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.

This page collects basic information about you, your clinic, and your role in establishing meaningful use. This information will help the Regional Extension Center tailor its efforts to help you establish meaningful use in your clinic to your particular needs.

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* 1. First Name

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* 2. Last Name

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* 3. 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

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* 4. Credentials

CNMW

DDM

DDS

DMD

DPM

MSW

PsyD

None applies

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* 5. Organization / Clinic Information

Primary Contact Person:

Organization / Clinic Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Fax:

Phone Number: *

Email Address: *

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

Yes

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* 7. Website:

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* 8. 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

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* 9. 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

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* 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?

Medicare

Medicaid

Not sure

None

Comment (optional)

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* 11. Does your clinic have an Electronic Health Record (EHR) / Electronic Medical Record (EMR) in use?

Please also specify the version in the comment field below.

Note: This question refers to the EHR systems, not practice management systems. If you have ONLY the practice management system by the same name installed, please answer "None Installed" to this question and note this in the 'version' comment section.

None Installed

Abraxas Medical Solutions

Allegiance MD/Veracity

Allscripts

Amazing Charts EHR

Aprima

Athenahealth

Cerner

Chartlogic

Conceptual MindWorks Sevocity

CureMD EHR

eClinicalWorks

Eclipsys

e-MDs Solution Series EMR

Epic

gloEMR

Greenway Prime Suite

Healthland

InforMed Praxis

Ingenix CareTracker

InTuun

LyTec MD EMR

Mckesson

Med 3000 InteGreat EHR

MedEZ

Medisoft Clinical EMR

MediTech LLS

Micro MD

MilEHS

NextGen EHR

NueMD EHR

OmniMD EMR

Polaris

Practice Partner

Quest 360 EHR

Sage

SequelMed

SOAPware

SuccessEHS

SynaMed

WorldVistA EHR

Other (please specify below)

If Other, please indicate name.

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

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

less than 1 year

1-2 years

2-3 years

3-4 years

4-5 years

5+ years

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

Existing EHR "Go-Live" Date:

Date

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* 1. First Name

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* 2. Last Name

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

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* 4. Credentials

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* 5. Organization / Clinic Information

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

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* 7. Website:

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

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

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* 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?

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

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

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

* 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?