ࡱ> @ bjbj.. DD@ xxxx4 4 4 $0 P<D0 T@ L%TOQQQQQQ$R4vu]4 <%uxx ooopx4 OoOoorT64 H h϶kK 0ZX Txxxx@4 PZ@oU4ruu0 0 R\)Y0 0 \ Initial Readiness Assessment The purpose of this assessment is to provide us with an operational overview of your practice. Instructions: Please follow the steps below for completing the assessment: The person most knowledgeable about the computing, clinical and administrative operations of the practice should complete the assessment. Responses can be estimates. When you read the question, record your initial reaction. Complete one form for each practice site. Submit your completed assessment to FAFP attention Ray Lowe via fax (904-726-0923) General Information  1.* Please provide your practice information below: Practice Name: Date: Practice Address: City: Zip Code: Phone: Fax: Email: Individual(s) Completing Assessment: Title: Preferred method of contact:  FORMCHECKBOX  Telephone  FORMCHECKBOX  Fax  FORMCHECKBOX  E-mail Number of additional office locations: If the practice has multiple office locations each with an interest in enrolling, please complete a separate form for each location.  2.* Practices group physician identification number (PIN): 3.* Does the practice use a single tax ID number to bill Medicare?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3a. If Yes please provide the tax ID number:  4.* Is the practice affiliated with an independent practice association (IPA) or medical group?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  4a. If Yes please indicate which IPA or medical group: 5.* Medical specialties (Check all that apply):  FORMCHECKBOX  Family Medicine FORMCHECKBOX  Cardiology: FORMCHECKBOX  Endocrinology FORMCHECKBOX  Internal Medicine FORMCHECKBOX  Geriatrics FORMCHECKBOX  Other:What percent is primary care? % Practice Profile (this site only) 6.* Please indicate the number per day of each of the following visit types Visit typeNumber/dayCommentsNew patientFollow up (active)Group visit#groups/dayAvg# patients/group visit 7.* Of your patients seen daily, what percentage are Medicare fee-for-service beneficiaries? %  8.* Percentage of practices active patients within prior year which have one or more chronic illnesses (e.g., coronary artery disease, diabetes, hypertension, osteoarthritis, heart failure): %  9.* Does the practice provide interpreter services for non-English speaking patients?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10.* Would the practice be interested in learning more about how it can provide more culturally responsive care?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11.* Please indicate the practices average claims turnaround time for all payors:  FORMCHECKBOX  Less than 30 days  FORMCHECKBOX  30-60 days  FORMCHECKBOX  Greater than 60 days 12.* What is the practices average collections ratio: %  13.* Please indicate the total number of staff in each of the following categories (this site only) ClinicalTotalAdministrativeTotalPhysicianOffice ManagerPhysician Assistant / ARNPReceptionist/SecretaryRN/LPNBillingMedical AssistantOther (specify)Other (specify)14. Check any of the following that apply to your practice setting:  FORMCHECKBOX  A. Rural  FORMCHECKBOX  B. Private clinic with no affiliations  FORMCHECKBOX  C. Affiliation with a hospital or integrated delivery network  FORMCHECKBOX  D. Member of an IPA  FORMCHECKBOX  E. Residency program Existing Infrastructure (this site only) 15.* What types of technology is the practice currently using on a regular basis? (Check all that apply)  FORMCHECKBOX  E-mail (administrative use)  FORMCHECKBOX  E-mail (clinical use)  FORMCHECKBOX  Disease registry  FORMCHECKBOX  E-prescribing  FORMCHECKBOX  High speed Internet connection  FORMCHECKBOX  Locally networked computers  FORMCHECKBOX  Document imaging system  FORMCHECKBOX  E-lab results Technology TypeVendorDisease RegistryE-prescribingDocument Imaging E-Lab 16. What is the total number of computers in the practice?  17. Are your computers connected to a network?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 18.* Do you share documents or information on your network?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 19. Which staff members have direct access to a computer and/or workstation?  FORMCHECKBOX  MDs  FORMCHECKBOX  Clinicians  FORMCHECKBOX  Administrative staff  FORMCHECKBOX  Other ___________________ 20. If you use an Internet connection, what are the primary uses for it? (Check all that apply)  FORMCHECKBOX  Medical Research (or other online peer reviewed resource)  FORMCHECKBOX  Hospital  FORMCHECKBOX  E-labs  FORMCHECKBOX  Medical charts  FORMCHECKBOX  Transcription  FORMCHECKBOX  Health plan reports  FORMCHECKBOX  Voice recognition  FORMCHECKBOX  E-mail  FORMCHECKBOX  Dont know  FORMCHECKBOX  Electronic claims submission  FORMCHECKBOX  Other: (Please specify) 21. Does the practice have a website?  FORMCHECKBOX  Yes  FORMCHECKBOX  No List address:  Information Systems (this site only) 22.* Has the practice tried to implement clinical information systems, such as an EHR or electronic prescribing in the past?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 22.a. If Yes how successful were these efforts? (Use a scale of 1-5, where 5 = very successful, 4 = somewhat successful, 3 = neither successful nor unsuccessful, 2 = somewhat unsuccessful, 1= very unsuccessful.)  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  5 23.* Does the practice have other projects either currently going on and/or starting soon that might affect the planning for and/or success of the EHR/HIT implementation project?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 23. a. If Yes, please specify:  24.* Does the practice utilize an E-prescribing system?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Vendor:  25.* Does the practice use a document imaging system?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Vendor:  Practice Management (PM) System 26.* Do you currently use a PM System?  FORMCHECKBOX  YES If you are using a PM System, please answer the following: Describe your system: I. Vendor name:  II. How long have you used the system? III. Who was involved in the buying decision? (Name and title) Please identify the components used:  FORMCHECKBOX  Billing  FORMCHECKBOX  Scheduling  FORMCHECKBOX  Registration  FORMCHECKBOX  Other  Do all providers use the same system components?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, explain difference:   FORMCHECKBOX  NO If not using PM System, please explain why you do not have a PM System   FORMCHECKBOX  Outsourced  FORMCHECKBOX  Other: (Please specify) A. Does the practice plan to have a PM system in place within 6 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Electronic Health Record (EHR) 27.* Does the practice use an EHR?  FORMCHECKBOX  YES-If you are using an EHR, please answer the following: A. Please identify the EHR used:  B. How do you utilize the EHR? (Check all that apply)  FORMCHECKBOX  Patient demographics  FORMCHECKBOX  Diagnostic test results  FORMCHECKBOX  Ordering  FORMCHECKBOX  Review reports/notes  FORMCHECKBOX  Order/referral tracking  FORMCHECKBOX  Problem list  FORMCHECKBOX  Medication list  FORMCHECKBOX  Automated checks  FORMCHECKBOX  E-prescribing  FORMCHECKBOX  Other: (Please specify)  C. What problems have been encountered with the EHR system? Please explain:  FORMCHECKBOX  NO If you are not using an EHR, please answer the following.  A. Have you explored any EHRs?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Which ones?  B. If yes, i. What is your timeframe goal?   FORMCHECKBOX  < 6 months  FORMCHECKBOX  6-12 months  FORMCHECKBOX  > 1 year  FORMCHECKBOX  > 2 years C. Will you have the system in place within 6 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 28.* Does the practice have or will have any other information technology system(s) in place within 6 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please specify vendors/systems: _____________________________________________ ______________________________________________________________________________ 29. Which operating systems (software) are used on computers in your clinic? _______________________________________________________________ 30. Does your clinic have a wireless network? Yes________ No________ 31. What is the speed of your clinics connection to the Internet? ____________________________________________________________ 32. Has your practice selected an EHR? Yes________ No________ 33. Does your practice collect quality or performance outcome measures for groups of patients with chronic illness (e.g., diabetes, asthma, congestive heart failure)?  FORMCHECKBOX  A. Yes, routinely, for our own and/or external (health plan) use  FORMCHECKBOX  B. Only occasionally, as required of us by health plans  FORMCHECKBOX  C. Only occasionally for our own use  FORMCHECKBOX  D. Rarely or never 34. To what extent have you discussed EHR implementation in your practice with co-workers?  FORMCHECKBOX  A. At great length, we have reached a consensus that this is the time to make this change  FORMCHECKBOX  B. Somewhat; weve talked about it, and there is general acceptance of the idea, but not everyone agrees its a good idea right now  FORMCHECKBOX  C. Not much; its my idea, and Im going to have some convincing to do with staff and colleagues who are satisfied with the status quo and paper systems 35. How have you investigated an EHR for your practice? (Check all that apply)  FORMCHECKBOX  A. Ive seen hands-on demonstrations with one or more EHRs vendors  FORMCHECKBOX  B. Ive participated in a course that discussed EHRs  FORMCHECKBOX  C. Ive visited a colleagues practice that uses an EHR.  FORMCHECKBOX  D. Ive read one or more articles about EHRs in primary care  FORMCHECKBOX  E. Ive discussed EHRs with an IT consultant 36. How confident are you that you can select a good EHR by yourself?  FORMCHECKBOX  A. Very Confident  FORMCHECKBOX  B. Confident  FORMCHECKBOX  C. Not really certain at this point  FORMCHECKBOX  D. Skeptical about making it alone  FORMCHECKBOX  E. Overwhelmed by the decision 37. With which of the following terms or concepts are you comfortable? (Check all that apply)  FORMCHECKBOX  A. Application service provider (ASP)  FORMCHECKBOX  B. Total cost of ownership  FORMCHECKBOX  C. HIPPA security standards  FORMCHECKBOX  D. Linux operating system  FORMCHECKBOX  E. Client server  FORMCHECKBOX  F. Integration  FORMCHECKBOX  G. Standards  FORMCHECKBOX  H. Work process redesign  FORMCHECKBOX  I. Source code escrow  FORMCHECKBOX  J. Service level agreements 38. Which of the following statements describe your current situation with regards to hardware and connectivity? (Check all that apply)  FORMCHECKBOX  A. I am using old computers and will probably need to replace them when I purchase an EHR  FORMCHECKBOX  B. I will need a faster Internet connection.  FORMCHECKBOX  C. I will need to upgrade my network.  FORMCHECKBOX  D. Everything is fine right now. 39. What hardware do you plan (or think you want) to be in place when you implement your EHR? (Check all that apply)  FORMCHECKBOX  A. Wireless network  FORMCHECKBOX  B. Desktop computers  FORMCHECKBOX  C. Laptops  FORMCHECKBOX  D. Tablet PCs  FORMCHECKBOX  E. PDAs  FORMCHECKBOX  F. In-house server  FORMCHECKBOX  G. Fax server 40. What do you need interfaced to your EHR? (Check all that apply)  FORMCHECKBOX  A. Hospital Information system  FORMCHECKBOX  B. External lab  FORMCHECKBOX  C. Internal lab  FORMCHECKBOX  D. Other _______________________________________________________ 41.* Please provide additional contact information below: Primary Provider Contact: Phone No: Fax No: E-mail Address: Secondary Provider Contact: Phone No: Fax No: _____________________ E-mail Address: Office Manager: Phone No: Fax No: _____________________ E-mail Address:  *Please provide the following information for all providers (e.g., MD, DO, NP, PA) within the practice (Please use an additional sheet if necessary): First NameLast NameUPIN (Medicare  Unique Physician Identification Number)PIN 1 Tax ID Number2National Provider Identification (NPI) NumberType (MD, DO, PA, NP)Specialty3Primary Practice Location4 (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      1 Please provide the Medicare Provider Identification Number (PIN) that is assigned by the Medicare Carrier in your state for use by this physician/clinician at this practice site only. 2 Please provide the Tax Identification Number that is used to bill Medicare for services provided by this physician/clinician as part of this practice site. 3 Please use the following codes to indicate specialty: Cardiology (C); Endocrinology (E); Family Practice (F); Geriatrics (G); Internal Medicine (I); Other (please specify) 4 Please indicate whether the provider listed primarily practices at this office location. 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