Form 1 Attachment 1 -- Evaluation Provider Survey

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Evaluation Provider Survey

On behalf of the MedStar-IMPAQ team, thank you for your interest and willingness to participate in this survey on the [CDS Tool Name]. Your feedback is very important to us! The information you provide is voluntary and will be kept strictly confidential. It will not be reported or released in any way that allows identification of respondents. If there is a question you would rather not answer, you can skip it.

We are not selling anything but are conducting a survey about your experience in using [CDS Tool Name] developed under the funding of the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services. We are interested in your experience and we hope to know how we can make the [CDS Tool Name] better for clinicians in the future.

This survey will take 10-15 minutes to complete.

1. How did you learn about [CDS TOOL NAME]?

• From a member of my team at MedStar

• From another staff member at MedStar

• In an advertisement in a MedStar facility

• From the research team at the MedStar Health Research Institute

• [Other response choices as relevant]

2. What was the main reason you decided to use [CDS TOOL NAME]?

• [Free text entry]

3. What was your biggest concern about using [CDS TOOL NAME]?

• [Free text entry]

How much do you agree with the following statements?

4. It was easy to get started with [CDS TOOL NAME].

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

5. I know how to get technical support for [CDS TOOL NAME].

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

6. [CDS TOOL NAME] provides me the needed information in a timely manner.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

7. [CDS TOOL NAME] respects my clinical decisions.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

8. I am confident that [CDS TOOL NAME] protects my patients’ private health information.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

9. [CDS TOOL NAME] is something I am willing to incorporate into my day-to-day care.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

10. [CDS TOOL NAME] is a valuable resource for my day-to-day care.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

These next questions ask about your experiences using [CDS TOOL NAME].

11. How often do you use [CDS TOOL NAME]?

• Every day

• A few times a week

• Once a week

• A few times a month

• Once a month

• Less often than once a month

12. How often do you contact your patient every time [CDS TOOL NAME] sends you a message alert regarding his or her health?

• Never

• Once

• A few times

• Most times

• Almost every time

13. How valuable is [CDS TOOL NAME] to you in treating patients with chronic conditions, such as substance use disorder?

• Not at all valuable

• A little valuable

• Very valuable

• Extremely valuable

14. Please rank each of the parts of [CDS TOOL NAME], where 1 is the most useful and 5 is the least useful.

• Diagnosis List

• Medication List

• Social History

• Current Prescriptions

• Prescription Drug Monitoring Program

• Patient-Reported Outcomes

• Non-Opioid Pain Management Plan

• Opioid Taper Calculator

15. Overall, how difficult is it to integrate [CDS TOOL NAME] into your routine practice of care?

• Not at all difficult

• A little difficult

• Very difficult

• Extremely difficult

16. Has difficulty with [CDS TOOL NAME] ever prevented you from using it when you wanted to?

• No

• Yes

17. [FOR RESPONDENTS WHO CHOSE “A LITTLE/VERY/EXTREMELY DIFFICULT” FOR Q15] What part or parts of [CDS TOOL NAME] were most difficult to use?

• [Free text entry]

18. How can we improve [CDS TOOL NAME] and make it easier for you to use in your routine practice of care?

• [Free text entry]

19. How likely are you to keep using [CDS TOOL NAME]?

• Definitely will

• Probably will

• Might or might not

• Probably will not

• Definitely will not

20. How likely are you to keep using [CDS TOOL NAME] if we made the improvement you mentioned?

• Definitely will

• Probably will

• Might or might not

• Probably will not

• Definitely will not

21. If you plan to keep using [CDS TOOL NAME] in your routine practice of care, what are your reasons for using it?

• [Free text entry]

22. If you do not plan to use [CDS TOOL NAME] in your routine practice of care, what areas do you think it needs to be improved?

• [Free text entry]

23. Please share any other thoughts you have about [CDS TOOL NAME] with us:

• [Free text entry]

Thank you for completing our survey! Your answers help us improve [CDS TOOL NAME] and make it more useful for clinicians like you.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 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-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857