Preliminary Application

1. Does your practice currently have a practice management system (PMS) for scheduling, billing, etc? (If no, then go to question 2)

a. What is the name/version of the PMS your practice is currently using?
Name of PMS:    Version:
b. In order to facilitate a successful EHR implementation, would you be willing to change practice management systems?

c. Is your PMS interfaced/integrated with your EHR?


2. Does your practice currently have an electronic health record (EHR) system? (If no, then go to question 3)

a. What is the name/version of the EHR system your practice is currently using?
Name of EHR:    Version:
b. How long have you been using your current EHR system for clinical documentation?
Number of years:
3. Are you interested in implementing an EHR system?

4. When do you anticipate purchasing and implementing an EHR?



5. Does your practice have access to financing for purchasing needed software and hardware?


6. What is the internet connectivity source you will be accessing in your area? (If none, then go to question 7)




a. Who is your current internet provider?
Provider Name:
7. Are you a primary care practice?

a. Please indicate specialty (select all that apply):





8. How many providers are at your practice site? (Please include APNs and PAs with prescriptive authority) 



9. Indicate the number of each of the following staff you have at your practice site(s):
a. Clinical director:
b. Nurses:
c. IT staff:
d. EHR implementation lead:
e. Medical director:
f. Office manager:
g. QI staff:
10. If IT staff are not onsite, does your practice have access to technical support when needed?

11. What is your average number of patient visits per day?
Number of visits:
12. How many sites does your practice have?


13. What percentage of your caseload is Medicaid?


Practice
Name: NPI#:
Address:
City:      State:      Zip:
Phone:      Fax:      County:
Email:
Physician Champion (leader of practice implementation)
First Name:     Last Name:
Specialty: NPI#:
Phone:
Email:
Clinical Primary
Contact First Name:
Contact Last Name:
Phone:
Email:
Administrative Primary
Contact First Name:
Contact Last Name:
Phone:
Email:
Practice/Office Manager
First Name:
Last Name:
Phone:
Email:
Information Technology
First Name:
Last Name:
Phone:
Email:
Please list all providers in your practice

If your clinic has more than 10 providers, please contact HITArkansas.

Provider First NameProvider Last NameSpecialtyNPI#
1
2
3
4
5
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7
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10
How did you hear about HITArkansas?
 



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