Initial Meaningful Use Stage 1 Questionnaire Survey

Initial Meaningful Use Stage 1 Questionnaire

1. Basic Information

**If you have not yet done so, please click here to complete the O-HITEC Interest Form first, and then return to complete the Assessment below. Thank you.

Please complete this questionnaire to help the O-Health Information Technology Extension Center (O-HITEC) better understand your current progress towards achieving meaningful use in your clinic. O-HITEC will then work with you and your team to get verification of each of these components for meaningful use in your practice, improving the quality of care for your patients and ensuring that you will be ready to receive incentive payments through attestation of necessary capabilities. O-HITEC will work with you each step of the way in your efforts to implement meaningful use standards.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA) established incentives for electronic health record (EHR) adoption by physicians and hospitals.

This Medicare and Medicaid payment incentive program was funded with stimulus dollars to help you and your clinic/organization to optimize the use of your Electronic Health Record and meet federal meaningful use requirements, or to help you begin to implement a system.

Each eligible professional in your practice may earn up to $44,000 over 5 years, starting with $18,000 in 2011.

For more information, please see Fact Sheets and other resources for meaningful use from the Office of the National Coordinator for Health IT.

Organization / Clinic Information Primary Contact Person:
Organization / Clinic Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Fax:
Phone Number:
Email Address:

Please list how many personnel are currently part of your organization: Primary care Physician (MD, DO, or equivalent)
Physician specialist (please specify below)
Physician Assistants (PAs)
Nurse Practitioners (NPs)
Registered Nurses (RNs)
Licensed Practical Nurses (LPNs)
Care Managers / Case Managers / Care Coordinators
IT Professional(s) / Consultants
Practice / Clinic / Office Managers
Billing Specialists
Educators
HIE (Health Information Exchange) managers
Other Office Staff (not listed above)
Other

What is the payer mix makeup of your patient population? (If you don’t know, give your best estimate.) % of Patients on Medicaid
% of Patients on Medicare
% of Patients on Managed Care
% of Patients on Private Insurance
% of Patients Uninsured

Initial Meaningful Use Stage 1 Questionnaire

1. Basic Information

*
1. First Name

*
2. Last Name

*
3. Your clinical role(s) and/or degrees (please select all that apply)

*
4. Credentials

*
5. Organization / Clinic Information

6. Is your clinic affiliated with the Oregon Office of Rural Health?

7. Website:

8. Please list how many personnel are currently part of your organization:

*
9. What is the payer mix makeup of your patient population?
(If you don’t know, give your best estimate.)

10. You can only participate in one of the incentive programs - either for Medicare or Medicaid payments.

Which meaningful use incentive payment program would you plan to participate in?

12. If you have an EHR installed, please specify Version:

13. If you have an EHR installed, how long have you been using it in your practice?

14. When did your practice begin using your current EHR?

Your clinical role(s) and/or degrees (please select all that apply) Billing Specialist Educator EHR Champion (Note: The EHR Champion is the person taking the lead in the EHR implementation.) EHR Vendor HIE (Health Information Exchange) Lead IT Consultant Office Manager	Office Staff Provider Primary Project Lead Secondary Project Lead Other (please specify below) None
If other, please indicate your role

Initial Meaningful Use Stage 1 Questionnaire

1. Basic Information

*1. First Name

*2. Last Name

*3. Your clinical role(s) and/or degrees (please select all that apply)

*4. Credentials

*5. Organization / Clinic Information

6. Is your clinic affiliated with the Oregon Office of Rural Health?

7. Website:

8. Please list how many personnel are currently part of your organization:

*9. What is the payer mix makeup of your patient population?(If you don’t know, give your best estimate.)

10. You can only participate in one of the incentive programs - either for Medicare or Medicaid payments.Which meaningful use incentive payment program would you plan to participate in?

12. If you have an EHR installed, please specify Version:

13. If you have an EHR installed, how long have you been using it in your practice?

14. When did your practice begin using your current EHR?

*
1. First Name

*
2. Last Name

*
3. Your clinical role(s) and/or degrees (please select all that apply)

*
4. Credentials

*
5. Organization / Clinic Information

*
9. What is the payer mix makeup of your patient population?
(If you don’t know, give your best estimate.)

10. You can only participate in one of the incentive programs - either for Medicare or Medicaid payments.

Which meaningful use incentive payment program would you plan to participate in?