Form Approved
OMB No.
0935-XXXX
Exp. Date XX/XX/20XX
On behalf of the MedStar-IMPAQ team, thank you for your interest and willingness to participate in this survey on the [CDS Tool Name]. Your feedback is very important to us! The information you provide is voluntary and will be kept strictly confidential. It will not be reported or released in any way that allows identification of respondents. If there is a question you would rather not answer, you can skip it.
We are not selling anything but are conducting a survey about your experience in using [CDS Tool Name] developed under the funding of the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services. We are interested in your experience and we hope to know how we can make the [CDS Tool Name] better for clinicians in the future.
This survey will take 10-15 minutes to complete.
How did you learn about [CDS TOOL NAME]?
From a member of my team at MedStar
From another staff member at MedStar
In an advertisement in a MedStar facility
From the research team at the MedStar Health Research Institute
[Other response choices as relevant]
What was the main reason you decided to use [CDS TOOL NAME]?
[Free text entry]
What was your biggest concern about using [CDS TOOL NAME]?
[Free text entry]
How much do you agree with the following statements?
It was easy to get started with [CDS TOOL NAME].
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I know how to get technical support for [CDS TOOL NAME].
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
[CDS TOOL NAME] provides me the needed information in a timely manner.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
[CDS TOOL NAME] respects my clinical decisions.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I am confident that [CDS TOOL NAME] protects my patients’ private health information.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
[CDS TOOL NAME] is something I am willing to incorporate into my day-to-day care.
[CDS TOOL NAME] is a valuable resource for my day-to-day care.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
These next questions ask about your experiences using [CDS TOOL NAME].
How often do you use [CDS TOOL NAME]?
Every day
A few times a week
Once a week
A few times a month
Once a month
Less often than once a month
How often do you contact your patient every time [CDS TOOL NAME] sends you a message alert regarding his or her health?
Never
Once
A few times
Most times
Almost every time
How valuable is [CDS TOOL NAME] to you in treating patients with chronic conditions, such as substance use disorder?
Not at all valuable
A little valuable
Very valuable
Extremely valuable
Please rank each of the parts of [CDS TOOL NAME], where 1 is the most useful and 5 is the least useful.
Diagnosis List
Medication List
Social History
Current Prescriptions
Prescription Drug Monitoring Program
Patient-Reported Outcomes
Non-Opioid Pain Management Plan
Opioid Taper Calculator
Overall, how difficult is it to integrate [CDS TOOL NAME] into your routine practice of care?
Not at all difficult
A little difficult
Very difficult
Extremely difficult
Has difficulty with [CDS TOOL NAME] ever prevented you from using it when you wanted to?
[FOR RESPONDENTS WHO CHOSE “A LITTLE/VERY/EXTREMELY DIFFICULT” FOR Q15] What part or parts of [CDS TOOL NAME] were most difficult to use?
[Free text entry]
How can we improve [CDS TOOL NAME] and make it easier for you to use in your routine practice of care?
[Free text entry]
How likely are you to keep using [CDS TOOL NAME]?
Definitely will
Probably will
Might or might not
Probably will not
Definitely will not
How likely are you to keep using [CDS TOOL NAME] if we made the improvement you mentioned?
Definitely will
Probably will
Might or might not
Probably will not
Definitely will not
If you plan to keep using [CDS TOOL NAME] in your routine practice of care, what are your reasons for using it?
[Free text entry]
If you do not plan to use [CDS TOOL NAME] in your routine practice of care, what areas do you think it needs to be improved?
[Free text entry]
Please share any other thoughts you have about [CDS TOOL NAME] with us:
[Free text entry]
Thank you for completing our survey! Your answers help us improve [CDS TOOL NAME] and make it more useful for clinicians like you.
This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Elizabeth Gall |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |