Registration: Maryland ACP Quality Connect Adult Immunization Program

Date: February 26, 2015
Time: 6:00 - 9:00 PM
Location: Brewer’s Alley - 124 North Market Street, Frederick, MD 21701

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* 1. Contact Information:

Name:

Degree (e.g., MD, PA, NP, etc):

Email:

Phone:

Practice Name:

Practice Address:

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* 2. RSVP:

Will you attend the Thursday dinner program on February 26, 2015? (yes/no):

Please specifically list any dietary restrictions. (list):

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* 3. Which of the following best describes your primary work setting (where you spend the majority of your professional time in medicine)? (Choose one)

Solo private practice

Smaller internal medicine private practice (<10 physicians)

Larger internal medicine private practice (10+ physicians)

Small multi-specialty private practice (<15 physicians)

Large multi-specialty private practice (15+ physicians)

Medical school or university

Community health center

Government-run facility

Hospital

Not applicable

Other (please specify)

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* 4. Which of the following best describes your primary employer? (Choose one)

Privately owned practice

Private community hospital

Academic medical center/medical school

Multispecialty clinic

Federal government (including military)

State or local government

Insurance company/health plan/HMO

Hospitalist company

Independent contractor/Industry

Not applicable

Other (please specify)

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* 5. Which of the following best describes the health/medical records system used for current patients in your primary work setting? (Choose one)

A computerized electronic health record (EHR) system

A combination system that incorporates elements of an EHR and a paper chart

Paper chart

Not applicable

If you indicated that you use an EHR system in your practice, which system does your work setting use?

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* 6. Which of the following quality improvement topics are you most interested in learning about? (Choose your top two)

Models to improve care coordination with internal team members

Fostering care coordination with external specialists and hospitals

Creating a Patient-Centered Medical Home/Neighborhood (PCMH/N)

Utilizing clinician-patient shared decision making tools

Improving communication to reduce disparities in care

Quality improvement overview

Participating in government quality initiatives (Meaningful Use, PQRS, ACOs, etc.)

Fulfilling certification requirements for practice improvement (MOC)

Other (please specify)

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* 7. Which of the following clinical topics are you most interested in learning about? (Choose your top two)

Updated adult immunization recommendations

Routine screenings and immunizations

Strategies for adult immunization implementation (e.g., standing orders, patient education, computerized record reminders)

Successful business models for adult immunizations

Other (please specify)

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* 8. For the upcoming year, which of the following professional goals and/or requirements do you plan to undertake? (Choose your top two)

Applying for ABIM certification or recertification

Implementing or upgrading your EHR

Demonstrating Meaningful Use of your EHR

Participating in programs for practice improvement credit

Achieving Patient-Centered Medical Home recognition

Implementing a quality improvement program

Other (please specify)

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* 9. How did you hear about this program?

Email invitation from the Maryland ACP Chapter

eNews or newsletter article

National ACP

Direct outreach from a colleague

Employer

Other (please specify)

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* 1. Contact Information:

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* 2. RSVP:

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* 3. Which of the following best describes your primary work setting (where you spend the majority of your professional time in medicine)? (Choose one)

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* 4. Which of the following best describes your primary employer? (Choose one)

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* 5. Which of the following best describes the health/medical records system used for current patients in your primary work setting? (Choose one)

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* 6. Which of the following quality improvement topics are you most interested in learning about? (Choose your top two)

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* 7. Which of the following clinical topics are you most interested in learning about? (Choose your top two)

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* 8. For the upcoming year, which of the following professional goals and/or requirements do you plan to undertake? (Choose your top two)

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* 9. How did you hear about this program?

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* 10. Please share any additional comments regarding your hopes for this programs and/or your interest in educational/quality resources and programs: