Nurses Form A Screener Administered on Paper

Form Approved

OMB No. 0955-

Exp. Date XX/XX/20XX

Form A Screener Questionnaire Administered on Paper

This study seeks to understand challenges with adopting and using EHRs and the help that practices that provide primary care services, like yours, have received to meet those challenges. The survey should be completed by the person most familiar with EHR selection, implementation, and use in your practice. This may be you, another clinician, practice manager, nurse, Information Technology staff, or another employee.

It should take you about 5 minutes to answer these questions. All the information you provide will be kept confidential.

Please answer each question as best you can by placing a check mark or an X to the left of the answer you choose. Sometimes you will be asked to skip a question. When this happens, an arrow to the right of the answer choice will tell you what question to skip to.

For example:

____ Yes  Go to Question 3

____ No  Go to Question 3

1. Does this practice use an electronic health record (EHR) or electronic medical record (EMR) system? Do not include billing record systems.

1. ____ Yes, all electronic  Go to Question 2

2. ____ Yes, part paper and part electronic  Go to Question 2

3. ____ No  Go to Question 3

4. ____ Uncertain  Go to Question 3

2. In which year did you install your current EHR?

__ __ __ __ Year (YYYY)  Go to Question 5

____ Uncertain  Go to Question 5

3. At this practice, are there plans for installing a new EHR system within the next 12 months?

1. ____ Yes, currently in process of installing an EHR  Go to Question 5

2. ____ Yes, there are plans to install an EHR within the next 12 months  Go to Question 5

3. ____ No, there are no plans to install an EHR within the next 12 months  Go

to Question 4

4. ____ Maybe  Go to Question 4

5. ____ Unknown  Go to Question 4

4. If you do not have an EHR system, why would your practice not plan on purchasing and installing an EHR system in the next 12 months? (Check all that apply).

1. ____ Physician(s) plan to retire soon

2. ____ Lack of time

3. ____ Lack of staff

4. ____ Lack of financial resources

5. ____ Privacy/security concerns

6. ____ No interest in doing so

7. ____ Don’t see enough patients to justify purchasing and installing an EHR

system

8. ____ Other. Please specify:_______________________

5. Which of the following would you classify your practice as? (Circle only one response for each item.)

Yes

No

1. Private office-based solo or group practice? Y N

2. Freestanding clinic/urgicenter

(not part of a hospital outpatient department)?.............………………………Y N

3. Community Health Center (e.g., Federally Qualified Health

Center (FQHC), federally-funded clinic or "look-alike" clinic)? Y N

4. Mental Health Center? Y N

5. Non-federal government clinic (e.g., state, county, city,

maternal-child health, etc.)? Y N

6. Family planning clinic (including Planned Parenthood)? Y N

7. Health maintenance organization or other pre-paid practice

(e.g., Kaiser Permanente)? Y N

8. Faculty practice plan (an organized group of physicians that

treat patients referred to an academic medical center)? Y N

9. Hospital emergency department? Y N

6. How many of the following types of staff are working at this practice, including yourself? If none, please write 0.

1. ____Number of physicians (MD, DO)

2. ____Number of nurse practitioners (NP), certified nurse midwives, and

physician assistants (PA)

3. ____Number of nurses

4. ____Number of medical assistants (MA) and other clinical staff (e.g., laboratory technician)

5. ____Number of Information Technology (IT) staff

6. ____Number of other administrative/other non-clinical staff (e.g., executives,

practice managers, billing specialists, front office staff)

7. Roughly, what percent of the patients treated at this practice are:

1. Insured by Medicare? ____%

2. Insured by Medicaid? ____%

3. Uninsured? ____%

8. We may call to hear more about your practice’s experiences with EHR systems.

We would like to speak with the person most familiar with EHR selection, implementation, and use in your practice. This may be you, a clinician, a practice manager, a nurse, Information Technology staff, or some other employee. Who is the person most familiar with EHR selection, implementation, and use in your practice?

What is the name of this person? (Please print name)

__________________________________________________

First Name Last Name

What is the best time and day(s) of the week to call him/her?

________________________________________________________

Day(s) Time(s)

What is the best work number to reach him/her?

(________) _______________________

Area Code Phone Number

Thank you very much for completing this survey. We appreciate your time.

Please return this survey in the enclosed envelope (no postage is necessary).

Please Turn to the Other Side

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-xxxx . The time required to complete this information collection is estimated to average 5 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