e-Health Network of Long Island


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F O R P R O V I D E R S

Provider Survey

Physician Name:
Practice Name:
Practice Address:

City, State:
Zip Code:
Telephone Number:
Fax:
Email Address:

Does your practice currently utilize a computer system?	Yes No

How Old is the computer hardware you are regularly using in your practice?

Do you currently use an Electronic Health Record (EHR)?	Yes No

What EHR do you use? Certified?	Yes No I do't know if my EHR is certified or not No EHR

If you Don't have a certified EHR, how close are you to puchasing one?	Have chosen a system/ready to implement Deciding on a vendor/will implement with a year Intend on choosing/Not sure of process No plan to purchase an EHR in the next few years

Is your practice connected to a Health Information Exchange (HIE) or Regional Health Information Organization (RHIO)?	Yes No

Which of the following activities do you currently perform electronically? (check all that apply)	Claim Submission ePrescribing Viewing Lab Results Viewing Patient Medical History

Do you plan to qualify for the new EHR encentives being offered by Medicare and Medicaid starting in 2011?	Yes No Still Deciding Not contracted for Medicaid or Medicare Not aware of incentives

What specific EHR feature do you need more information about?	Functionality Compatibility Software/Hardware Requirements Pricing Other If Other:

Please include any additional comments or questions you may have.