2018 Health Care Provider Data Survey Questions? Please call (919) 754-6912 This survey is being distributed to support a legislative feasibility study per the HIE Act. Your participation is extremely important. OK Question Title * 1. Which listed Service Provider type(s) most characterizes your work in the health services industry? Please check all that apply. Agencies Allopathic & Osteopathic Physicians Ambulatory Health Care Facilities Behavioral Health & Social Service Providers Chiropractic Providers Dental Providers Dietary & Nutritional Service Providers Eye & Vision Service Providers Group Hospital Units Hospitals Laboratories Managed Care Organizations Nursing & Custodial Care Facilities Other Service Providers Pharmacy Service Providers Physician Assistants & Advanced Practice Nursing Providers Podiatric Medicine & Surgery Service Providers Respite Care Facility Speech Language and Hearing Service Providers Supplies Transportation Services OK Question Title * 2. Please identify the clinical data elements you routinely capture during clinical encounters? Note: If you do not collect clinical information, please use "other" to document data collected during an encounter with a patient. Care Team Members Date of Birth Ethnicity Patient Name Preferred Language Race Sex Care plan field(s), including goals and instructions, referrals Problems Medication Allergies Medications Laboratory Test(s) Laboratory Value(s)/Result(s) Smoking Status Vital signs Diagnoses Other Test Results (i.e. diagnostics, etc.) Other (i.e. daily tasks, notes, patient address, transportation needs, equipment needs, etc.) OK Question Title * 3. What is the approximate number of providers in your organization? 1-49 50-999 1000-4999 Greater than 5000 Do not know OK Question Title * 4. Do you currently have an electronic health/medical care (EHR/EMR) record? Yes No No, but plan to in the next 12 months Other (please specify) OK Question Title * 5. If yes, to question 4. What is the name of the EHR/EMR product? OK DONE