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Health Information Technology (IT) Assessment

Demographics

Organization Information *This question is required.

Who is completing this assessment? *This question is required.

Name
Job Title
Email

Additional Contact

Name
Job Title
Email

Additional Contact

Name
Job Title
Email

Additional Contact

Name
Job Title
Email

1. Does your organization have an electronic health record system (EHR)? *This question is required.Reference:
Electronic Health Record (EHR) Summary

What electronic system/EHR does your organization utilize? *This question is required.

System Name

Other

System Name

Other

System Name

How does your organization currently manage and maintain records? (i.e., paper, PDF, Word) *This question is required.

2. Does your organization use third-party external applications for the following? Check all that apply. *This question is required.

Please list the applications you use for BILLING: *This question is required.

Please list the applications you use for TELEHEALTH: *This question is required.

Please list the applications you use for APPOINTMENTS/SCHEDULING: *This question is required.

Please list the applications you use for PATIENT GENERATED HEALTH DATA: *This question is required.

If other, please explain: *This question is required.

3. Health IT is overseen by:

If other, please explain: