Schs.dph.ncdhhs.gov
North Carolina Central Cancer Registry
Department of Health and Human Services – Division of Public Health
State Center for Health Statistics
Physician’s Office Electronic Health Record (EHR) Adoption Survey
Date ________________
Please fill out the physician’s office information:
First Name __________________________ Last Name ________________________ MD/DO (circle one)
Name of Practice ______________________________________________________________________
City ____________________________________ State ___________________ Zip ________________
Telephone (Area Code) ________________________Business Email Address ______________________
Preferred primary contact (if different from above):
First Name __________________________ Last Name ________________________ MD/DO (circle one)
Title ______________________________________________
Telephone (Area Code]) ________________________Business Email Address ______________________
1. How would you describe your practice?
(Please check all that apply)
← Solo medical oncology practice ( Freestanding
← Medical oncology group or partnership ( Physician-owned center
← Solo radiation oncology practice ( Hospital-based practice
← Radiation oncology group or partnership
← Multi-specialty group or partnership
← Other (Please specify) ___________________________________________
2. Please provide the following information for the key contact information in your laboratory:
Name: ___________________________________________________________________________
Position: __________________________________________________________________________
Department: _______________________________________________________________________
Phone: ___________________________________________________________________________
Email ID: _________________________________________________________________________
3. Consider all full and part-time clinicians at your main practice. Including you, how many are:
Physicians: ______________________________
Nurse
Practitioners: _____________________________
Physician
Assistants: ________________________________
4. Please estimate the percentage of Medicare and Medicaid patients seen in your practice.
Medicare___________ Medicaid__________
5. What types of tests are performed at your facility?
6. Is your facility part of a multi-facility health system?
← Yes
← No
a) If yes, which health system? _______________________________
b) How many facilities are included in your health system? _______
7. How many primary hospitals do you serve? __________________
8. Please specify the names of the primary hospitals:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Upon completing a typical office visit, how do you generate medication prescriptions for your patients?
← Handwritten
← Computerized, No Decision Support
← Computerized, With Decision Support (e.g., drug interaction alerts)
← Other, please describe: ___________________________________
Electronic Health Record related questions:
10. Does your primary hospital have an EHR?
← Yes
← No
a) If yes, does your practice connect electronically to the hospital’s EHR?
← Yes
← No
11. Does your practice use a computerized scheduling system?
(IF YES, PLEASE APPROXIMATE THE NUMBER OF YEARS YOU HAVE USED THIS SYSTEM.)
← Yes Years of computerized scheduling:________
← No
12. Does your practice use an electronic billing system?
← Yes If yes, name of billing system: _______________________
← No
13. Does your main practice use the certified EHR system?
← Yes
a) If yes, please name the EHR system:__________________
b) Please specify the name of,
▪ EHR vendor: _______________________________
▪ Product name:_______________________________
▪ Version: ____________________________________
← No
If no, when do you plan to implement an EHR?
← Within the next 12 months
← Within the next one to two years
← No specific plans
← Other, please specify: __________________________
Please proceed to question #14 and #15 if the answer to question #13 is yes:
14. Do you use EHR during patient visit? (i.e., tablets, PDAs, computers on wheels, etc.)?
← Yes
← No
15. Please provide EHR software vendor representative contact information:
First Name: _____________________ Last Name: _______________________
Position: ________________________ Department: ______________________
Telephone (Area Code):____________ Business Email Address: ___________________
16. What would be the greatest help to your practice in moving to an EHR?
← Internet access
← Technical support
← Funding
← Other, please specify:_______________________________
17. What does your practice perceive as benefit(s) of Electronic Health Records?
(PLEASE CHECK ALL THAT APPLY)
← Access to current patient data
← Ability to complete records from remote location
← Accessibility of data regardless of setting or provider (interoperability)
← Office process efficiency
← Reduce administrative costs associated with practice
← Increased communication within the office
← Increased communication with the patient
← Disease management
← Ability to monitor and improve patient/population clinical outcomes
← Cancer Registry reporting
← Meeting Medicare/Medicaid meaningful use objectives
← Cost reduction
← Increased revenue
← No perceived value (Benefits do not justify costs)
← Other, please specify:________________________________
18. How much of a barrier is each of the following to beginning or expanding the use of computer technology in your main practice? (Please circle the number that corresponds with your answer)
| |Not a Barrier |Minor Barrier |Major Barrier |
| |1 |2 |3 |
|Computer skills of you and/or colleagues/staff | | | |
| |1 |2 |3 |
|Computer technical support |1 |2 |3 |
|Lack of time to acquire knowledge about systems | | | |
| |1 |2 |3 |
|Start-up financial costs |1 |2 |3 |
|Ongoing financial costs |1 |2 |3 |
|Training and productivity costs |1 |2 |3 |
|Physician skepticism of EHRs |1 |2 |3 |
|Privacy and security concerns |1 |2 |3 |
|Lack of uniform standards (e.g. multiple systems | | | |
|are used by different providers) | | | |
| |1 |2 |3 |
| | | | |
|Technical limitations of system |1 |2 |3 |
19. What stage has your practice reached with EHR adoption?
← Purchased, but have not started implementing system
← Installed, training in progress
← EHR implemented and in use for less than one year
← EHR implemented and used for greater than one year
Other, please specify: ____________________________________________
20. Please indicate the features of the EHR that you have available in your practice:
| |Yes, But do not |Yes, Use sometime |Yes, Use most of the |No, Not Available |Do Not Know |
| |Use | |time/always | | |
| | |2 |3 |4 |5 |
| |1 | | | | |
| | | | | | |
|Laboratory Results |1 |2 |3 |4 |5 |
| | | | | | |
|PACS |1 |2 |3 |4 |5 |
| | | | | | |
|Electronic Visit Notes |1 |2 |3 |4 |5 |
| | | | | | |
|Electronic medication lists for each |1 |2 |3 |4 |5 |
|patient | | | | | |
| | | | | | |
|Electronic reporting to cancer registry |1 |2 |3 |4 |5 |
|Electronic referral or | | | | | |
|clinical messaging (secure |1 |2 |3 |4 |5 |
|emailing between providers) | | | | | |
| | | | | | |
|Reduce clinical and medication|1 |2 |3 |4 |5 |
|errors | | | | | |
| | | | | | |
|Improve access to medical |1 |2 |3 |4 |5 |
|record information | | | | | |
| | | | | | |
|Improve charge capture |1 |2 |3 |4 |5 |
| | | | | | |
|Improve patient communications|1 |2 |3 |4 |5 |
Have any questions regarding the survey? Please contact:
NCCCRMU2@dhhs.
Phone: (919) 715-97287474
**If you would like to receive this survey in Microsoft Word format, please send email.
THANK YOU!
PLEASE RETURN THE SURVEY IN THE RETURN ENVELOPE OR FAX TO THE FOLLOWING ADDRESS:
NORTH CAROLINA CENTRAL CANCER REGISTRY
STATE CENTER FOR HEALTH STATISTICS
1908 MAIL SERVICE CENTER222 N. DAWSON STREET
RALEIGH, NC 2760327699-1900
FAX: 919-715-72947294
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