Online EHR Readiness Assessment

1. Practice Information

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Welcome to Health Informatics Consulting's Online Readiness tool. Please fill out the questions below and we will send you a response of your readiness and the next steps you need to take for a successful EHR implementation. Thank your for your participation.

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Please provide the following information Name:
Physician Office or Group Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

Who will lead the practice's Electronic Health Record (EHR) system implementation? (check all that apply) Physician(s) Office Manager	Mid-level provider(s) (e.g. NP) Clinical (e.g. RN, MA)	Administrative (e.g. medical records)
Other (please specify)

What is your specialty? Family Medicine Internal Medicine Geriatrics	Pediatrics Cardiology OB/GYN	Endocrinology Orthopaedics Opthalmology
Other (please specify)

Please provide a count of practice staff (excluding MD, DO, and PA/NP providers) by type: (number of each) RNs
LPNs
MAs
Administratice/Clerical

Online EHR Readiness Assessment

1. Practice Information

1. Please provide the following information

2. Lead Physician Name:

3. Lead Administrative Staff Name:

4. Who will lead the practice's Electronic Health Record (EHR) system implementation? (check all that apply)

5. Is your practice affiliated with an independent practice association (IPA)?

6. What is your specialty?

7. How many sites does your practice have?

8. How many physicians are in your practice (all sites)?

9. How many patients are seen in your practice on an average day?

10. Please provide a count of practice staff (excluding MD, DO, and PA/NP providers) by type: (number of each)

Is your practice affiliated with an independent practice association (IPA)? Yes	No
If yes, please specify