Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Consumer Survey: May 2, 2012 version
First, let’s talk about your visits to health care providers. By health care providers, we mean primary care physicians, specialists, mental health professionals, physician assistants, nurses, clinics, and hospitals.
A. Topic: Experience with Health Care System
i. Health Seeking Behavior – Health Care Usage
First, how many different health care providers have you visited in the last 12 months?
1 to 2
3 to 5
6 to 9
10 or more
None [SKIP TO Q3]
Altogether, how many total visits did you make to a health care provider in the last 12 months?
1 to 2
3 to 5
6 to 9
10 or more
None
B. Topic: Health Status
Now I would like to find out more about your health.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
In general, how would you rate your overall health now?
Excellent
Very good
Good
Fair
Poor
Are you being treated for any chronic disease or medical condition such as high blood pressure, diabetes, heart or lung disease, or arthritis?
YES
NO
ii. Gaps in Information/Coordination
[SKIP TO Q6 IF Q1=NONE]
Now let’s talk about the coordination of your medical care and sharing of your medical record with health care providers. A medical record is information that your health care provider keeps about your health care, such as notes from your visits, a list of drugs that you take or lab test results.
In the past 12 months, when getting care for a medical problem, was there a time when you:
a. Had to bring an X-ray, MRI, or other type of test result with you to the appointment?
YES NO
b. Had to wait for test results longer than you thought reasonable?
YES NO
c. Had to redo a test or procedure because the earlier test results were not available?
YES NO
d. Had to provide your medical history again because your chart could not be found?
YES NO
e. Had to tell a health care provider about your medical history because they had not gotten your records from another health care provider?
YES NO
f. Received a paper or electronic copy of your medical record from any of your health care providers?
YES NO
g. Were given online access to any part of your medical record by any of your health care providers?
YES NO
How comfortable would you feel asking for a copy of your medical record from your health care provider?
Very comfortable
Somewhat comfortable
Not very comfortable
Not comfortable at all
Within the past 12 months, have you asked for copies of your medical record from any of your health care providers?
YES
NO [SKIP TO Q10]
How difficult was it to receive the medical record you requested?
Very difficult
Somewhat difficult
Not very difficult
Not difficult at all
Or did you not get the medical record you requested [SKIP TO Q10]
What was the format of the copy of the medical record you received, paper or electronic?
RECEIVED AN ELECTRONIC COPY
RECEIVED A PAPER COPY
RECEIVED BOTH
Overall, how satisfied are you with the quality of the health care you have received from any of your health care providers?
Very satisfied
Somewhat Satisfied
Not very satisfied
Not satisfied at all
Caregiving
Are you currently caring for or making health care decisions for a child, a spouse, a parent, or other family member?
YES
NO
C. Topic: Prior Experience and Exposure to IT and Health IT – Computer/Internet Access and Use
The next questions are about your use of the internet and familiarity with electronic medical records. Electronic medical records are created, stored and viewed on computers.
How often do you access the Internet?
Every day
Most days
Some days
Rarely
Never
[ASK ONLY IF Q12 = NEVER] Is that because you do not want to use the internet or because it is difficult for you to access it?
DO NOT WANT TO USE THE INTERNET
DIFFICULT TO ACCESS THE INTERNET
Have you ever…?
a. Searched online for information about a disease or medical problem
YES NO
b. Looked at any of your medical test results online
YES NO
c. Sent or received an e-mail message from your health care provider
YES NO
d. Sent or received a text message from your health care provider
YES NO
e. Renewed a prescription online
YES NO
f. Used a smart phone health application
YES NO
A personal health record (or PHR) is an electronic application that allows you to access, enter, and manage some of your health information. Have you ever heard of a PHR?
YES
NO [SKIP TO Q18]
Do you currently have a personal health record, or PHR?
YES
NO
Do you currently have a personal health record, or PHR that you keep for a family member?
YES
NO
D. Topic: Perceived Benefits of Health IT/Health Information Exchange
The next questions are about your views on electronic medical records and electronic sharing of medical records.
As far as you know, do any of your health care providers maintain your medical record in an electronic system?
YES
NO [SKIP TO Q20]
Would you say electronic medical records have an overall positive impact, negative impact, or no impact on the care you receive from your health care providers?
POSITIVE IMPACT
NEGATIVE IMPACT
NO IMPACT
To the best of your knowledge, does your health care provider:
a. Electronically send prescriptions or refill requests directly to your pharmacy?
YES NO
b. IF NO: Should they be able to do this?
YES NO
c. Electronically send your medical record to other health care providers that are caring for you?
YES NO
d. IF NO: Should they be able to do this?
YES NO
Please tell me how important each of the following is to you.
Health care providers should be able to share your medical record with each other electronically.
Very important
Somewhat important
Not very important
Not important at all
Health care providers should make your medical record available to you electronically.
Very important
Somewhat important
Not very important
Not important at all
E. Topic: Perceived Risks
Now I would like to ask you about the privacy and security of your medical record.
CORE QUESTION: Privacy means you have a say in who can collect, use and share your medical record. How concerned are you about the privacy of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: Security means having safeguards to keep your medical record from being seen by people who aren’t permitted to see them. Safeguards may include technology. How concerned are you about the security of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
[ASK ONLY IF Q14B (LOOKED AT MEDICAL TEST RESULTS ONLINE)=YES] How confident do you feel that your online medical record, such as notes from your visits, a list of drugs that you take or lab test results, is kept private and secure?
Very confident
Somewhat confident
Not very confident
Not at all confident
CORE QUESTION: Have you ever kept information from your health care provider because you were concerned about the privacy or security of your medical record?
YES
NO
Confidentiality means that information in your medical record will not be disclosed to others in a way that would be inappropriate. How concerned are you about the confidentiality of your medical record?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: If your medical record is sent by fax from one health care provider to another, how concerned are you that an unauthorized person would see it?
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
CORE QUESTION: If your medical record is sent electronically from one health care provider to another, how concerned are you that an unauthorized person would see it? Electronically means from computer to computer, instead of by telephone, mail, or fax machine.
Very concerned
Somewhat concerned
Not very concerned
Not concerned at all
F: Topic: Control Over Data Sharing
When medical records are shared between health care providers, the entire record may be shared. Should patients be able to decide whether the following information is included when their record is shared?
a. The medications they have been prescribed
YES NO
b. Results of genetic tests
YES NO
c. Results of HIV tests
YES NO
d. Results of test for sexually transmitted diseases
YES NO
e. Mental health diagnoses and treatment
YES NO
G. Topic: Awareness of Privacy Regulations/Laws
I am going to read some statements about protection of electronic medical records. How much do you agree with each of the following statements?
Existing laws provide a reasonable level of protection for electronic medical records today.
Strongly agree
Agree
Disagree
Strongly disagree
Health care providers have measures in place that provide a reasonable level of protection for electronic medical records today.
Strongly agree
Agree
Disagree
Strongly disagree
H. Topic: Overall Support in Spite of Concerns
Now how much do you agree with these statements about support for the use of electronic medical records?
CORE QUESTION: I want my health care providers to use an electronic medical record to store and manage my health information despite any concerns I might have about privacy and security.
Strongly agree
Agree
Disagree
Strongly disagree
CORE QUESTION: I want my health care providers to use a computer to share my medical record with other providers treating me despite any concerns I might have about privacy and security.
Strongly agree
Agree
Disagree
Strongly disagree
I. Topic: Demographics
We are nearly finished. I would like to get a little information about your background.
What is your zip code?
________ (ZIP CODE)
In what year were you born?
________ (YEAR)
What is your sex?
MALE
FEMALE
Are you of Hispanic, Latino/a, or Spanish origin?
No, not of Hispanic, Latino/a or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a, or Spanish origin
What is your race? (One or more responses can be selected)
White
Black or African-American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other (please specify): __________ (to be coded after data collection)
How well do you speak English?
Very well
Well
Not well
Not at all
Are you deaf or do you have serious difficulty hearing?
YES
NO
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
YES
NO
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
YES
NO
Do you have serious difficulty walking or climbing stairs?
YES
NO
Do you have difficulty dressing or bathing?
YES
NO
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
YES
NO
What is the highest grade or level of school that you have completed?
NOT A HIGH SCHOOL GRADUATE
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE OR 2-YEAR DEGREE
4-YEAR COLLEGE GRADUATE
MORE THAN 4-YEAR COLLEGE DEGREE
Which category comes closest to your total household income before taxes in 2011?
Less than $25,000
Between $25,000 and $49,000
Between $50,000 and $99,999
$100,000 or greater
To the best of your knowledge have you ever been the victim of identity theft or fraud?
YES
NO
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Survey Questions: |
| Author | DHHS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |