First Name	(required)
Last Name	(required)
Degree	- Select - MD DO Other (required)
E-mail	(required)
Country	United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Aruba Australia Austria Bahamas Bahrain Bangladesh Barbados Belgium Belize Benin Bermuda Bhutan Bolivia Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Keeling Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Enderbury Islands Equatorial Guinea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Germany Ghana Gibraltar Greece Greenland Grenada Grenadines/St Vincent Guadeloupe and Martinique Guam Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kenya Kirbati Korea Dem Peoples Rep Korea Rep of Kuwait Lao Peoples Dem Rep Latvia Lebanon Lesotho Liberia Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Lucia Samoa Western San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Islands Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain and Canary Islands Sri Lanka St Helena St Kitts St Pierre and Miquelon Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Vanuatu Venezuela Vietnam Virgin Islands British Virgin Islands US Wallis and Futuna Islands Yemen Yugoslavia Zaire Zambia Zimbabwe   (required)
Zip Code	(required)

How to use this tool:
Answer the following questions to help you assess your office practice and then determine if electronic health records would be beneficial to your practice.

Patient Population

1. How many patients do you see in your office on an average day?
A. 0-20 patients
B. > 20 patients

2. Of all your patients seen daily, what percentage has one or more chronic illnesses (e.g., CAD, diabetes, hypertension, osteoarthritis, heart failure, depression)?
A. 0-25%
B. 26-50%
C. 51-75%
D. > 75%

Practice Workflow Problems

3. Please check the workflow issues that cause the greatest problems in your office: (check all that apply)

A	Having medical records unavailable at time of office visit
B	Unable to stay on office schedule
C	Poor legibility of medical records
D	Patients unable to access physician when they want/need
E	Patient waits
F	Inefficient use of resources
G	Chart chasing
H	Phone and fax processing
I	Results (e.g. labs, referrals), tracking, and follow-up
J	Patient satisfaction
K	Medication refills
L	Timely referrals
M.	Other

4. Of your patients seen daily, how many are seen without an available medical record?
A. 1-5
B. 6-10
C. > 10

5. What workflow solutions have you implemented or considered? (check all that apply)

A.	Hired a practice management consultant
B	Hired additional clinicians (e.g., NP, PA)
C	Reorganized supplies in exam room/office
D	Implemented patient tracking system
E	Outsourcing billing services
F	Changed workflow to address inefficiencies
G	Changed/added staffing to address phone triage
H	Automated phone service
I.	Other

Practice Management

6. Does your practice use an electronic registration, scheduling, and/or billing system?
A. Yes
B. No

7. Do you currently create reports or use a registry (patient tracking system) method to manage patients with similar conditions (e.g., diabetes, cardiac)?
A. Yes
B. No

7b. If yes, do you share the data electronically in any form?
A. Yes
B. No

8. If any of the following applications were available to you, would you be interested in using them? (check all that apply)
A. EHR system
B. E-prescribing
C. E-laboratory (e.g., orders, reports)
D. Disease management systems
E. Other

9. How many of the following do you have in your practice (all sites)?
A. Non-physician clinicians
B. RN/LVN
C. Other office staff

10. Do you conduct staff (clinicians and administrative staff) meetings?
A. Yes
B. No

10a. If yes, what are some of the discussion topics? (check all that apply)

A	Workflow
B	Patient satisfaction issues
C	Revised procedures
D	Management of chronic disease
E	Interesting medical cases
F	Customer Service
G.	Other

10b. If yes, what is the frequency of the meetings?
A. Once per week
B. Once per month
C. Once per quarter
D. Once per year
E. Other

11. How much of the administrative staff's daily work is spent on inefficient tasks? (e.g., searching for misplaced medical charts)?
A. < 1 hour
B. 1-2 hours
C. > 2 hours
D. Other

Laboratory

12. Thinking about the laboratory services your practice uses, please estimate what percentage is referred to each of the following settings.
A. % in office
B. % Quest Diagnostic
C. % LabCorp
D. % Community hospital or medical center
E. % Other

13. Thinking about how your practice receives lab reports, please estimate what percentage is received by each of the following methods.
A. % Electronic
B. % Fax
C. % Hard copies (Printer in office or delivery)
D. % Other

14. On average, about how many calls each week do you or your staff make to the lab reports about lab reports?
A. None
B. < 5
C. 5-10
D. > 10

Prescriptions

15. On average, what is the number of new (non-refill) prescriptions you write daily?

A.	None
B	< 10
C	10-19
D	20-29
E	30-39
F	40-49
G	50-59
H	> 60

16. On average, how many refills or renewal requests do you authorize daily?

A	None
B	< 10
C	10-19
D	20-29
E	30-39
F	40-49
G	50-59
H	> 60

17. On average, how many patients per day need their prescriptions rewritten?
A. None
B. < 5
C. 5-10
D. > 10

18. On average, please estimate the number of follow-up calls or faxes your practice receives each week for RX issues?

A	None
B	< 10
C	10-19
D	20-29
E	30-39
F	40-49
G	50-59
H	> 60

Clinical Referrals

19. How many referrals to specialists do you make each week?
A. None
B. < 5
C. 5-10
D. > 10

Transcription Services

20. Do you use transcription services in your practice?
A. Yes
B. No

20b. If yes, what are your average transcription costs per month?
$

Billing

21. What is your current method of billing? (check all that apply)
A. Electronic
B. Paper-based
C. Contracted external services
D. Other

22. What are your average claims turn around time (TAT) from submission to payment?
A. < 30 days
B. 30-60 days
C. > 60 days
D. Other

23. Do you have any problems with or concerns about your coding?
A. Yes
B. No

Information Technology

24. Which staff members have direct access to a computer/terminal? (check all that apply)
A. Physicians
B. Clinicians (e.g., NP, PA, RN)
C. Administrative staff
D. Other

25. What is the total number of computers in your practice?

25a. Number of workstations?

25b. Are your computers connected to a network?
A. Yes
B. No

25c. Do you share documents or information on your network?
A. Yes
B. No

25d. Do you communicate within your practicing using e-mail?
A. Yes
B. No

26. Does your practice have a high-speed internet connection?
A. Yes
B. No

26a. If yes, is the internet connection used by the staff daily?
A. Yes
B. No

26b. If yes, what are the primary uses for the internet connection? (check all that apply)

A	Pub Med (or other online peer reviewed resource)
B	Hospital / Medical Center (data transfer)
C	Medical charts
D	Health plan reports
E	E-mail
F	E-prescribing
G	Electronic Claims Submission
H	E-labs
I	Transcription
J	Referral request submission
K	Don't know
L.	Other

27. Does your Practice Management System (PMS)/billing system provide interfaces to EHR system(s)?
A. Yes
B. No

Evaluation Questions

28. This online course met the objectives listed at the beginning of the course.
A. Agree
B. Disagree

29. The instructional quality of this online course is good.
A. Agree
B. Disagree

30. Reading this online course enhanced my professional effectiveness.
A. Agree
B. Disagree

31. There is no evidence of commercial bias.
A. Agree
B. Disagree

32. The content was objective and balanced.
A. Agree
B. Disagree

33. The content was evidence-based.
A. Agree
B. Disagree

34. The type of evidence was identified.
A. Agree
B. Disagree

35. The source of evidence was identified.
A. Agree
B. Disagree

Comments or future topics: