HFSA Heart Failure Clinic Database

Question Title

* 1. Is this an update to an existing clinic, or are you entering a new clinic?

Update to an Existing Clinic

Entering a New Clinic

Question Title

* 2. Facility Information

Facility Name *

Facility Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Facility Contact Email *

Facility Main Phone Number *

Question Title

* 3. What best classifies your facility location?

Urban

Suburban

Rural

Question Title

* 4. What type of hospital is your facility associated with?

Academic

Tertiary Care

Community

Other

Question Title

* 5. Who is the clinic admin at your facility?

Question Title

* 6. Who is the clinical trials contact for your facility?

Question Title

* 7. Are you willing to be contacted by HFSA or Industry Sponsors regarding research, funding and grant opportunities?

Yes

Question Title

* 8. Which EHR (Electronic Health Record) vendor does your facility use? Please select all that apply.

AllScripts

Athena

Cerner

CPRS

eClinicalWorks

EPIC

Meditech

NextGen

Other

None

Question Title

* 9. Which EHR (Electronic Health Record) modules does your facility use? Please select all that apply.

Ambulatory

Cupid

Expanse

Hyperspace

Inpatient/Outpatient

Phoenix

Powerchart

Other

None

Question Title

* 10. What is the volume of heart failure patients that your facility sees per year?

<100

100-500

501-1000

1000 - 2000

>2000

Question Title

* 11. On average, how many patients are discharged each month from your facility with a principal diagnosis of heart failure or heart failure exacerbation?

<10

10-50

51-100

>100

Question Title

* 12. Does your facility have a Clinical Director?

Yes

Question Title

* 13. What is the designation of your Clinical Director?

MD (Doctor of Medicine)

APP (Advanced Practice Provider)

Other

None

Question Title

* 14. Is there a heart failure cardiologist in your program?

Full-time

Part-time

Question Title

* 15. How many heart failure cardiologists are in your program?

Question Title

* 16. If there is a heart failure cardiologist in your program, are they board certified in advanced heart failure transplant cardiology?

Yes, all are board certified

Yes, some are board certified

No, none are board certified

No HF cardiologist in our program

Question Title

* 17. How many other staff members are at your facility (please provide the number of corresponding staff members)?

RNs (Registered Nurse)

APPs (Advanced Practice Provider)

Social Worker

Dietitian

Pharmacist

Psychologist

Financial Coordinator

Question Title

* 18. Does your facility offer GDMT (guideline-directed medical therapy) titration protocol?

On-Site

Remote

All of the above

None of the above

Question Title

* 19. Does your facility offer palliative care services?

On-Site

Remote

All of the above

None of the above

Question Title

* 20. Does your facility have the ability to do same day IV diuretic infusions?

On-site

Off-site infusion center

Both

None of the above

Question Title

* 21. Does your facility offer telehealth or virtual visits?

Yes

Question Title

* 22. If yes, what platform does your facility use for remote patient monitoring? Please select all that apply.

Amwell

CardioMems

EPIC

eVisit

Health Recovery Solutions (HRS)

Heart Logic

Medtronic

Merlin

Octegas

Vivify

Other

None

Question Title

* 23. Which of the following therapeutic heart failure services does your facility provide? Please select all that apply.

Protocols for guideline-directed medical therapy (ACE/ARB/ARNI, BB, MRA, SGLT2i)

Onsite/partner pharmacy or med adherence program

IV diuretic administration (infusion suite or partnered facility)

Iron infusions

Vaccination access (e.g., flu, COVID, pneumococcal)

None of the above

Question Title

* 24. Which standard functional status evaluation does your facility use? Please select all that apply.

NYHA (New York Heart Association) class

6 min walk

CPET (cardiopulmonary exercise testing)

Other

None

Question Title

* 25. Does your facility routinely use prognostic tools to assess patients? Please select all that apply.

Seattle Heart Failure Model (SHFM)

MAGGIC Score

Other

None

Question Title

* 26. Does your facility use patient-reported outcomes?

Yes, for clinic use

Yes, for research

Question Title

* 27. Does your facility have a standard operating procedure to evaluate patients for advanced heart failure therapies?

Done by heart failure provider

Done by multi-disciplinary team

Question Title

* 28. Does your facility perform transplantation? Please select all that apply.

Single organ

Multi-organ

Shared care

Question Title

* 29. What capabilities does your clinic offer for VADs?

Implanting center

Shared care

N/A

Question Title

* 30. Does your facility have a specialty cardiomyopathy center? Please select all that apply.

HCM (hypertrophic cardiomyopathy)

Familial CM

Amyloid

Sarcoid

Cardio Obstetrics

Cardio-oncology

None

Question Title

* 31. Does your facility offer genetic testing? Please select all that apply.

On-site

Remote

Question Title

* 32. For which of the following device and structural interventions does your facility provide a partnership/referral pathway? Please select all that apply.

ICD / CRT implantation

CardioMEMS PA pressure monitoring

Transcatheter edge-to-edge repair (mitral valve and tricuspid valve)

TAVR for aortic stenosis

VAD and transplant evaluation program integration (if advanced HF)

Question Title

* 33. Does your facility perform coronary angiography on site?

Yes

Question Title

* 34. Are you able to perform endomyocardial biopsy at your facility?

Yes

Question Title

* 35. How is research conducted at your facility? Please select all that apply.

Investigator-initiated

Multi-center

None

Other

Question Title

* 36. From which sources does your facility receive research funding? Please select all that apply.

NIH (National Institutes of Health)

AHA (American Heart Association)

Industry

Internal

University

VA (Veterans Affairs)

Investigator initiated

None

Other

HFSA Heart Failure Clinic Database - Survey #1

Question Title

* 1. Is this an update to an existing clinic, or are you entering a new clinic?

Question Title

* 2. Facility Information

Question Title

* 3. What best classifies your facility location?

Question Title

* 4. What type of hospital is your facility associated with?

Question Title

* 5. Who is the clinic admin at your facility?

Question Title

* 6. Who is the clinical trials contact for your facility?

Question Title

* 7. Are you willing to be contacted by HFSA or Industry Sponsors regarding research, funding and grant opportunities?

Question Title

* 8. Which EHR (Electronic Health Record) vendor does your facility use? Please select all that apply.

Question Title

* 9. Which EHR (Electronic Health Record) modules does your facility use? Please select all that apply.

Question Title

* 10. What is the volume of heart failure patients that your facility sees per year?

Question Title

* 11. On average, how many patients are discharged each month from your facility with a principal diagnosis of heart failure or heart failure exacerbation?

Question Title

* 12. Does your facility have a Clinical Director?

Question Title

* 13. What is the designation of your Clinical Director?

Question Title

* 14. Is there a heart failure cardiologist in your program?

Question Title

* 15. How many heart failure cardiologists are in your program?

Question Title

* 16. If there is a heart failure cardiologist in your program, are they board certified in advanced heart failure transplant cardiology?

Question Title

* 17. How many other staff members are at your facility (please provide the number of corresponding staff members)?

Question Title

* 18. Does your facility offer GDMT (guideline-directed medical therapy) titration protocol?

Question Title

* 19. Does your facility offer palliative care services?

Question Title

* 20. Does your facility have the ability to do same day IV diuretic infusions?

Question Title

* 21. Does your facility offer telehealth or virtual visits?

Question Title

* 22. If yes, what platform does your facility use for remote patient monitoring? Please select all that apply.

Question Title

* 23. Which of the following therapeutic heart failure services does your facility provide? Please select all that apply.

Question Title

* 24. Which standard functional status evaluation does your facility use? Please select all that apply.

Question Title

* 25. Does your facility routinely use prognostic tools to assess patients? Please select all that apply.

Question Title

* 26. Does your facility use patient-reported outcomes?

Question Title

* 27. Does your facility have a standard operating procedure to evaluate patients for advanced heart failure therapies?

Question Title

* 28. Does your facility perform transplantation? Please select all that apply.

Question Title

* 29. What capabilities does your clinic offer for VADs?

Question Title

* 30. Does your facility have a specialty cardiomyopathy center? Please select all that apply.

Question Title

* 31. Does your facility offer genetic testing? Please select all that apply.

Question Title

* 32. For which of the following device and structural interventions does your facility provide a partnership/referral pathway? Please select all that apply.

Question Title

* 33. Does your facility perform coronary angiography on site?

Question Title

* 34. Are you able to perform endomyocardial biopsy at your facility?

Question Title

* 35. How is research conducted at your facility? Please select all that apply.

Question Title

* 36. From which sources does your facility receive research funding? Please select all that apply.