3 Attachment D: Process Usage Worksheet (Providers)

Form Approved
OMB No. 0935-0179
Exp. Date 11/30/2020

Attachment D. Process Usage Worksheet (Providers)

To understand the provider organizations, view of how the PRO measures are used by the clinical team each site lead will complete a brief usage process worksheet. This worksheet will be another lens on how the PRO application is being used by providers.

We will collect two data points each week. These data points are:

1. Number of patients whose PRO data was accessed by the provider: defined as the number of times any provider at the site accessed the patients PRO measure data.

2. Informative information: defined as how informative the PRO measure was to the goals of the provider accessing the information. Providers will be asked to rate this on a 1 to 5 scale with 5 being highly informative to their goals.

The worksheet is displayed below and will be completed on a weekly basis by the lead at each site and then confirmed by our research team.

	Number of patients whose PRO data was accessed by the provider	How informative was this information? (1-5 with 5 being highly informative)
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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 (0935-0179) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

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