER] Is that because you do not want to use the internet or because it is difficult for you to access it?
DO NOT WANT TO USE THE INTERNET
DIFFICULT TO ACCESS THE INTERNET
Have you ever…?
a. Searched online for information about a disease or medical problem
YES NO
b. Looked at any of your medical test results online
YES NO
c. Sent or received an e-mail message from your health care provider
YES NO
d. Sent or received a text message from your health care provider
YES NO
e. Used a smart phone health application
YES NO
D. Topic: Perceived Benefits of Health IT/Health Information Exchange
The next questions are about your views on electronic medical records and electronic sharing of medical records. Electronic sharing refers to computer-to-computer sharing.
As far as you know, do any of your health care providers maintain your medical record in an electronic system?
YES
NO [SKIP TO Q17]
Would you say electronic medical records have an overall positive impact, negative impact, or no impact on the care you receive from your health care providers?
POSITIVE IMPACT
NEGATIVE IMPACT
NO IMPACT
To the best of your knowledge, does your health care provider electronically send your medical record to other health care providers that are caring for you?
YES NO
How important is it to you that health care providers be able to share your medical record with each other electronically?
Very important
Somewhat important
Not very important
Not important at all
E. Topic: Perceived Risks
Now I would like to ask you about the privacy and security of your medical record.
CORE QUESTION: Privacy means you have a say in who can collect, use and share your medical record. How concerned are you about the privacy of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: Security means having safeguards to keep your medical record from being seen by people who aren’t permitted to see them. Safeguards may include technology. How concerned are you about the security of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
[ASK ONLY IF Q14B (LOOKED AT MEDICAL TEST RESULTS ONLINE)=YES] How confident do you feel that your online medical record, such as notes from your visits, a list of drugs that you take or lab test results, is kept private and secure?
Very confident
Somewhat confident
Not very confident
Not at all confident
CORE QUESTION: Have you ever kept information from your health care provider because you were concerned about the privacy or security of your medical record?
YES
NO
Confidentiality means that information in your medical record will not be disclosed to others in a way that would be inappropriate. How concerned are you about the confidentiality of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: If your medical record is sent by fax from one health care provider to another, how concerned are you that an unauthorized person would see it?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: If your medical record is sent electronically from one health care provider to another, how concerned are you that an unauthorized person would see it? Electronically means from computer to computer, instead of by telephone, mail, or fax machine.
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
F: Topic: Control Over Data Sharing
Information in a patient’s medical record may include medications, results of genetic tests, and mental health diagnoses. When medical records are shared between health care providers, do you think that patients should be able to decide what specific information should be included?
YES
NO
G. Topic: Awareness of Privacy Regulations/Laws
I am going to read some statements about protection of electronic medical records. How much do you agree with each of the following statements?
Existing laws provide a reasonable level of protection for electronic medical records today.
Strongly agree
Agree
Disagree
Strongly disagree
Health care providers have measures in place that provide a reasonable level of protection for electronic medical records today.
Strongly agree
Agree
Disagree
Strongly disagree
Existing laws require that health care providers give me a copy of my medical record in the way I want—either an electronic or paper copy.
Strongly agree
Agree
Disagree
Strongly disagree
H. Topic: Overall Support in Spite of Concerns
Now how much do you agree with these statements about support for the use of electronic medical records?
CORE QUESTION: I want my health care providers to use an electronic medical record to store and manage my health information despite any concerns I might have about privacy and security.
Strongly agree
Agree
Disagree
Strongly disagree
CORE QUESTION: I want my health care providers to use a computer to share my medical record with other providers treating me despite any concerns I might have about privacy and security.
Strongly agree
Agree
Disagree
Strongly disagree
I. Topic: Online Medical Records
Some patients can access information from their medical records online—that is, through the Internet—on secure websites set up for this purpose. By going to the secure website, patients can view parts of their own medical record, download the information, or send it somewhere else.
Have any of your health care providers or health insurers ever informed you that you could access your health information from your medical record through a secure website?
YES
NO [SKIP TO Q36]
Were you offered access to your online medical record…?
By your health care provider?
YES
NO
By your health insurer?
YES
NO
How many times did you access your online medical record through the website over the last 12 months?
1 to 2 times
3 to 5 times
6 to 9 times
10 or more times
None
[IF Q34 =NONE (R DID NOT ACCESS ONLINE RECORDS), GO TO Q35. ELSE SKIP TO Q36]
I would like to learn more about why you have not accessed your online medical records through the website. Was it because…
You do not have a way to access the website?
YES
NO
You did not have a need to use your online medical record?
YES
NO
You did not find the medical information provided through the website to be useful?
YES
NO
The website was difficult to use?
YES
NO
You were concerned about privacy or security of the website that had your medical records?
YES
NO
How important is it to you to have online access to your medical record through a secure web site?
Very important
Somewhat important
Not very important
Not important at all
[IF Q32=NO OR Q34 =NONE (R DID NOT ACCESS ONLINE RECORDS), GO TO Q38. ELSE GO TO Q37]
37. How did you use the medical record that you accessed through the website?
a. Did you download the information to your computer or mobile device, such as a cell phone or tablet?
YES
NO
Did you send the information somewhere else, such as to an app on a mobile device or to a personal health record? A personal health record, or PHR, is an electronic application that allows you to access, enter, and manage some of your health information.
YES
NO
Did you share it with another health care provider treating you?
YES
NO
Did you share it with a family member or someone else involved with your health care?
YES
NO
Did you ask your health care provider to correct any errors you found in the online record?
YES
NO
Did you use the online record to monitor your health, for example by using it to check on a medication or to check the date of a test result?
YES
NO
Did you use it to help make decisions regarding your health care?
YES
NO
How useful did you find the information that you accessed online, on a scale of 0 to 10, with 0 being not at all useful and 10 being very useful?
Questions on Caregivers
Were you given access to a family member’s medical record through a website?
YES
NO (SKIP TO Q41)
How many times did you access your family member’s medical record through the website over the last 12 months?
1 to 2 times
3 to 5 times
6 to 9 times
10 or more times
You did not access the records
Would you want to be able to update or add health-related information about yourself electronically - to include in your medical record?
YES
NO
J. Topic: Demographics
We are nearly finished. I would like to get a little information about your background.
What is your zip code?
________ (ZIP CODE)
In what year were you born?
________ (YEAR)
What is your sex?
MALE
FEMALE
Are you of Hispanic, Latino/a, or Spanish origin?
No, not of Hispanic, Latino/a or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a, or Spanish origin
What is your race? (One or more responses can be selected)
White
Black or African-American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
How well do you speak English?
Very well
Well
Not well
Not at all
Are you deaf or do you have serious difficulty hearing?
YES
NO
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
YES
NO
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
YES
NO
Do you have serious difficulty walking or climbing stairs?
YES
NO
Do you have difficulty dressing or bathing?
YES
NO
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
YES
NO
What is the highest grade or level of school that you have completed?
NOT A HIGH SCHOOL GRADUATE
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE OR 2-YEAR DEGREE
4-YEAR COLLEGE GRADUATE
MORE THAN 4-YEAR COLLEGE DEGREE
Which category comes closest to your total household income before taxes in 2012?
Less than $25,000
Between $25,000 and $49,999
Between $50,000 and $99,999
$100,000 or greater
To the best of your knowledge have you ever been the victim of identity theft or fraud?
YES
NO
[FOR CELL SAMPLE ONLY]: How many different cell-phone numbers, if any, could I have reached you for this call?
[FOR LANDLINE SAMPLE ONLY]: How many different landline telephone numbers, if any, are there in your home that I could have reached you on for this call? This includes listed or unlisted numbers. Please don’t count telephone numbers used only for faxes or modems.
ENTER NUMBER: _______
[ASK ALL]: Would you say that you and others living in your household only have cell phones, only have landline phones, or have both cell phones and landline phones?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Survey Questions: |
| Author | DHHS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |