VITL Electronic Health Records Readiness Assessment

The VITL EHR Readiness Assessment Survey is a tool that will help VITL staff to determine how prepared your practice is to deploy an EHR. The answers on this survey are for VITL’s use only and will not be shared. Using your answers, VITL will be able to craft the best possible package of services specifically for your practice to help you most efficiently move towards Meaningful Use. This survey will take about 20 minutes to complete.

**Section A: General Information ( * indicates required information)**

1. Contact Information

First Name Required Question

Last Name

Title

Company Name Required Question

Street Address Required Question

Apt/Suite/Office

City

State

Postal Code Required Question

Country

Email Address Required Question

Phone Number Required Question

Fax Number Required Question

Mobile Phone

Website

2. What is your organization type? Required Question

3. Is the organization a Federally Qualified Health Center? Required Question

4. Please provide the organization NPI ID:

5. How many practice sites does the organization have?

6. What specialties are offered within your organization (check all that apply)? Required Question

7. What is the organization's ownership? Required Question

8. Please indicate the number of staff in the practice. Required Question

	Physician
	Nurse practitioner
	Physician assistant
	Nurse
	Medical assistant
	Clerical and other support staff
	Other

0

9. Does the practice have a:

10. What hospitals does the practice or your patients use?

11. Please provide information on your patient population. If you do not have exact numbers, please use your best estimate.

Total number of patients
Average number of patients/week
Average number of patients/day
Percent of patients with no insurance
Percent of patients with Medicaid
Percent of patients with Medicare
Percent of patients with commercial insurance
Other insurance (please list)
Number of patient encounters per year
Number of unique patient encounters per year
Percent of patients on managed care

12. Please describe your level of participation in the Vermont Immunization Registry:

	Do not participate
	Manually enter immunizations into registry
	Send electronic data (files) to the immunization registry for upload

13. Comments on immunization registry participation

	Private practice 1-10 providers
	Rural Health Clinic
	Community Health Center
	Critical Access Hospital
	Public Hospital
	Other Underserved Setting
	Other hospital
	Private Practice 11 or more providers
	Other

	Internal medicine
	Family practice
	Ob/Gyn
	Pediatrics
	Geriatrics
	Adolescent Medicine
	General Practice
	Specialty (please specify type)
	Multi-Specialty (please specify types)
	Other

	Brattleboro Memorial
	Central Vermont Medical Center
	Copley Hospital
	Dartmouth Hitchcock Medical Center
	Fletcher Allen Health Care
	Gifford Medical Center
	Grace Cottage Hospital
	Mt. Ascutney Hospital
	North Country Hospital
	Northeastern Vermont Regional Hospital
	Northwestern Medical Center
	Porter Medical Center
	Rutland Regional Medical Center
	Southwestern Vermont Health Care
	Veterans Administration Medical Center
	Other
	Other
	Other