Form CM-10264 CMs-10264 Survey Instrument

Medicare PHR Pilot Survey
Dear Medicare Beneficiary:
As you know in 2007, the Centers for Medicare and Medicaid Services (CMS) initiated a pilot
program to provide Medicare patients such as yourself access to a Personal Health Record.
Personal Health Records are online tools designed to help people understand their health
and health care services. This program provides you and others with information regarding
the health care you receive (the medications you are taking for example) online through you
Medicare health plan.
CMS, with the National Opinion Research Center (NORC) at the University of Chicago, is
conducting a survey of people in Medicare health plans to learn more about their experiences
using a PHR. If you have not used your Personal Health Record because a caregiver or
another adult has used it for you, please invite this person to fill out the survey.
Your name was selected at random by CMS from among the enrollees in your health plan.
We would greatly appreciate it if you could take the time, about 30 minutes, to fill out this
questionnaire. The accuracy of the results depends on getting answers from you and other
people with Medicare selected for this survey. This is your opportunity to help us, and your
health plan, serve you better.
All information you provide will be held in confidence and is protected by the Privacy Act.
The information you provide will not be shared with anyone other than authorized persons at
CMS and NORC, the survey research organization assisting us in this survey.
You do not have to participate in this survey. Your help is voluntary, and your decision to
participate or not to participate will not affect your Medicare benefits in any way. However,
your knowledge and experiences will help us to improve care for all Medicare beneficiaries, so
we hope you will choose to help us.
If you have any questions about the survey or would like to find out how to complete the
survey by phone, please do not hesitate to contact Alison Muckle by phone at (301) 6349461, Monday through Friday between 9:00am and 6:00pm Eastern Standard time, or by
email at: Muckle-Alison@norc.org.
Thank you for your help with this important survey.
Sincerely,

SU_ID:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The
time required to complete this information collection is estimated to average 30 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If
you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

													
													
General Instructions
													
													

Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/20XX

If you agree to participate in the survey, please complete it to the best of your ability. To answer the
questions, write an “X” inside the box next to the answer choice that best fits your response. If the
instructions for a question say, “Mark all that apply” you may mark more than one answer choice for
that question.
You are sometimes told to skip over some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this:
	
2	
1

	Yes  If yes, go to Question 2
	No  If no, go to Question 3

2

Beneficiary Survey

Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/20XX

I. Your Registration Experience
3.	 Please mark the statements below that
apply to your experience registering
for your Personal Health Record. If
none of the statements apply to your
experience, leave all blank. Mark all that
apply.

The following section is about your
experiences in registering for your
Personal Health Record or “PHR”, an online
summary of your health care information
provided to you by [INSERT NAME OF
PLAN]

	
2	
		
3	
		
4	
		
5	
		
1

1.	 How did you first learn about your
[INSERT NAME OF PLAN]’S Personal
Health Record? Mark all that apply.
	
2	
3	
4	
		
5	
6	
7	
1

	Mailing from [HEALTH PLAN]
	[HEALTH PLAN]’s website
	Mymedicare.gov website
	Doctor, nurse or other healthcare
provider
	Friend or family
	Advertisement
	Other (please specify):

		
4.	 Did you receive any help from a friend,
family member, or caregiver when you
signed up for your Personal Health
Record?

		
2.	 How easy was it for you to register
or sign up for your Personal Health
Record? 	
	
2	
3	
4	
1

	
	
	
	

	I had no problem registering
	It was difficult for me to find a
computer I could use
	It was difficult for me to use the
internet
	It was difficult for me to use my
health plan’s website
	It was difficult for me to register
for other reasons (please specify):

	
2	
1

Easy	
Neither easy nor difficult	
Difficult	
Very difficult	

	Yes
	No

5.	 Did you receive any help from your
health plan when you signed up for
your Personal Health Record?
	
2	
1

3

	Yes
	No

6.	 Why did you sign up for your Personal
Health Record? Mark all that apply.

9.	 Have you given permission to family
members or caregivers to use your
Personal Health Record on your
behalf?

	 	Because it would help me better
		 understand my health
2	
	Because it would help me schedule
		 appointments with my doctor(s)
3	
	Because it would improve
		 communication with my doctor
4	
	Because I like the idea of using a
		 computer to keep track of my health
		 care and conditions
5	
	Because it would help me take an
		 active role in my own health care
6	
	Because someone I trust
		 recommended that I use a Personal
Health Record
7	
	Other (please specify):
1

1
2

	
		
		
		
		
		
2	
3	
4	
1

II. Your Personal Health Record Use

	 	Not applicable, no one else has
		 access to my PHR
5

7.	 How often do you view your Personal
Health Record?
	Daily
	A few times a week
	Once a week
	A few times a month
	Once a month
	A few times a year or less

8.	 How long have you been using your
Personal Health Record?
	
2	
3	
1

	One or more of my family member(s):
Mark all that apply.
Spouse
Son or Daughter
Niece or Nephew
Sibling
	My caregiver(s) (other than family)
	My doctor(s)
	Others (please specify):

		

The next section has to do with your use of
your Personal Health Record and some of
its functions.

	
2	
3	
4	
5	
6	

	Yes
	No

10.	 Which of the following people have
access to your Personal Health
Record? Mark all that apply.

		

1

	
	

	Less than 3 months
	Between 3 and 6 months
	6 months or longer

4

11.	 “Using” the functions of your Personal Health Record can include viewing, updating,
printing, sharing, adding or removing information in your Personal Health Record. Please
indicate how often you use the following functions of your Personal Health Record.
Never

a.	 My medication information
b. My personal information
(for example: your address or phone number)
c.	 My medical test information
(for example: diagnostic tests, labs, radiology,
procedures, or results)
d.	 My health care visits
(for example: doctor visits)
e.	 My health conditions
f.	 Health education information
(for example: tips on how to stay healthy)
g.	 Sending messages to my doctor

Rarely

Sometimes

Often

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

12.	 In general, please indicate how much you agree or disagree with the following statements
regarding your use of your Personal Health Record. For each statement, choose only one
answer.
Strongly
disagree

a.	 It is easy for me to use my Personal
Health Record
b.	 It is easy for me to read information in
my Personal Health Record
c.	 It is easy for me to understand my
information in my Personal Health
Record
d.	 It is easy for me to share information
from my Personal Health Record with
my doctor(s)
e.	 It is easy for me to add or remove
information from my Personal Health
Record
f.	 I am confident that the information in my
Personal Health Record is correct
g.	 It is easy for me to print my health
information from my Personal Health
Record

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

5

13.	 Please indicate how much you agree or disagree with the following statements regarding
your use of information on medications in your Personal Health Record. For each
statement, choose only one answer.
Strongly
disagree

a.	 It is easy for me to find my medication
information in my Personal Health
Record
b.	 It is easy for me to understand the
content of my medication information in
my Personal Health Record
c.	 I am confident that my medication
information is correct in my Personal
Health Record
d.	 It is easy to print a copy of my
medication information if I want to
e.	 It is easy for me to add or remove
medications in my Personal Health
Record

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

14.	 Please indicate how much you agree or disagree with the following statements regarding
your use of the information medical tests such as lab tests or X-rays in your Personal
Health Record. For each statement, choose only one answer.
Strongly
disagree

a.	 It is easy for me to find my medical tests
in my Personal Health Record
b.	 It is easy for me to understand the
content of my medical tests in my
Personal Health Record
c.	 I am confident that information on my
medical tests is accurate in my Personal
Health Record
d.	 It is easy for me to print a copy of my
medical tests if I want to
e. It is easy for me to add or remove
information on my medical tests in my
Personal Health Record

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

6

15.	 Please indicate how much you agree or disagree with the following statements regarding
information on your health conditions Personal Health Record. For each statement, choose
only one answer.
Strongly
disagree

a.	 It is easy for me to find information on
my health conditions in my Personal
Health Record
b.	 It is easy for me to understand the
content of my health conditions in my
Personal Health Record
c.	 I am confident that the information on
my health conditions in my Personal
Health Record is accurate
d.	 It is easy for me to print a copy of my
health conditions if I want to
e. It is easy for me to add or remove
information from my health conditions in
my Personal Health Record

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

16.	 Please indicate how much you agree or disagree overall with the following statements
regarding using your Personal Health Record to exchange messages with your doctor.
For each statement, choose only one answer.
Strongly
disagree

a.	 It is easy for me to use my Personal
Health Record to send messages to my
doctor
b.	 It is easy for me to use my Personal
Health Record to receive messages
from my doctor

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

17.	 How confident are you that your information is secure in your Personal Health Record?
Please choose only one answer.
	
2	
3	
1

	Very confident
	Somewhat confident
	Not confident
7

III. Usefulness of your Personal Health Record
The next section has to do with the usefulness of your Personal Health Record to you.
18.	 In general, do you feel that your Personal Health Record is useful to you?
	
2	
1

	

	Yes
	No

Please explain why your Personal Health Record is or is not useful.

19.	 In general, please indicate the degree to which you agree or disagree with the following
statements about the usefulness of your Personal Health Record for you. For each
statement, choose only one answer.
Strongly
disagree

a.	 Having my Personal Health Record
has improved my knowledge about my
health care and conditions
b.	 Having my Personal Health Record
helped me to schedule visits
c.	 Having my Personal Health Record
helped me keep track of my
medications
d.	 My communication with doctors(s) has
improved as a result of my personal
health record
e.	 Having my Personal Health Record
helps me take a more active role in
my own health care
f.	 My overall health has improved as a
result of having my Personal Health
Record

Somewhat
disagree

Neither
agree nor
disagree

Somewhat
agree

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

8

23.	 How comfortable are you using a
computer?

IV. About you

	
2	
3	
4	
1

The next set of questions has to do with
you and your health care experiences.
20.	 In general, how would you rate your
overall health now? Choose only one
answer.
	
	
3	
4	
5	
1
2

24.	 What is your age?

	Excellent
	Very good
	Good
	Fair
	Poor

	
	
3	
4	
5	
6	
1
2

21.	 During the past 12 months, how many
times have you seen a doctor or other
health care professional about your
health? Do not include times you were
hospitalized overnight.
	
	
3	
4	
5	
6	
7	
1
2

	Very comfortable
	Somewhat comfortable
	Somewhat uncomfortable
	Very uncomfortable

	64 and younger
	65-70
	71-75
	76-80
	81-84
	85 and older

25.	 Are you male or female?
1
2

	None
	1
	2-10
	10-12 (about once a month)
	13-20
	20-30 (about twice a month)
	30 or over

	
	

	Male
	Female

26.	 Would you consider yourself of
Hispanic or Latino origin or descent?
	
2	
1

	Yes
	No

27.	 What is your race? Mark all that apply.
	
2	
3	
4	
5	
		
1

22.	 Have any of your doctors told you
that you have a chronic condition
(for example, high blood pressure,
diabetes, or asthma or heart disease)?
	 	Yes, I have one or more chronic
conditions
2	
	No
3	
	Don’t know
1

9

	White
	Black/African-American
	Asian
	American Indian or Alaska Native
	Native Hawaiian or other Pacific
Islander

28.	 What language do you mainly speak at
home? Choose only one answer.
	
2	
3	
		
1

30.	 Did someone help you complete this
survey?

	English
	Spanish
	Some other language
(please specify):

31.	 How did that person help you?
Mark all that apply.
	
	
3	
4	
		
5	
	 	
1

		

2

29.	 What is the highest level of education
you have completed?
	
	
3	
4	
5	
		
1
2

	Yes	  If yes, go to Question 31
	No	  If no, go to end of survey	

	
2	
1

	Less than high school diploma
	High school diploma/GED
	Some college or 2-year degree
	4-year college graduate (Bachelor’s)
	More than 4-year college degree
(Graduate degree)

	Read the questions to me
	Wrote down the answers I gave
	Answered the questions for me
	Translated the questions into my
language
	Helped in some other way
(please specify):

		

Thank you.
Please return the completed questionnaire
in the enclosed postage paid envelope to:
NORC
Attn: Medicare PHR Pilot Survey
4350 East-West Highway, Suite 800
Bethesda, MD 20814

10