E-Prescribing Readiness Assessment

PART 1: Your Practice's Current Use of Technology
1. How many prescribers are in your practice?
2. How many prescribers are using your EMR or e-prescribing application:
3. What is the name of the EMR / e-prescribing application your practice uses?
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If “Other” please specify
4. Do you currently prepare prescriptions from your EMR?
Yes, I hand my patient a computer generated printed prescription Yes, I send the prescription to the pharmacy directly from my computer No, I write prescriptions by hand Other
5. Are you interested in having access to patient medication history from community pharmacies across providers through your EMR?
Yes No
PART 2: Current Prescribing Volume
6. How many prescription refill requests does your practice receive per day via phone and fax?
Est. #
7. How much time (in hours) is spent per day managing prescription refill requests? NOTE: Please use decimals to indicate time increments that are less than an hour or for partial hours (e.g., 30 min = .5; 1 hour, 30 min = 1.5).
Each Prescriber:	Office Staff (Collectively):
PART 3: Your Information
First Name:
Last Name:
Your Title/Role:	Select title Physician Office Manager Office Staff Nurse Practitioner RN Medical Assistant Physician Assistant Other (please specify)
If other, please specify:
Practice Name:
Address:
City:
State:	Select.. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Fax:
Phone:
Email: