About how many patients does your micro-system care for?

/ Day, week, year, etc.

Is your micro-system embedded in a larger organization such as a hospital or hospital system, chain, academic medical center, staff model HMO, or integrated delivery system?

_ No _ Yes, please provide the organization's name:

What sort of organization is this?

2. Reimbursement Mix

Please provide the approximate proportion of patients in each reimbursement category:

__ % FFS% __ Prepaid __ % Uninsured or self-pay (Total = 100%)

__ % Commercial __ Medicare __ % Medicaid __ Uninsured or self-pay (Total = 100%)

Has this reimbursement mix been changing in the last year? If so, how?

Do you expect the reimbursement mix to change in the coming year? If so, how?

How is compensation for the physicians in your micro-system determined? (Check as many as apply)

_ FFS/fee schedule _ salary _ capitation _ bonus _ witholds

Are formulas based on:

_ panel size _ productivity _ patient satisfaction _ clinical performance

_ financial performance _ other?, please specify:

3. Computer-based Information Technology

Most offices have computer-based billing information, but we are particularly interested in this section in computer-based clinical information. Does your micro-unit have computer-based patient records?

__ No, Patient records are paper-based (If No, Please skip to section 4 below)

__ Yes, Patient records and financial systems are computer based, but separate

__ Yes, Patient records and financial systems are to some extent or entirely integrated

If you answered yes above, is the clinical information system linked to any data sources outside the micro-system, such as laboratories, pharmacies, or ER? __ No __ Yes, please specify:

Does the clinical information system include direct data input by patients _ No _ Yes (e.g., blood glucose levels or blood pressure measurements)?

Our computer-based information system is used for: Please check all that apply

_generating reports about the practice _ real-time patient care _ clinical decision support (e.g., reminders, drug-drug warnings)

4. Other

Do patients interact with clinicians by e-mail? _ No _ Yes

Using web-based resources? _ No _ Yes

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