Fast Track Supporting Statement

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0935-0179)

T ITLE OF INFORMATION COLLECTION: Patient Interview Guide

PURPOSE: Interviews will be conducted with up to 18 patients to elicit feedback on general use of PRO app, including ease of use, preferences, and experience with the app.

DESCRIPTION OF RESPONDENTS: Providers noted that data from a PRO app would be most useful when the PRO data are likely to have clinical significance and can guide treatment of the patient. As interviews will be conducted following app usage, only patients who have completed the app will be eligible to participate in patient interviews.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software) [ ] Small Discussion Group

[ ] Focus Group [ X] Other: _Interview____

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:___Alexandra Burn_____________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	18	30/60	9
Totals			9

FEDERAL COST: The estimated annual cost to the Federal government is $219.06_

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X ] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

To elicit the most representative and generalizable feedback, we will sample a diverse

group of stakeholders from our network of MedStar and CAPRICORN sites. At each pilot testing site, we will target a minimum of 1 patient per clinic. Based on initial site visits, feedback from providers suggest this is an appropriate number of patients to identify and enroll while being minimally disruptive to the clinics. The site coordinators at both MedStar and CAPRICORN sites will work with clinic staff to identify potentially eligible patients (i.e., those who complete the PRO app).

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ X ] In-person

[ ] Mail

[ ] Other, Explain:

2. Will interviewers or facilitators be used? [ ] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

A

Form Approved
OMB No. 0935-0179
Exp. Date 11/30/2020

ttachment A. Patient Interview Guide

We are working on a study to learn more about your experience with the PRO app. We want to get some feedback from you on the things you like and dislike, and the things that can be improved.

Office Location:
Physician:
Physician Specialty:

Demographics Questions

1. What is your age?

1. 18 – 30

2. 31 – 40

3. 41 – 50

4. 51 – 60

5. 61 – 70

6. 71 – 80

7. 81 – 90

8. 90+

1. What is your gender?

   1. Male

   2. Female

   3. (Open field)

2. What level of education have you completed?

   1. 8^th grade or less

   2. Some high school

   3. High school diploma or GED

   4. Associates degree

   5. Bachelor’s degree

   6. Master’s degree

   7. Doctoral degree

Interview Moderator Guide

App Usage

4. How many times of have you filled out the PRO survey?

   1. None

   2. Once

   3. More than once

Public reporting burden for this collection of information is estimated to average 30 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 (0935-0179) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

Process

5. How did you access the survey?

1. Did you understand how to access the survey? Was there any confusion/uncertainty?

6. How did you submit your responses to the survey?

1. Did you understand how to submit your responses? Was there any confusion/uncertainty?

7. Where you able to tell that you had successfully submitted your survey? How could you tell?

8. How long did it take you to complete the survey?

9. Do you have any concerns about the amount of time it took you to complete the survey?

10. Do you have any concerns about the amount of time it took you to complete the survey if you had to complete the survey for multiple doctor visits?

11. Did you need any assistance when filling out the survey?

1. Why did you need assistance?

1. Were there questions in the survey that you did not understand (comprehension issue)?

2. Did you not understand how to enter in your responses (i.e., technology issue)?

3. Did you feel uncomfortable or unsure about how to use the tablet (i.e., technology issue)

4. Was the font, font size, text layout difficult to read (i.e., format issue)?

12. Thinking about the process to fill out the survey (i.e., obtain the tablet from HCP upon arrival to appointment, fill out the survey, return the tablet to the HCP before appointment), is there anything about the process that works well?

1. Is there anything about the process that could be improved?

13. Do you think that you would feel most comfortable if you were asked to answer the PRO survey on your phone in your home, or here in the clinic?

1. Would you use your phone to complete the PRO survey if you had the option?

14. Would you prefer to fill out the PRO survey at home before you came to your appointment or at the clinic immediately before your appointment?

15. Please rate your preference in terms of which of the following you would rather use to fill out the PRO survey: (Tablet__ Personal Smart Phone__ Desktop computer__ Other (specify)

Content

16. How do you feel about the content of the survey?

1. Were the questions applicable to you?

2. Were there any questions or information missing that you would have liked to report?

17. How easy or difficult was it for you to understand the content/questions in the survey?

1. Did you have any questions or confusion about the content/questions in the survey?

1. How did you make sense of this in the end?

2. Did the survey provide any support or information that helped you to make sense of this?

3. Is there any additional information that should be added to help someone make sense of what the app is asking them to do (e.g., help text, customer service number for questions/issues)?

18. Did you find the survey to be useful? In what way

19. Did filling out the survey have any impact (good or bad) on the conversation between you and your provider during your appointment?

1. Did you feel the conversation was different this time compared to other appointments? In which way?

1. Did the conversation with your provider seem more focused or less focused? More focused? Less focused? (In what way)

1. Did the survey make it easier or more difficult (or just the same) in terms of talking to your doctor?

   1. Were there any unplanned conversations about your condition (e.g., did the survey alert you to questions or concerns that you wanted to talk about with your physician that you were not previously thinking about)?

Comprehension

20. Do you know why you were filling out the PRO survey?

21. Do you know what the physician is doing with your survey information or how the information will be used?

Overall

22. Do you have any concerns about the privacy of the information that you entered into the survey? If yes, what are the concerns?

23. Is there anything else we should know about the PRO app or the process?

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