Testing Experience and Functional Tools Demonstration: PHR User Survey Instrument
PRA Disclosure Statement 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 0938-TBD (expires: TBD). The time required to complete this information collection is estimated to average 20 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850
This survey will ask you questions about an electronic tool for your computer or phone called [Insert state-specific PHR name]. Using the tool, you can see information about the help you get. You may also use it to talk with the people who help you. These questions will help collect information about your experiences with [Insert state-specific PHR name]. It is okay if you ask for help with your answers from someone you trust. It will take you about 20 minutes to finish. Filling out this survey is voluntary. Your answers are anonymous and will be kept confidential. It is your choice to answer these questions. None of your services will change if you answer them.
By clicking START SURVEY you are confirming that you read this introduction. You also confirm that you agree to participate. You also understand that your participation in this study is voluntary.
If you have questions about the survey or how to respond, please contact [INSERT NAME] at [INSERT NUMBER] or e-mail [INSERT EMAIL].
About Me
I am completing the survey (Check only one):
By myself, as a person receiving services (like meals brought to my home, someone that helps with bathing and dressing, or helps with cooking and cleaning)
With help from someone (like a family member or my case or care manager)
As a caregiver or care provider that uses the [Insert state-specific PHR name] to manage someone else’s care
Other: _ Click here to enter text.____________________________
How did you learn about [Insert state-specific PHR name]? (Check all that apply)
Family member or friend
Case or care manager
Service provider (like the agency that brings meals to my home, helps with bathing and dressing, or helps with cooking and cleaning)
Doctor or nurse
Focus group or other community group
I have not heard about [Insert state-specific PHR name] (Survey will skip to Question 15)
Other: _ Click here to enter text.____________________________
Do you view or update your [Insert state-specific PHR name]? (for example, using the [Insert state-specific PHR name] could include using a paper form, texting information to someone, or logging into the Personal Health Record to view or update information)
Yes (Survey will continue to Question 4)
I did, but I do not anymore (Survey will skip to Question 15)
No, but I plan to start using it (Survey will skip to Question 15)
No (Survey will skip to Question 15)
My Use of the [Insert state-specific PHR name]
Do you agree or disagree with the following statements about [Insert state-specific PHR name]?
4a. General PHR Use
Do you agree or disagree with the following statements about [Insert state-specific PHR name]? |
Agree |
Disagree |
Not Applicable |
It is easy for me to find and use [Insert state-specific PHR name]. |
☐ |
☐ |
☐ |
I would like to continue using the [Insert state-specific PHR name]. |
☐ |
☐ |
☐ |
I would recommend the [Insert state-specific PHR name] to a friend or family member. |
☐ |
☐ |
☐ |
I have physical problems (like problems with my vision) that make viewing the [Insert state-specific PHR name] hard. |
☐ |
☐ |
☐ |
I think the information on [Insert state-specific PHR name] is safe and secure. |
☐ |
☐ |
☐ |
4b. Social Services and Needs
My [Insert state-specific PHR name]…. |
Agree |
Disagree |
Not Applicable |
Helps me to communicate my needs to those helping me |
☐ |
☐ |
☐ |
Helps me to know about the care I receive |
☐ |
☐ |
☐ |
Helps me understand my eligibility for services at my home |
☐ |
☐ |
☐ |
Gives me contact information for my care team members |
☐ |
☐ |
☐ |
Keeps me informed about scheduled visits for services I am receiving |
☐ |
☐ |
☐ |
Gives me access to helpful information resources |
☐ |
☐ |
☐ |
Provides a place for my caregivers to receive information about me and my needs |
☐ |
☐ |
☐ |
4c. Health Services and Needs
My [Insert state-specific PHR name]…. |
Agree |
Disagree |
Not Applicable |
Helps me to know more about my health |
☐ |
☐ |
☐ |
Helps me do things to improve my health (like improve my diet or exercise) |
☐ |
☐ |
☐ |
Helps me make my own healthcare decisions |
☐ |
☐ |
☐ |
Gives me access to information for doctor visits or home health visits |
☐ |
☐ |
☐ |
Helps my caregivers to be up to date on my health information |
☐ |
☐ |
☐ |
How did you learn to use [Insert state-specific PHR name]? (Check all that apply)
I learned on my own
One-on-one training (like with my case or care manager or personal aide)
Group training (like a group class in my community)
Written guide(s) (like a paper training guide with instructions)
A video training, like on YouTube
Help desk (like a 1-800 number or online chat)
Computer lab training
Family member or friend
Other: _ Click here to enter text.____________________________
How do you use [Insert state-specific PHR name]? (Please check all that apply)
My private computer
My mobile phone or tablet
A public computer
Other: _ Click here to enter text.____________________________
Do you get help from someone to use [Insert state-specific PHR name]?
Yes, I always need help to use the [Insert state-specific PHR name]
Sometimes, I need help to use the [Insert state-specific PHR name]
No, I do not need help to use the [Insert state-specific PHR name]
Other: _ Click here to enter text.____________________________
How often do you view or update your [Insert state-specific PHR name]? (Please check only one)
Every day
Several times a week
Once a week
Once every few weeks
Once a month
Other: _ Click here to enter text.____________________________
What kinds of service information do you view or update in [Insert state-specific PHR name]? (Check all that apply)
Personal information (like my name, address, or birthday)
Services and supports data (like home delivered meals, self-care help, and/or help in my home)
Care plan
Medicaid eligibility (for receiving services at home)
Care team contact information
Care team availability
Other: _ Click here to enter text.____________________________
What kinds of health information do you view or update in [Insert state-specific PHR name]? (Check all that apply)
Doctor appointment scheduling
Medical records
Lab test results (like blood sugar levels)
Medication information
Health insurance information (like Medicaid)
Resources about my condition
Other: _ Click here to enter text.____________________________
What kinds of information do you receive from your [Insert state-specific PHR name]? (Check all that apply)
Reminders about upcoming doctors’ appointments
Reminders about upcoming home visits
Reminders about Medicaid eligibility (for receiving services at home)
Reminders about medication refills
Secure messages with my provider (like your doctor, nurse, or care or case manager)
Other: _ Click here to enter text.____________________________
What kinds of information do you give access to from your [Insert state-specific PHR name]? (Check all that apply)
Allow my providers and/or caregivers to get updates about how my day is going
Allow my providers and/or caregivers to get updates about my health status (like doctor visits)
Allow my providers and/or caregivers to view information about who I am and what I care about
Allow my providers and/or caregivers to view information about possible health concerns
Allow me to easily communicate issues with my support team
Other: _ Click here to enter text.____________________________
I have shared (or given someone access to) information from [Insert state-specific PHR name] with: (Check all that apply)
Family member or friend
Caregiver
Case or care manager
Service provider (like the agency that brings meals to my home, helps with bathing and dressing, or helps with cooking and cleaning)
Doctor or nurse
I have not shared (or given access to) this information
Other: _ Click here to enter text.____________________________
What kinds of information have you shared (or given someone access to)? (Check all that apply)
Personal information (like my name, address, or birthday)
Services and supports data (like home delivered meals, self-care help, and/or help in my home)
Care plan
Medicaid information
Care team contact information
Care team availability
Doctor appointment scheduling
Past and current medical records
Lab test results (like blood sugar levels)
Medication information
I do not know
Other: _ Click here to enter text.____________________________
I have not shared information from [Insert state-specific PHR name]
[Survey will skip to Question 18 for PHR Users in order to complete the rest of the survey.]
My Interest Level in a Personal Health Record
It is okay that you do not use [Insert state-specific PHR name]. Please give more information about why you are not using [Insert state-specific PHR name].
I do not use [Insert state-specific PHR name] because: (check all that apply)
I did not know the [Insert state-specific PHR name] was available to me
I did not see value in using the [Insert state-specific PHR name]
I found the [Insert state-specific PHR name] difficult to use
I worry about the privacy and security of my information
It would take too much time
I do not like computers/internet
I do not have internet access
I do not have a computer or mobile phone
Other: _ Click here to enter text.____________________________
How interested are you in using [Insert state-specific PHR name] to look at your health and service information?
Very much
Somewhat
Not really
Please mark whether you think [Insert state-specific PHR name] could be helpful for the following reasons. [Insert state-specific PHR name] would:
17a. Social Services and Needs
The [Insert state-specific PHR name] could be helpful to: |
Agree |
Disagree |
Not Applicable |
Communicate my needs to those helping me |
☐ |
☐ |
☐ |
Know about the care I receive |
☐ |
☐ |
☐ |
Understand my eligibility for services at my home |
☐ |
☐ |
☐ |
Give me contact information for my care team members |
☐ |
☐ |
☐ |
Keep me informed about scheduled visits for services I am receiving |
☐ |
☐ |
☐ |
Give me access to helpful information resources |
☐ |
☐ |
☐ |
Provide a place for my caregivers to receive information about me and my needs |
☐ |
☐ |
☐ |
17b. Health Services and Needs
The [Insert state-specific PHR name] could be helpful to: |
Agree |
Disagree |
Not Applicable |
Know more about my health |
☐ |
☐ |
☐ |
Do things to improve my health (like my diet or exercise) |
☐ |
☐ |
☐ |
Help me make my own healthcare decisions |
☐ |
☐ |
☐ |
Give me access to information for doctor visits or home health visits |
☐ |
☐ |
☐ |
Help my caregivers to be up to date on my health information |
☐ |
☐ |
☐ |
[Survey will continue with Question 18; all respondents will be asked to complete the rest of the survey.]
Demographic Information
Thank you for answering questions about your experience with [Insert state-specific PHR name]. The last few questions focus on you. These questions will be used to help understand how different people experience the [Insert state-specific PHR name].
Please mark your sex.
Male
Female
Please mark what age range you are in.
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75- 84 years old
85 years or older
Please mark your race or ethnicity. (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other: _ Click here to enter text.____________________________
Please mark the highest level of education you have completed. (Check all that apply)
Did not complete high school
High school/GED
Some college
Completed college
Advanced college degree (Masters, JD, PhD, or MD)
Other: _ Click here to enter text.____________________________
Which of the following do you experience? (Check all that apply)
A vision or hearing impairment
A speech or language disability
A mobility or physical impairment
A learning or developmental disability
A cognitive impairment or dementia
A mental health disorder
A brain injury
Other: _ Click here to enter text.____________________________
None of the above
What do you get help with at home and in the community? (please check all that apply)
Daily activities (like bathing, dressing, feeding, transferring, and mobility)
Activities in my home (like cleaning, housekeeping, preparing meals, shopping, and managing money)
Activities at my work, my job, or my school
Activities in my community
Social, emotional, or behavioral needs
Medication or health care
Transportation
Other: _ Click here to enter text.____________________________
None of the above
We want to understand how fast you start using new technology. Please check all the statements that apply to you below.
I have to be one of the first people to buy new technology
I am the last of my peers to begin using new technology
I am afraid or unwilling to use new technology
Other: _ Click here to enter text.____________________________
Additional Comments
Please provide any additional comments or feedback about [Insert state-specific PHR name].
_ Click here to enter text.____________________________
If you are a caregiver filling out this survey, or helping someone fill out this survey, please provide any additional comments about the [Insert state-specific PHR name].
_ Click here to enter text.____________________________
Thank you for completing this survey. Your responses will be kept anonymous and confidential. Your responses will be used to understand experiences with PHRs.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Appendix A: Personal Health Record Survey Instrument |
| Subject | PHR User Survey |
| Author | CMS;The Lewin Group |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |