HIT Landscape Survey

The State of Alaska intends to participate in the Electronic Health Record (EHR) incentive program that was authorized under the HITECH provisions of the American Reinvestment & Recovery Act.

The program offers incentive dollars to qualifying Medicaid providers. Prior to implementing the program, the state is required to determine provider’s readiness for meaningful use and anticipated numbers of eligible providers. The information provided by this survey will assist in developing program guidelines that support health care providers practicing in varied and unique Alaskan circumstances.

Your participation is appreciated

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1. Individual National Provider Identifier (NPI) number

Individual National Provider Identifier (NPI) number

2. Please provide your group NPI if applicable.

Please provide your group NPI if applicable.

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3. Please enter the name of the individual responding to this survey.

Please enter the name of the individual responding to this survey. Last Name
First Name
Middle Name

The incentive is available to each qualifying provider for a single location. Please enter the following information for the location you would use in applying for the incentive.

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4. Provider

Provider Practitioner Name:
Business Entity Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

Incentive funds are going to be made available to assist federally designated medical professionals in adopting, implementing or upgrading electronic health records systems to meet federal requirements.

In order to qualify for Medicaid EHR Incentives you must meet a minimum Medicaid patient percentage. Please answer the following questions to assist in determining the best method of calculating Medicaid patient volume.

5. Estimate the percentage of your active patients that are Medicaid eligible.

Estimate the percentage of your active patients that are Medicaid eligible. 0-10%

11-20%

21-30%

31-50%

51-100%

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6. On average, approximately what percentage of your weekly office visits are for Medicaid eligible patients?

On average, approximately what percentage of your weekly office visits are for Medicaid eligible patients? 0-10%

11-20%

21-30%

31-50%

51-100%

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7. Which of the following did you use in determining the percentage?

Which of the following did you use in determining the percentage? Scheduled appointments

Actual visits

Number of claims

Dollar value of claims

Other (please specify)

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8. If you meet the EHR incentive program eligibility criteria do you intend to participate?

If you meet the EHR incentive program eligibility criteria do you intend to participate? Yes

No

9. If you do intend to participate in the EHR incentive program what calendar quarter and year do you plan to register in the program?

	Quarter	Year
Registration	If you do intend to participate in the EHR incentive program what calendar quarter and year do you plan to register in the program? Registration Quarter	Year

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10. What type of internet connection do you have at your practice?

What type of internet connection do you have at your practice? Dial-up connection

Wired broadband (i.e., DSL or cable modem) or faster connection (e.g. T1 or T3 line)

Cellular connection

Satellite connection

No internet connection

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11. Does your practice setting use an EHR?

Does your practice setting use an EHR? Yes, EHR with a Practice Management system

Yes, EHR without a Practice Management system

No EHR

HIT Landscape
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1. Electronic Health Records (EHR) Survey

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1. Electronic Health Records (EHR) Survey

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