Cognitive Testing Protocol

Attachment 4a

OMB No. xxxx-xxxx:

Expires: xx/xx/XXXX

NOTICE - Public reporting burden of this collection of information is estimated to average 75 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, 1600 Clifton Road, MS D-17, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Assurance of Confidentiality - All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

NAMCS Supplement on Primary Care Policies for Managing Patients

With High Blood Pressure, High Cholesterol, or Diabetes

The National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC), Division for Heart Disease and Stroke Prevention (DHDSP) and

Division of Diabetes Translation (DDT)

Pretest Debriefing Interview:

Introduction and Guide

Respondent ID#:___________________

Respondent job title: __________________

Type of practice: ___________________

No. of physicians in practice: ________________________________

Number of family practice physicians in practice: ____________________________________

Number of internal medicine physicians specializing in primary care in practice: ___________

Date of interview: _________________

Time of interview: _________________

Interviewer: __________________

Tape recorded? _________________

Introduction to IN-PERSON Interview

Hello ______________________. My name is _____________, and I work at Westat, which is a social science research company in Rockville, Maryland. Thank you for taking the time to speak with me today.

Westat is under contract with CDCs’ National Center for Health Statistics, also known as NCHS, to develop a survey that focuses on primary care management of patients with high blood pressure, high cholesterol, or diabetes.

Interviewer: Read through the “Informed Consent Form for One-on-One Interviews” from NCHS.

I will be happy to answer any questions you may have. If you later have any questions about the study, you may call the Project Director, Terri Davis, at 301-294-2864. For questions about your rights as a research participant, you may contact Westat’s Human Subjects Protections Office. Please call 1-888-920-7631 and leave a message with your full name, the name of the research study that you are calling about, and a phone number beginning with the area code. Someone will return your call as soon as possible. You may also call the NCHS Research Ethics Review Board at 1-800- 223-8188.

Would you please read and sign this consent form.

[HAND THE RESPONDENT THE NCHS INFORMED CONSENT FORM FOR ONE-ON-ONE INTERVIEWS]

TURN ON THE RECORDER AFTER THE PARTICIPANT SIGNS THE FORM

State the date and TIME and ask again if you have permission to record the interview.

Thank you. Now let me explain how the interview will proceed. Today I am interested in learning about your reactions to the questionnaire we are pretesting. To do that, I would like you to read the questions and talk out loud about the reasons for the answers you are selecting. Also, please state your answers out loud, and mark your answers on your copy of the survey. Let me know right away if anything in the survey seems confusing, unclear, or difficult to answer.

After you complete each section – and sometimes sooner, I will stop you and probe to see if there are ways to improve the survey. Do not hesitate to share any problems or criticisms you may have with the questions and response options.

Are you ready to begin? Okay, please read the first one and a half pages and answer aloud for the eligibility questions.

Introduction to Telephone Interview (in the event the in-person interview is not possible)

Hello ______________________. My name is _____________, and I work at Westat which is a social science research company in Rockville, Maryland. Thank you for taking the time to complete the survey and speak with me today.

Westat is under contract with the National Center for Health Statistics, also known as NCHS, to develop a survey that focuses on primary care management of patients with high blood pressure, high cholesterol, or diabetes.

We appreciate your willingness to help us pretest the survey questions. We are trying to find out if the questions are easy to understand and answer, if there is anything in the survey that is confusing or difficult, and whether the issues asked about are relevant to you and your medical practice. Your input will help us identify ways to improve the survey. I expect the interview to last no more than 75 minutes. You will receive $150 in appreciation for your assistance. In order to receive the incentive, you will need to fill out a receipt indicating that you received the incentive for record-keeping purposes.

Everything we cover today will be treated as confidential. Confidential means that your name and the name of your medical practice will never be associated with anything we talk about. We will write a report, but there will be no names and nothing will be mentioned that can identify you. This is a research project and your participation is voluntary. You may choose not to answer any question at any time and you may stop the interview at any point.

I will be happy to answer any questions you may have. If you later have any questions about the study, you may call Christine Lucas, Survey Statistician at NCHS, by phone at (301) 458-4071 and/or the Westat Project Director, Terri Davis, at 301-294-2864. For questions about your rights as a research participant, you may contact Westat’s Human Subjects Protections Office. Please call 1-888-920-7631 and leave a message with your full name, the name of the research study that you are calling about, and a phone number beginning with the area code. Someone will return your call as soon as possible. You may also call the NCHS Research Ethics Review Board at 1-800- 223-8188.

Acting an agent of NCHS, I’d like your consent to audio record our interview. The recording allows us to keep a record of what was asked and what was said. Only project team members and NCHS team members will have access to the recording. If you agree, you may ask to stop the recording at any time, and the interviewer will turn off the machine. If you decide to stop recording, the interviewer will ask your consent to retain the portion already recorded. We will destroy the recording at the end of the project. If you prefer that I do not record the interview, you may still participate in the interview.

Interviewer: Read through the “Informed Consent Form for One-on-One Interviews” from NCHS.

Do you consent to participate in this interview and to have it audio recorded?

(IF OKAY TO RECORD): I’m going to turn on the tape recorder now and ask for your consent again.

***Turn on the tape recorder! ***

It is “date and time.” _____________Do you consent to participate in this interview and do I have your permission to record this conversation?

Thank you. Now let me explain how the interview will proceed. Today I am interested in learning about your opinion of the questions to the questionnaire we are pretesting. To do that, I would like you to read the questions and talk out loud about the reasons for the answers you are selecting. Also, please state your answers out loud, and mark your answers on your copy of the survey. Let me know right away if anything in the survey seems confusing, unclear, or difficult to answer.

After you complete each section – and sometimes sooner, I will stop you and probe to see if there are ways to explain what you were thinking as you answered the questions. Do not hesitate to share any problems or criticisms you may have with the questions and response options.

Are you ready to begin? Okay, please read the first one and a half pages and answer aloud for the eligibility questions.

Pretest Debriefing Interview Guide

for the

NAMCS Supplement of Primary Care Policies for Managing Patients

With High Blood Pressure, High Cholesterol, or Diabetes

The Centers for Disease Control and Prevention (CDC), Division for Heart Disease

and Stroke Prevention (DHDSP) and Division of Diabetes Translation (DDT)

Survey Eligibility

Please provide the following counts:

1. The number of physicians currently employed in your practice (across all practice locations): __ __ __ __

2. Among these, the number who specialize in . . .

a. Family Medicine: __ __ __

b. Internal Medicine: __ __ __

Probes

How easy or difficult was it to answer Question 1?

How confident are you that your counts are accurate?

1. What is your specialty?

Family medicine

Internal medicine, specializing in primary care

Neither of the above ► Please stop here and return the questionnaire in the envelope provided. Thank you for your time.

Probe if you notice any issues.

2. During a typical work week, do you spend 20 percent or more of your time treating adult patients in at least one of the following ambulatory settings?

Check ALL that apply

□1 Private solo or group practice

□2 Freestanding clinic (not part of a hospital outpatient department)

□3 Community Health Center (e.g., Federally Qualified Health Center (FQHC) or federally funded clinics (or “look like” clinics)

□4 Non-federal government clinic (e.g., state, county, city, maternal and child health)

□5 Health maintenance organization or other prepaid practice (e.g., Kaiser Permanente)

□6 Faculty practice plan

□7 None of the above ► Please stop here and return the questionnaire in the envelope provided. Thank you for your time.

Probes

How easy or difficult was it to answer question C? (Why?)

3. Do you treat adult ambulatory patients with high blood pressure, high cholesterol, or diabetes?

1 Yes

2 No ► Please stop here and return the questionnaire in the envelope provided. Thank you for your time.

Survey Introduction

The goal of this study is to help CDC learn about the current state of primary care management policies in physician practices in the United States. Policies of interest are those aimed at management of adult patients with high blood pressure, high cholesterol, or diabetes. CDC and its partners want to better support primary care physicians and their medical practices in reducing these chronic conditions. They will use the survey data to assess (1) the extent to which primary care physicians deliver care in ways that have been shown to improve health outcomes and (2) the extent to which the ways they deliver care are established policies in their practices. CDC and its partners will then develop materials in support of such delivery methods. The survey will yield both national and regional estimates, providing practices with information to compare with their own management policies.

Probes

Did you read the Introduction?

What was your reaction to the Introduction?

If you received the survey in the mail, would you be motivated to complete it?

Definitions of Terms - IMPORTANT

Clinician: Refers to primary care physicians (MD or DO), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications.

Staff: Refers to all others who work in the practice.

Practice Policies: For this survey, policies include use of standardized treatment protocols, clinical decision supports, clinical guidelines, multidisciplinary teams, patient population registries, electronic functions, and other patient education and care management policies.

Your Medical Practice: Includes all locations where your clinicians see ambulatory patients. When answering questions about your practice in this survey, think about your entire medical practice.

Probes

Did you read the definitions?

How familiar are you with this definition of clinician?

Do you use any other term or terms for this group of physicians, PAs, and NPs?

(IF MULTIPLE SITES): On a typical day, when thinking about your medical practice, exactly what are you thinking about as your medical practice?

(Does R think about all practice sites when talking about his/her practice?)

Instructions to Complete the Survey

Answer the questions with regard to the care you provide to adult ambulatory patients. Please mark an X or a  in the box that best represents your answer (X or ). Use a blue or black pen. If you want to change your answer, mark on the wrong answer. For many questions, you are instructed to answer for each of three medical conditions. You will sometimes see an arrow and instruction to skip questions (► GO TO Question X).
Probes How likely would you be to read the instructions if you were taking the survey? How clear were the instructions to complete the survey?
	Clinical Decision Supports and Protocols

1. Do you use the following decision supports or protocols when treating adult patients for high blood pressure, high cholesterol, or diabetes? Also, in the last column, please mark if it is an established policy for primary care clinicians in your practice to use the decision support/protocol.

	I use this support/protocol		Using this support/ protocol is an established policy in my practice
	Yes	No	Yes	No
Cut-off points when making diagnostic decisions				
Laboratory test(s) and results				
Recommendations for lifestyle modifications (e.g., diet, exercise)				
10-year CVD risk calculator				
First-line medications to initiate treatment				
Drug-dosing (titration) support				
Second-line or additional medication if the condition is not controlled				
Specified follow-up time period				
Documentation of positive or negative change in condition at followup				
Alerts (flags in patients’ paper charts or electronic prompts) when a patient’s medical condition is uncontrolled				
Prompts (flags in patients’ paper charts or electronic prompts) for determining when tests should be done				
Prompts (flags in patients’ paper charts or electronic prompts) for medication adjustment				

Probes

For question 1, how familiar are you with the supports and protocols in each item?

(Are there any you are not familiar with?)

Please say more about the items that you use.

Item a.

Item b.

Item c.

Item d.

Item e.

Item f.

Item g.

Item h.

Item i.

Item j.

Item k.

Item l.

Now, can you say more about your No responses for support/protocols you don’t use.

Are there any other support or protocol you think should be on this list?

Next, please tell me how you arrived at you answers about whether use of the support/protocol is a practice policy.

[Note how solo practitioners answered the question]

Item a.

Item b.

Item c.

Item d.

Item e.

Item f.

Item g.

Item h.

Item i.

Item j.

Item k.

Item l.

How do you know use of those supports is a practice policy?

Is such use by primary care clinicians in your practice monitored in any way? (Say more.)

How easy or difficult was it to answer this question? (say more)

2. Which, if any, of the following supports does your practice make available to primary care clinicians?

Check ALL that apply

a. Cut-off points for diagnostic decisions

b. 10-year CVD risk calculator

c. Drug-dosing (titration) support

d. Alerts (flags in patients’ paper charts or electronic prompts) when a patient’s medical condition is uncontrolled

e. Prompts (flags in patients’ paper charts or electronic prompts) for determining when tests should be done

f. Prompts (flags in patients’ paper charts or electronic prompts) for medication adjustment

g. Other (Please specify): ______________________________________________________________________

h. None of the supports in this list ► GO TO QUESTION 5

3. Does your practice make the clinical decision supports available to primary care clinicians in the following ways? Check Yes or No for items a – e.

	Yes	No
In printed format: In the rooms where clinicians see patients		
At clinicians’ desks or work stations, away from the point of care		
In electronic format: Fully integrated into your practice’s EHR system		
In the rooms where clinicians see patients		
At clinicians’ desks or work stations, away from the point of care		

4. Do all or most primary care clinicians in your practice routinely use the supports and protocols when making clinical decisions for the majority of their patients?

a. Yes

b. No

c. Don’t know

Probes on Qs 2, 3, and 4

Q2:

In your own words, what is Q2 asking?

Please say more about your answers to the items in Q2.

How easy or hard was it to answer Q2?

Q3: How did you arrive at your answers for Q3?

What did you think of when you read “At clinicians’ desks or work stations”?

What does the phrase “point of care” mean to you?

[IF R SAID BOTH PRINTED AND ELECTRONIC FORMAT]:

Are some of the supports available only in printed form or electronic form? (Please say more about that.)

How long has your practice made the supports available electronically?

Q4: Tell me more about how you arrived at your answer for Q4.

What practice site(s) were you thinking of when you answered Q4?

What does “routinely use” mean to you?

Clinical Guidelines

5. Which of the following are sources of the clinical guidelines you use to treat patients with the following medical conditions? Check ALL that apply for each medical condition.

	High blood pressure	High cholesterol	Diabetes
Clinical guidelines released by national organizations (such as NHLBI JNC 7, NHLBI ATP III, American Diabetes Association, American Association of Clinical Endocrinologists, American Heart Association)			
State-released clinical guidelines			
Clinical guidelines issued by a health system that your practice is affiliated with (e.g., HMO, hospital, medical school, or other health-related system)			
Clinical guidelines prepared by your practice that differ from the guidelines listed in a, b, and c			
Other source(s) – Please check the box and specify below:: HBP:____________________________________________ HC: ____________________________________________ Diabetes: ______________________________________			

6. Which is the primary source of the clinical guidelines you use? Check ONE source for each medical condition.

	High blood pressure	High cholesterol	Diabetes
Clinical guidelines released by national organizations (e.g., NHLBI JNC 7, NHLBI ATP III, American Diabetes Association, American Association of Clinical Endocrinologists, American Heart Assoc.)			
State-released clinical guidelines			
Clinical guidelines issued by a health system that your practice is affiliated with (e.g., HMO, hospital, medical school, or other health-related system)			
Clinical guidelines prepared by your practice that differ from the guidelines listed in a, b, and c			
Other source(s) – Please specify: HBP:___________________________________________ HC: ___________________________________________ Diabetes: _____________________________________			

Probes for Q5 and Q6

Q5: How did you arrive at your answers for Q5?

(What is it about the guidelines that influences you to use them?)

How easy or hard was it to answer Q5? (Say more.)

[If R chose items b, c, or d, ASK]: Please briefly describe those guidelines.

[If R LISTED “OTHER SOURCE,” ASK]: How do the guidelines from the other source(s) you listed differ from those in the other items?

Q6: How easy or hard was it to specify a single primary source for each of the medical conditions? (Why?)

7. Is it an established policy for primary clinicians in your practice to use the same clinical guidelines? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No	 Yes  No	 Yes  No

8. Do all or most primary clinicians in your practice regularly use the same clinical guidelines when treating the majority of patients in the practice with the following medical conditions?

High blood pressure	High cholesterol	Diabetes
 Yes  No  Don’t know	 Yes  No  Don’t know	 Yes  No  Don’t know

Probes for Q7 and Q8:

Q7: Please say more about your answers for Q7.

IF YES FOR ANY MEDICAL CONDITION: Who develops the practice policy for that (those) medical condition(s)?

How did you learn about the policy(ies)?

Q8: How did you arrive at your answers for Q8?

How confident are you that they are correct?

In Q8, what do the words “regularly use” mean to you?

Question 8 asks about a majority of your patients. Would your answers have been different if the question simply asked about their regular use for treating patients in the practice with the medical conditions?

Use of Multidisciplinary Teams

9. We define multidisciplinary teams as groups of professionals (e.g., clinician, pharmacist, nurse, and regular dietician) who collaboratively manage patient care. Team members may be from different organizations, but they routinely communicate with one another; team composition may change as the patient’s needs change.

Please check the box if you use a multidisciplinary team in the following situations to collaboratively manage patient care for adults with high blood pressure, high cholesterol, or diabetes:

	High blood pressure	High cholesterol	Diabetes
When a patient is not reaching targeted goals (1) with the usual treatment or (2) within the expected period of time.			
When a patient is newly diagnosed. The team role ends when targeted goals are reached.			
Other situation in which multidisciplinary team care is used (Check the box and please specify): ______________________________ _____________________________________________________			

 Question 9 does not apply-Never use multidisciplinary teams for these conditions. ► GO TO QUESTION 14.

[NOTE: OBSERVE IF R NOTICES AND FOLLOWS SKIP INSRUCTION.]

Probes for Q9:

How did you arrive at your answers to question 9?

[FOR ANY YES ANSWERS]: Please briefly describe the team(s) you use and how they function and communicate with one another.

[IF “OTHER” CHECKED, ASK]: Please say more about the other situation you listed.

How familiar are you with the use of multidisciplinary teams?

Does the definition of such teams here match what you are familiar with?

If the question simply defined multidisciplinary teams and asked if you use them for any of three medical conditions, rather than asking about multiple ways in which they are used, would you change any of your answers?

10. Please mark the job titles of ALL members of the multidisciplinary team collaboratively managing the care of your patients with the following medical conditions. Answer for each medical condition.

    Check the box if you do not use a multidisciplinary team for the medical condition.	High blood pressure	High cholesterol	Diabetes
    	Teams do not apply	Teams do not apply	Teams do not apply
    Primary care physician (MD or DO)			
    Other physician (MD or DO)			
    Physician assistant (PA)			
    Nurse practitioner (NP)			
    Pharmacist			
    Registered nurse			
    Licensed practical nurse			
    Medical assistant			
    Dietitian/nutritionist			
    Community health worker			
    Social worker			
    Health educator			
    Exercise physiologist			
    Podiatrist			
    Ophthalmologist			
    Information technology manager/staff			
    Other team members, specify __________			

11. Now, please consider the majority of your patients with diabetes, high blood pressure, and high cholesterol whose care is managed by a multidisciplinary team. Whom would you identify as the key, or core, members of the team who interact with those patients? Answer for each medical condition.

Check the box if you do not use a multidisciplinary team for the medical condition.	High blood pressure	High cholesterol	Diabetes
	Teams do not apply	Teams do not apply	Teams do not apply
Primary care physician (MD or DO)			
Other physician (MD or DO)			
Physician assistant (PA)			
Nurse practitioner (NP)			
Pharmacist			
Registered nurse			
Licensed practical nurse			
Medical assistant			
Dietitian/nutritionist			
Community health worker			
Social worker			
Health educator			
Exercise physiologist			
Podiatrist			
Ophthalmologist			
Information technology manager/staff			
Other team members, specify __________			

Probes for Q10 and Q11:

Q10: How easy or hard was it to answer Q10? (Say more.)

Did you notice the instruction about marking the box if you don’t use a team for any of the three medical conditions?

Did any of the job titles on the list surprise you?

[IF MARKED OTHER, ASK]:

Are there other job titles we should add to the list of possible team members?

How often do team members they communicate with one another?

Q11: In Q11, how would you define key, or core, members of the team?

Please say more about the role and responsibility of those you listed as key team members.

Do all of the key members communicate regularly with you and other team members?

In what ways do they communicate with one another?

12. Is it an established policy in your practice to use multidisciplinary teams to collaboratively manage the care of patients with the following medical conditions? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No	 Yes  No	 Yes  No

►If you answered No for each medical condition in Q12, go to Question 14.

13. Do most or all primary clinicians in your practice routinely follow the policy to use multidisciplinary teams to manage the care of patients with the following medical conditions?

Check the box if using a multidisciplinary team is not a practice policy for the medical condition.	High blood pressure	High cholesterol	Diabetes
	Teams do not apply	Teams do not apply	Teams do not apply
Yes			
No			
Don’t know			

Probes for Q12 and 13:

[NOTE ANY COMMENTS FROM SOLE PRACTITIONERS ABOUT ANSWERING Q12 and Q13]

(For example, should they skip out of Q13?]

Q12: Please say more about your answers to Q12 (IF YES):

What does “established policy” mean to you?

How confident are you that your answers to Q12 are correct?

Q13: Please say more about your answers for each medical condition.

High BP

High Ch

Diabetes

What did you think about when you read the words “routinely follow” in Q13?

How do you know they follow the policy?

How confident are you that your answers to Q13 are correct? (thinking about all practice sites?)

Patient Registry System

14. Patient registry systems allow staff to generate a list of all patients with high blood pressure, high cholesterol, or diabetes and provide information such as whose condition is out of control or who is overdue for tests, screenings, or office visits. The system may be fully electronic or an electronic component in combination with paper records.

Does your practice have such a system for tracking patient populations with the following medical conditions? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No	 Yes  No	 Yes  No

►If No for all three medical conditions, GO TO QUESTION 19.

Probes for Q14:

How familiar are you with patient registry systems?

(Is that a term you are familiar with, or do you call them something else?)

Please say more about your answers for Q14.

[IF YES FOR ONE OR MORE MEDICAL CONDITIONS]:

What type of data does the system generate?

When did your practice first use a patient registry system for patients with ____________________?

What was the reason for using one?

[IF NO FOR ALL 3, DID R NOTICE AND FOLLOW THE SKIP INSTRUCTION?]

15. Which of the following best describes your practice’s patient population tracking system? Check ONE answer for each medical condition. Check the box for “Does not apply” if your practice does not have a population tracking system for the medical condition.

Your patient population tracking system is a:	High blood pressure	High cholesterol	Diabetes
	 Does not apply	 Does not apply	 Does not apply
Fully integrated component of your practice’s EHR system			
Stand-alone electronic system that shares some information with the practice’s EHR system			
Stand-alone electronic system that does not share any information with an EHR system			
Standard database program (e.g., Microsoft Access)			
Spreadsheet program (e.g., Microsoft Excel)			

Probes for Q15:

How did you arrive at your answers to Q15?

How easy or hard was it to understand the differences across the various types of tracking systems?

(Were any of the descriptions confusing or unclear to you?)

[IF YES TO ITEM b]: What information does it share with the EHR system?

16. Do you routinely use the system to track care management for the following patient population(s)? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No  Does not apply – no system	 Yes  No  Does not apply – no system	 Yes  No  Does not apply – no system

Probes for Q16:

How did you arrive at your answers to Q16?

(Were you answering about your use or your practice’s use?)

[IF USED}: How often do you use the tracking system?

What do the words “routinely use” in Q16 mean to you?

17. Is it an established policy in your practice to use the system to track care management for the following patient populations? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No  Does not apply – no system	 Yes  No  Does not apply – no system	 Yes  No  Does not apply – no system

Probes for Q17:

Please say more about your answers in Q17.

What does “established policy” mean in the context of your practice?

Who sets this policy?

(Were you involved in setting it?)

18. Do all or most primary care clinicians in your practice routinely use the system to track care management for the following patient population(s)?

High blood pressure	High cholesterol	Diabetes
 Yes  No  Don’t know/Does not apply	 Yes  No  Don’t know/Does not apply	 Yes  No  Don’t know/Does not apply

Probes for Q18:

Tell me how you arrived at your answers for Q18.

How would you define “routinely use”?

[IF PRACTICE HAS MULTIPLE SITES]: When you answered this question, were you thinking about this site only, or all sites in your practice?

Electronic Functions

19. Does the current EHR system, patient registry system, or any other electronic system used by your practice include the following functions in electronic format?

□ Does not apply—Our practice does not have any of these electronic functions ► GO TO QUESTION 20.

	Yes	No
Record demographics		
Record medical history (e.g., diagnoses, risk factors, allergies)		
Record current and past medications		
Record medication changes (e.g., change in dose, instructions)		
Use prompts to order tests and screens		
Use notification prompts when the patient’s medical condition is not controlled		
Track key measures (e.g., blood pressure, lipid levels, and A1c)		
Track abnormal test results		
Track referrals to specialists		
Document clinicians’ notes		
Document other clinical staff / team member notes		
l. Generate and transmit permissible prescriptions (electronic prescription [eRx])		
Order laboratory tests		
View lab reports and diagnostic test results		
View diagnostic test images		

Probes on Q19:

When answering Q19, which electronic system or systems in your practice were you thinking about? (IFNEEDED: For example, your EHR system or your EHR and, say, a standalone patient registry system?)

Was anything in the list confusing, or surprising to you?

Would you add any electronic functions to this list?

How easy or hard was it to answer this question (IF HARD: Why?)

How confident are you that your answers are correct?

20. Are primary care clinicians in your practice expected to routinely use available electronic functions to manage the care of patients with the following medical conditions? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes	 Yes	 Yes
 No	 No	 No

Probes for Q20

Please say more about your answers.

[IF YES]: What is routine use in your practice?

How, if at all, is routine use of the electronic functions monitored and enforced?

Would you say that most or all of the primary care clinicians in hour practice routinely use the functions?

Methods for Patient Followup

21. Various methods are used to remind patients about scheduled office visits. Do you use the following methods with your patients? Also, please check the box in the last column if using the reminder method is an established policy in your practice. Please answer for each reminder method.

	Yes	No	Don’t know	Check if this is a practice policy
Appointment reminder cards issued at the time of visit?				
Letters or postcards?				
Telephone calls?				
Email?				
Electronic text messages?				
Reminders on a secure web site that patients can access?				

Probes for Q21

What were you thinking about when you read item e?

How easy or difficult was it to answer whether the method was a practice policy?

[IF R SAID YES BUT DID NOT CHECK IT AS A PRACTICE POLICY]: What percentage of primary care clinicians in your practice use ________ to remind patients of office visits?

Patient Education and Self-Management

22. In addition to educating patients during office visits, in which of the following ways do you routinely educate patients? Check ALL that apply for each medical condition.

	High blood pressure	High cholesterol	Diabetes
By telephone			
By email			
In group classes (2 or more patients) at a practice site			
Via referrals to group classes at other locations in your area			
By providing printed materials			
By providing DVDs/Videos			
By providing self-study programs about the medical condition for home use (paper or online)			
Via referrals to other organizations’ websites or online programs about the medical condition			

Probes for Q22:

How did you interpret the words “routinely educate” in Q22?

Please say more about answer for each item in Q22:

[FOR ITEMS c – h, ASK FOR EXAMPLES IF NOT PROVIDED]

Item a:

Item b:

Item c:

Item d:

Item e:

Item f:

Item g:

Item h:

Item i:

23. Now think about your practice. Is it an established policy in your practice to routinely use the following additional ways to educate patients? Check ALL that apply for each medical condition.

	High blood pressure	High cholesterol	Diabetes
By telephone			
By email			
In group classes (2 or more patients) at a practice site			
Via referrals to group classes at other locations in your area			
By providing printed materials			
By providing DVDs/Videos			
By providing self-study programs about the medical condition for home use (paper or online)			
Via referrals to other organizations’ websites or online programs about the medical condition			

Probes for Q23

How easy or hard was it answer about your practice policy in Q23?

How confident are you that your answers for each item are correct?

24. Consider the following methods for communicating patient self-management goals. How often do you use each method? Also, please check the box in the last column if the method is an established practice policy for communicating such goals.

	Always/ most of the time	About half the time	Some-times	Rarely or Never	Check if this is a practice policy
Orally					
Jotted down on a piece of paper that the clinician gives to the patient during a visit					
In a “summary visit” record provided to the patient					
In a form specifically designed for recording patient self-management goals					
In an online location that the patient has access to					

Probes for 4

Please say more about how you arrived at your answers for items a – e in Q24.

Item a:

Item b:

Item c:

(IF > RARELY for c, d, or e ): Please describe this method.

Item d:

Item e:

Were any of the items confusing or unclear to you?

[IF R CHECKED THAT ANY OF THE METHODS WAS A PRACTICE POLICY, ASK]:

What makes [this method/these methods] an established practice policy?

Who decides on the policy?

How is the policy made known to primary care clinicians in your practice?

25. Consider the following methods for promoting patient skills and compliance in managing their health problems. Which of these are used routinely by members of your practice for patients needing support? Check ALL that apply for each medical condition.

		High blood pressure	High cholesterol	Diabetes
	Provide nurse case management			
	Provide nurse case oversight of community health workers or patient navigators
	Provide special followup care by staff nurses			
	Provide special followup care by other clinical staff in your practice or on your multidisciplinary team (e.g., social worker, dietitian, pharmacist)			
	Record patients’ self-monitored clinical values (e.g., blood pressure, glucose levels)			
	Employ proven methods to empower patients (such as counseling techniques that motivate patients to think differently about their health behaviors and consider the benefits of changing them)			
	Teach patients problem-solving skills to reach self-management goals			
Probes for Q25 Please say more about how you arrived at your answer for each item in Q25. Item a: (How familiar are you with nurse case management of primary care patients?) Item b: (How familiar are you the term and role of patient navigators?) Item c: Item d: [IF CHECKED ITEM d, ASK]: What other clinical staff were you thinking about? Item e: [IF CHECKED ITEM e, ASK]: Who in your practice does this? Item f: (How familiar are you with such problem-solving skills?)

About Your Practice

26. What is your practice type?

a. Single specialty – Family practice

b. Single specialty – Internal medicine providing primary care

c. Multispecialty – Family practice and internal medicine only (provide primary care)

d. Multispecialty that includes at least one family practice or internal medicine physician providing primary care plus one or more physicians in other specialties

Probe for Q26

Do you have any comments about Q26?

27. Who owns your practice? Choose the best description.

a. Physician, physicians, or physician group

b. Hospital or hospital system ► GO TO QUESTION 30

c. Health maintenance organization (HMO) ► GO TO QUESTION 30

d. Insurance company ► GO TO QUESTION 30

e. University or medical school ► GO TO QUESTION 30

f. State or local government ► GO TO QUESTION 30

g.Other type of organization (Please specify type): ____________________ ► GO TO QUESTION 30

Probe for Q27

How easy or hard was it to answer Q27?

(Were the categories unclear in any way?)

Can you think of other types of ownership we should add to the response list?

[DID R NOTICE THE SKIP AND FOLLOW IT?]

28. Which statement best describes how your independently owned practice relates to other health care organizations? Check one.

a. Practice is free standing, independent of other health care organizations ►GO TO QUESTION 30

b. Practice is independently owned and managed but has a contractual relationship with a health care organization such as a hospital, university, medical school, or an HMO.

Probe for Q28

Please say more about your answer.

[LISTEN FOR COMMENTS ABOUT CONTRACTUAL RELATIONSHIPS WITH INSURANCE COMPANIES]

[IF a, Did R skip correctly?]

29. Does this health care organization provide guidance on practice policies for patients with diabetes, high cholesterol, or high blood pressure?

a. Yes

b. No

Probe for Q29

Please say more about your answer.

[IF YES]: Can you give an example?

30. At how many locations does your practice see ambulatory patients?

__ __ __ No. of practice locations

Probe for Q30

[IF MORE THAN 4]: Please say more about your answer.

31. Of the physicians in your practice, how many provide primary care? Include all physicians working full- or part-time at all practice locations.

a. 1

b. 2

c. 3-5

d. 6-9

e.10-19

f. 20-49

g.50 or more

Probe for Q31

How easy or hard was it to answer this question?

32. What is the total number of primary care NPs and PAs in your practice? Include full- and part-time NPs and PAs at all practice locations.

a. Zero

b. 1-2

c. 3-5

d. 6 or more

Probe for Q32

Are there any NPs in your practice who provide specialty care only rather than primary care? [IF YES]: Did you include them in your count?

33. Do physicians and other clinicians in your practice meet at least once a month as a group?

a. Yes

b. No

Probes for Q33

How did you arrive at your answer?

What “other clinicians” were you thinking about?

[IF YES TO q33 AND R SAID 1 OR MORE NPs/PAs in Q32, PROBE IF NEEDED ON WHETHER THEY ARE INCLUDED IN THE MEETINGS]

34. Who establishes policies for your practice regarding care management of adult patients with high blood pressure, high cholesterol, and diabetes? Check All that apply.

a. Practice owners/partners

b. Other senior-level physicians in our practice

c. All or most primary care clinicians in our practice

d. Someone other than owners at the system level of our practice

d. Someone in an outside organization that our independent practice has a contractual relationship with

e. Does not apply – we do not have any practice policies of this type ► GO TO QUESTION 35

Probes for Q34

Please say more about your answer.

What policies were you thinking about?

[IF YES TO ITEM e, DID R SKIP CORRECTLY?)

35. Does your practice monitor clinician adherence to practice policies for managing the care of adult patients with high blood pressure, high cholesterol, and diabetes?

a. Yes

b. No

Probes for Q35

Please say more about your answer.

(How is the monitoring done?)

36. Does your practice routinely provide formal reports to clinicians about whether their patients with high blood pressure, high cholesterol, or diabetes are meeting clinical goals?

a. Yes

b. No

Probes for Q36

Please say more about your answer.

Who generates the reports?

What information do they contain?

37. Does your practice currently participate in a patient-centered medical home (PCMH) program?

a. Yes

b. No ►GO TO 39

Probes for Q37

Please say more about your answer.

[NOTE IF R IS NOT AWARE A WHAT A PCMH IS]

[IF YES]: How long has your practice been a PCMH member?

Have you changed any practice policies or processes as a result of your membership?

[IF NO, DID R SKIP CORRECTLY?]

38. What is the highest level, if any, of National Center for Quality Assurance (NCQA) PCMH certification that your practice currently has?

a. None currently

b. Level 1

c. Level 2

d. Level 3

e. Don’t know current level

Probe for Q38

Please say more about your answer.

Has your practice ever had NCQA certification?

[IF EVER HAD CERTIFICATION]: Were any requirements for certification related to the practice policy questions in the survey?

39. Please estimate the percentage of adult patients in your practice who have a limited ability to speak or read English.

a. Less than 10%

b.10% to 24%

c. 25% to 49%

d. 50% or more

Probe for Q39

How did you arrive at your answer?

40. Please estimate the percentage of adult patients in your practice who are . . .

	Less than 10%	10% to 24%	25% to 49%	50% or more
Uninsured				
Insured by Medicaid				
Insured by Medicare				

Probe for Q40

How confident are you that your estimates are correct?

About You

41. Which ONE of the following BEST describes your position in this medical practice?

a. Physician practice owner or partner

b. Head of practice/practice group

c. Family practice physician

d. Internal medicine physician specializing in primary care

Probe for Q41

What does response b, “head of practice/practice group,” mean to you?

[Probe if R expresses any difficulty choosing one answer]

42. Are you actively involved in establishing practice policies for care management of adult patients with high blood pressure, high cholesterol, or diabetes? Answer for each medical condition.

High blood pressure	High cholesterol	Diabetes
 Yes  No	 Yes  No	 Yes  No

Probe for Q42

[IF YES]: Please say more about your involvement in setting practice policies.

43. Consider any policies for care management of adult patients with high blood pressure, high cholesterol, and diabetes that have been established at your practice. How knowledgeable are you about these policies?

a. Very knowledgeable

b. Knowledgeable

c. Somewhat knowledgeable

d. Not at all knowledgeable

e. Does not apply – we do not have established practice policies for the care management of adult patients with those medical conditions

Probe for Q43

How did you arrive at your answer?

[IF SAID c or d]: What contributes, do you think, to your lack of knowledge or limited knowledge?

44. Since you graduated from medical school, how many years have you been a primary care physician treating adult patients in practice settings?

a. Less than 5 years

b. 5 years to less than 10 years

c. 10 years to less than 30 years

d. 30 years or more

Probe for Q44

Did you include or exclude residency training in primary care when you answered this question?

45. How long have you worked in this practice?

a. Less than 1 year

b. 1 year to less than 2 years

c. 2 years to less than 5 years

d. 5 years or more

Probe for Q45

[IF LESS THAN 1 YEAR]: How many months have you worked in this practice?

How confident did you feel answering the questions about practice policies? (Why?)

Thank you for completing this survey.

Please return your survey in the enclosed envelope. To obtain a replacement return envelope, please contact the [email protected] call (855) 798-3191, or use your own envelope and mail your survey to: Westat, 1600 Research Blvd., Rockville, MD 20850

END OF SURVEY PROBES: That’s the end of my questions. Do you have any comments about the survey that we have not talked about?

Or do you have any topics not included in the survey that you think should be included?

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