Practice Demographics Practice Name:
Practice Address:
Practice Telephone Number:
Practice Fax Number:
Tax ID Number:
REC Implementation Agent:
Lead Physician:
Lead Physician Email Address:
Project Primary Contact:
Primary Contact Email Address:
Number of Physicians in the Practice:
Number of LPN/RN in the Practice:
Number of Clinical Staff in the Practice:
Number of Office Support Staff in the Practice:
Additional Affiliations:
Preffered Method of Contact:
Telephone Fax Email
Reason for Participation (check all that apply)
Practice is interested in adopting an EHR and other technology
Practice is interested in optimizing workflow with use of health technology Practice is interested in support in achieving meaningful use
Practice is interested in applying for Patient-Centered Medical Home (PCMH)
Practice is interested in qualifying for additional incentive programs offered by Medicare and/or Medicaid Percentage of Patients Seen Daily by the Practice Annually
% of Medicare % of Medicaid
% of Private Insurance % of Uninsured Patient Population
How many patients are seen in your practice on an average day? 0 – 20 patients >20 patients
Of the patients seen daily, what percentage has one or more chronic illnesses (i.e. CAD, diabetes, hypertension, heart failure, or depression)?
Of the patients seen daily, what percentage would benefit from smoking cessation assistance? Medical Specialties
Family Medicine Internal Medicine Pediatrics
Geriatrics Cardiology Endocrinology
Podiatry Ophthalmology Dentistry
Radiology Oncology Nephrology
Other
Practice Workflow Evaluation
Please check all the workflow issues that are of the greatest concern in your practice (check all that apply): Unable to stay on office schedule Health maintenance tracking
Poor legibility of medical records Handling requests generated by fax or phone Patient wait time in the office or on the phone Scheduling appointments
Practice Workflow Evaluation (continued)
Of the patients seen daily, how many are seen without an available medical record?
Has the practice implemented any of the following workflow solutions? (check all that apply)
Hired a practice management consultant Hired additional clinicians (e.g. NP, PA) Attended seminars on improving clinical office practice Implemented a patient tracking system Conducted quality improvement projects Automated phone service
(e.g. patient flow studies)
Redesigned workflow to address inefficiencies Changed/added staff to address phone triage
Other
Has the practice tried to remedy workflow issues or operational inefficiencies in the past? Yes No
If ‘Yes,’ how successful were these efforts? Using a scale of 1-5 for your answer. (1 = very unsuccessful, 3 = neither successful nor unsuccessful, 5 = very successful) 1 2 3 4 5
Practice Management
Does the practice have other projects going on and/or starting soon that might affect the planning for and/or success of the HIT implementation project (e.g. moving to a new location, changing the telephone system)?
Yes No
If ‘Yes,’ please specify
What types of technology is the practice currently using on a regular basis? (check all that apply) E-mail (administrative use) E-mail (clinical use)
Disease/Immunization registries E-prescribing
High-speed internet connection Locally networked computers Document imaging system E-lab results
Technology Type Vendor Disease Registries E-prescribing Document Imaging E-lab RHIO Portal
Please indicate whether the practice has or will have the following systems in place within 6 months: Practice Management System
Please specify vendor/system and version
Electronic Medical Record (EMR) or Electronic Health Record (EHR) System Please specify vendor/system and version
Does the system support disease specific registries (yes/no): Other Information Technology (IT) system(s)
Please specify vendor/system and version
Do you currently create reports or use a registry (i.e. patient tracking system) to manage patients with chronic conditions (e.g. diabetes, cardiac, hypertension, immunizations)? Yes No
If ‘Yes,’ what do you do with the data? (check all that apply)
Share with all clinicians and physicians, either internal or external to your practice Share with your administrative staff
Generate reminders for patients
Do you currently provide printed information on drug therapies, disease management, diet, etc.? Yes No
Does the practice provide interpreter services for non-English speaking patients? Yes No
Would the practice be interested in learning more about how to provide more culturally responsive care? Yes No
Do you conduct weekly or monthly staff meetings? (Clinicians & administrative staff) Yes No If ‘Yes,’ what are some of the discussion topics? (check all that apply)
Workflow Interesting Medical Cases Patient Satisfaction Issues Customer Service
Revised Procedures Other Management of Chronic Disease
If ‘Yes,’ what is the frequency of the meetings?
Once per week Once per year Once per month Once per quarter Other
Laboratory
Please estimate the proportion of total lab services generated in your practice that are processed: % by your office % by a community hospital or medical center % by your primary lab (name of laboratory):
% by your secondary lab (name of laboratory): % Other
Do you collect blood specimens in your office? Yes No
Thinking about how your practice receives lab reports, please estimate what percentage is received by each of following methods:
% Electronic % Hard Copies (printer in office or delivery)
Prescriptions
On average, what number of new (non-refill) prescriptions does your practice write daily?
None 30-39
< 10 40-49
10-19 50-59
On average, how many refills or renewal requests does your practice process daily?
None 30-39
< 10 40-49
10-19 50-59
20-29 > 60
On average, how many of your practice patients per day need their prescriptions rewritten?
None 5-10
< 5 > 10
On average, please estimate the number of follow-up calls or faxes your practice receives each week for medication prescribing issues (illegible handwriting, drug-drug interactions, allergy alerts, non-formulary):
None 30-39
< 10 40-49
10-19 50-59
20-29 < 60
Are you currently tracking groups of patients taking certain mediations (e.g. patients on Warfarin)?
Yes No
If ‘Yes,’ what is the method of tracking?
Spreadsheet Card file Database EMR PMS ICD 9 abstract Clinical Referrals
How many referrals to specialists do you make each week?
Transcription Services
Does your practice use transcription services? Yes No
If ‘Yes,’ what is your practice’s average transcription costs per month? $ Billing
What is the practice’s current method of billing? (check all that apply) Electronic (Vendor Name Contracted external services
Paper-based Other
If you are billing electronically, is your system HIPAA compliant? Yes No
Does your current system allow you to generate reports sorted by CPT or ICD 9 code? Yes No
What is your average turnaround time on claims from submission to payment? None 30-39
< 10 40-49
D o you have a ny pr oblems with or concer ns about your coding? Yes No
Information Technology
Please indicate the current status of the practice’s EHR/HIT system implementation efforts: Beginning the process of selecting a system.
In the process of implementing a system. Currently live with a system.
Which of the following technologies would you be interested in, if you are not using them currently (check all that apply):
Which staff members have direct access to a computer/terminal? (check all that apply) Physicians Clinicians (e.g., NP, PA, RN)
Administrative staff Other
What is the total number of computers currently in your practice?
Are your computers connected to a network? Yes No Do you share documents or information on your network? Yes No Do you communicate within your practice using e-mail? Yes No Does your practice have high-speed Internet connection? Yes No If ‘Yes,’ is the Internet connection used by the staff daily? Yes No If ‘Yes,’ what are the primary uses for the Internet connection? (check all that apply) Pub Med (or other online peer-reviewed resources) Electronic Claim Submission Hospital/Medical Center (data transfer) E-lab
Medical Charts Transcription
Health plan reports Referral request submission
E-mail Don’t know
E-prescribing Other
Is your current Practice Management System (PMS)/billing system capable of interfacing with an Electronic Health Record (EHR) system? Yes No Not Sure Are you interested in upgrading your current PMS? Yes No Not Sure Are you interested in an integrated solution? Yes No Not Sure Has your practice explored any EHR systems? Yes No
If you have not implemented an EHR system, what barriers are you facing? (please prioritize the top three reasons from the list below)
Financial constraints
Unable to secure all partners’/clinicians’ commitment to use EHR
Vendor support was inadequate for technological needs Initial data entry is too labor intensive
Vendor stability and viability
Software requires extensive customization to fit into practice Lack of standards
Difficult to select a system Do not know where to begin Other
Current EHR Users Only-Answer remaining questions
Who was involved in the decision to purchase an Electronic Health Record (EHR) system? One physician All the physicians at the practice Entire staff at the practice Other
Were your partners and staff as eager to progress to EHR as you were? Yes No What is the name of the EHR selected?
What are your goals (benefits) for using an EHR? (Please prioritize in order with “1” being the most important and “9” being the least important)
Reduce transcription costs Receive return on investment associated with software Reduce paper based medical charts Increase Patient satisfaction
Reduce administrative costs of practice Improve phone and fax processing Provide more services to patients per visit Timely access to patient records
