Survey Templates Surveys Electronic Health Records

Electronic Health Records

use this free template

Preview this template

Part I: Physician Background

Zip code

Gender

Age

Year of graduation from medical school

Year you joined current practice

Number of physicians at current practice

Estimated number of outpatients per week

Are you a member of Physician Alliance for Quality at The Methodist Hospital?

Physician specialty

Do you use the internet on a daily basis?

If yes, which functions do you use? (check all that apply)

Electronic correspondence with colleagues

Electronic correspondence with patients

Search: Medical literature

Search: Drug information

Search: Clinical trials

Other

Have you had prior experience with EHR systems?

If yes, where? (check all that apply)

Medical school

Internship/residency

Fellowship

Prior practice

Other

Do you currently utilize in-hospital Electronic Health Records (EHRs)?

Do you currently utilize in-office Electronic Health Records (EHRs)?

If yes, what EHR software vendor do you use?

If yes, how often do you utilize your EHR to complete patient care tasks?

If no, do you plan on implementing an EHR system in the near future (within the two years)?

Part II: Perceived/experienced effect of EHR systems

Please select the corresponding column addressing the following effects of EHRs.

	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative
Quality of care	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Workflow efficiency	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Office visit efficiency: increased patient capacity	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Access to patient information	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Patient/physician communication	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Control of health care costs	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Medical record storage and retrieval costs	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Medical transcription costs	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Documentation of services for billing	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Patient information privacy	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative
Reliance on computer hardware	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Reliability of computer software	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Physician workload	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

Long term technical support costs	Extremely positive	Somewhat positive	No opinion	Somewhat negative	Extremely negative

If your practice does not currently utilize Electronic Health Records, please skip Part III and proceed to Part IV. Thank you.

Part III: Current use of EHR functions

Please rank how often you use EHRs to accomplish the following tasks.

	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability
Clinical notes	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Patient demographics	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Patient portal: patient access to personal records, doctors' reminders, and electronic lab results	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Secure intraoffice messaging	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Secure external healthcare messaging	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Medication lists	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Drug allergy alerts	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Drug interaction alerts	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Electronic prescribing	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Laboratory test order entry	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability
Laboratory test results	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Imaging test order entry	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Imaging test results	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Document services for billing	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Reportable diseases/public health	Always	Often	Occasionally	Rarely	Never	EHR lacks the capability

Part IV: Desired capabilities

Please select the functions you would find most useful in an EHR.

	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful
Clinical notes	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Patient demographics	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Patient portal: patient access to personal records, doctors' reminders, and electronic lab results	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Secure intraoffice messaging	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Secure external healthcare messaging	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Medication lists	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Drug allergy/interaction alerts	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Electronic prescribing	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Laboratory test order entry	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Laboratory test results	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful
Imaging test ordering	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Imaging test result	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Document services for billing	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Decision support	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Reportable disease/public health	Most Useful	Extremely Useful	Useful	Moderately Useful	Not Useful

Part V: Barriers to Implementation

Please check the corresponding column regarding the significance of barriers to EHR adoption.

	Extreme concern	Strong concern	Some concern	Very mild concern	No concern
Initial implementation costs	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Initial reduction in workflow efficiency	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Ongoing maintenance and technical support costs	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Uncertain return on investment	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Reliance on computer hardware	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Reliability of computer software	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

EHR vendor selection and reliability	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Lack of industry-wide data standards	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Interface between EHR and practice management system	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Time required to enter data	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

	Extreme concern	Strong concern	Some concern	Very mild concern	No concern
Ease of data entry	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Patient privacy	Extreme concern	Strong concern	Some concern	Very mild concern	No concern

Part VI: Effect of potential policy changes

How would the following affect your (physician) use of EHR technology?

Very large arge effect
Large effect
Moderate effect
Little effect
No effect
No Opinion
Standardized EHR interface
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Increased funding through quality improvement incentives
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Reimbursement for web-based office visits or patient consultation
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Improved privacy assurance
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Increased technology training
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Capability for data exchange between hospitals and ambulatory care sites
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion
Increased functions
Very large arge effect
Large effect Moderate effect Little effect No effect No Opinion

Any additional comments?

use this free template

Electronic Health Records

Related templates and questionnaires

QuestionPro in your language

Awards & certificates

The Experience Journal