Clinic Assessment Tool – without EHR

(For use with clinics that do not currently use EHR systems)

Clinic Contact Information

Assessment date: / Assessor(s):
Clinic name: / PIN and Tax ID:
Affiliation (e.g., IHC, U, AUCH):
Address:
Telephone:
Primary contact:
Direct phone:
E-mail:
Fax:
Physician champion (if not primary contact):
Direct phone:
E-mail:
Fax:

1.Number of locations: ____

May the same patients visit all/both clinics?

No

Yes

2.Do you conduct staff meetings?

NoBest time and day for clinic meetings:

Yes When: ______

STAFF CHARACTERISTICS

3.List provider and IT staff by name. List or just indicate the number of other staff. Note any staff members who aren’t full time.
PHYSICIAN Name, UPIN / Specialty (If FP, are they AAFP member?)
NON-PHYSICIAN CLINICIAN Name, UPIN / Type (PA, NP, ANP)
RESIDENT (name or number/frequency) / Specialty
CLINICAL SUPPORT STAFF (name or just number) / Type (RN, LPN, MA, Phleb., etc.)

ADMINISTRATION (e.g., office manager, financial officer, etc.)

/

Duties

RECEPTION STAFF (name or just number)
MEDICAL RECORDS STAFF (name and tasks, e.g., scanning)
IT SUPPORT STAFF Name (note if they are consultants or contractors and not employees) / Duties (e.g., backups, upgrades, hardware repairs)

4.Check any other staff positions:

Phone bank/call center: ______

Billing: ______(charge entry/service posting staff, coders)

Other: ______

PRACTICE CHARACTERISTICS

5. Number of exam rooms: ____ Number of treatment (procedure/surgery) rooms: ____

6.Are there plans for significant changes in the clinic for the next few years (e.g., new providers, retirements, move location or add site, new affiliations, etc.)?

No

Yes Please describe:

PATIENT MIX

7. Estimated number of active patients: ____ (if known)

Are patients distributed evenly among providers?

 No

Yes

8.What is the estimated percent of active patients with one or more chronic illness (CAD, diabetes, hypertension, osteoarthritis, heart failure)? ____

9. Approximate percentage of patient visits from each of the following carriers:

Both States / % / Nevada / % / Utah / %
Medicare / PacifiCare / Altius
Medicaid / Sierra Health / IHC
BCBS / Culinary Fund / DMBA
UHC / Educators (Teacher’s Trust) / Educators (EMIA)
Other / PEHP
Other
  1. Please estimate the percentage of your patients/clients who are minorities?

Minority / %
African American
Native American
Hispanic
Asian
Other:
Total

11.Do you collect data on your patients’ ethnicity or race? Are you able produce reports by race from your practice management system?

WORK VOLUMES

12. Average number of patient visits per day: ______

13. About how long do dictations take to get back from transcribing and into charts?

(NA if they don’t transcribe)

14.Percentage of patients seen without:

Charts available? ____

Most recent dictation available? ____

15.Who pulls the charts most frequently? ______

16.Estimate the average time it takes to pull a chart: ______

17. How often are charts lost/misplaced? ______(Estimated number of times per week.)

18. Per day, about how many phone calls require a chart pull (Including calls for new prescriptions, refills, labs, radiology and procedure orders, insurance questions, etc.)? _____

19. Do prescriptions ever have to be rewritten or clarified due to illegibility?

No

YesHow often? ______

20.On average, how many referrals/authorization transactions are processed each month? ____

How are these transactions processed (ask about automation)?

21.What types of manual logs are maintained by the clinic?

Immunizations/Vaccines

Ancillary orders

Mammograms

Referrals/authorizations

Other: ______

22. Think about the forms you use in your office. How many of them would be helpful to have integrated into an EHR?

COSTS

23. Estimate the average monthly cost for:

Copy paper: ______Folders: ______

Medical charts: ______Tabs: ______

Encounter form: ______Other: ______

24.Cost to rent space to house medical records: ______(ask about any offsite storage)

25.What are current monthly transcription costs? (List by provider if costs vary among them) ______

26.List other costs that might decrease or go away with an EHR:

PRACTICE MANAGEMENT SYSTEM

27.Do you currently use an automated practice management system?

No Please explain why not and Skip to QUESTION 34

YesANSWER QUESTIONS 27–33

28. Describe your system?

Type: ______Version: _____

For how long have you used the system? ______

Do you have plans to update the system?

No

Yes Why?

29.Which system modules/components do you use?

Billing:

Scheduling:

Registration:

Other: ______

30. Do all providers use the same system components?

NoExplain differences: ______

Yes

31. What problems have you encountered with the system?

32.On a scale of 1–10 (10 = perfect), rate your overall satisfaction with the system: ____

33.Are there plans for changing the system in the next few years?

No

YesPlease describe:

EHR PLANS

34.Do you intend to adopt and use an Electronic Health Record (EHR) system in the near future?

No Please explain why not (Skip to QUESTION 38)

YesEstimate timeframe?:______(Go on to QUESTIONS 34–37)

35.Which EHR system modules/components are you considering using?

Scheduling / Automated checks
Problem list / E-Prescribing
Medication list / Track orders/referral/results
Patient demographics / Ordering labs, etc.
Entering notes / Lab results
Review reports/notes / E & M coding
Messaging system / Other: ______

36.What type of documentation method do you intend to use (mark all that apply)?

Pull-downs

Direct entry

Import transcription

Note template

Voice

Other: ______

37.Please check any external or internal systems that would require linkages (interface):

Prescription writing

Laboratories (in-house, local hospital, ARUP, Quest, Labcorp, IHC, Lab One, etc.)

(Estimate clinic’s volume as a percentage with each lab to see where most orders are done)

Radiology

Disease Registries

Hospital: ______

Other: ______

EXISTING COMPUTER STRUCTURE

38. How many PCs are used within the clinic? ____

In which business/clinical areas: ______

What operating system(s): ______

39. Number of network (LAN/WAN) connections: ____

Server in office or web based? ______

Any wireless connections? ______

40.Number of printer locations: ____

41. What do providers/staff use the PCs for (check all that apply and note who uses)?

E-mail ______

Web browsing ______

Word processing ______

Other: ______

42.What sort of Internet access do you have?

High-speed (DSL, T1)

Modem (dial-up or cable)

Other: ______

43.List any staff that cannot type or use a mouse:

THE BIG PICTURE

44.What do you see as your biggest problems/areas of concern regarding an EHR?

45.What do you expect to gain from an EHR?

46.Are you currently doing any type of population-based care management (e.g., tracking diabetes visits, identifying patients who are overdue for health maintenance, group visits, etc)?

 No Are your providers interested in starting? Do they want to use the EHR for this?

Yes Are you interested in learning more about what other practices are doing?

  •  Ask specifically about:
  • Do you have the ability to identify specific populations (diabetics, etc)? ______
  • Do you use a system with reminders and prompts? ______
  • Do you use patient specific care plans? ______

Notes:

Did we leave them a copy of the Outlook Associates EHR Selection Guide?

No

Yes

Outline follow-up and next steps:

HealthInsight prepared this material under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS). The contents presented do not necessarily reflect CMS policy. PUB# 8SOW-OM-TN-14

Black = Administrative staff Page 1

Blue = Both MD and administrative staff