Federal Register / Vol. 78, No. 30 / Wednesday, February 13, 2013 / Notices 10175 

personnel and to be able to respond to 

a collection of information, to search 

data sources, to complete and review 

the collection of information, and to 

transmit or otherwise disclose the 

information. The total annual burden 

hours estimated for this ICR are 

summarized in the table below. 

TOTAL ESTIMATED ANNUALIZED BURDEN—HOURS

Number of 

respondents 

Number of 

responses per 

respondent 

Average 

burden per 

response 

(in hours) 

Total burden 

hours 

Ineligible ........................................................................................................... 45 1 .05 2 .25 

Eligible ............................................................................................................. 600 1 .25 150 

Total .......................................................................................................... 645 1 .24 152 .25 

OS specifically requests comments on 

(1) the necessity and utility of the 

proposed information collection for the 

proper performance of the agency’s 

functions, (2) the accuracy of the 

estimated burden, (3) ways to enhance 

the quality, utility, and clarity of the 

information to be collected, and (4) the 

use of automated collection techniques 

or other forms of information 

technology to minimize the information 

collection burden. 

Darius Taylor, 

Deputy, Information Collection Clearance 

Officer. 

[FR Doc. 2013–03270 Filed 2–12–13; 8:45 am] 

BILLING CODE 4150–45–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Agency for Healthcare Research and 

Quality 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Agency for Healthcare Research 

and Quality, HHS. 

ACTION: Notice. 

SUMMARY: This notice announces the 

intention of the Agency for Healthcare 

Research and Quality (AHRQ) to request 

that the Office of Management and 

Budget (OMB) approve the proposed 

information collection project: ‘‘PatientReported Health Information 

Technology and Workflow.’’ In 

accordance with the Paperwork 

Reduction Act, 44 U.S.C. 3501–3521, 

AHRQ invites the public to comment on 

this proposed information collection. 

DATES: Comments on this notice must be 

received by April 15, 2013. 

ADDRESSES: Written comments should 

be submitted to: Doris Lefkowitz, 

Reports Clearance Officer, AHRQ, by 

email at doris.lefkowitz@AHRQ.hhs.gov. 

Copies of the proposed collection 

plans, data collection instruments, and 

specific details on the estimated burden 

can be obtained from the AHRQ Reports 

Clearance Officer. 

FOR FURTHER INFORMATION CONTACT: 

Doris Lefkowitz, AHRQ Reports 

Clearance Officer, (301) 427–1477, or by 

email at doris.lefkowitz@AHRQ.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

Proposed Project 

Patient-Reported Health Information 

Technology and Workflow 

Health IT can improve quality of care 

by arraying relevant information, 

displaying clinical guidelines, 

highlighting test values of concern, 

calculating medication doses, and 

supporting clinical decisionmaking in 

many ways (Chaudhry et al., 2006). 

Successful health IT implementation 

requires careful attention to the 

workflow of clinicians and others 

involved in care delivery. However, few 

studies have examined how health IT 

can change workflow in ambulatory 

physician practices. Further, in most 

studies that address health IT in 

ambulatory settings, workflow is not the 

main focus of the research (Unertl, 

Weinger, Johnson et al., 2009, Carayon, 

Karsh, Cartmill et al., 2010a). The health 

IT literature has not focused on 

sociotechnical factors, such as patient or 

provider characteristics, physical 

environment and layout; technical 

training and support; functionality and 

usability of health IT; worker roles, staff 

workload, stress, and job satisfaction; 

and communication flows. Important 

work that does address such factors 

comes mainly from inpatient settings, or 

from other countries where the health 

care system is quite different than in the 

U.S. (Tjora and Scambler, 2009; 

Ammenwerth, Iller, and Mahler, 2006; 

Niazkhani, Pirnejad, de Bont et al., 

2008; Niazkhani, Pirnejad, Berg et al., 

2009). Although many of these studies 

have concluded that changes in 

workflow occur when implementing 

different health IT applications, few 

studies have actually examined how 

workflow changes. 

In recent years there has been an 

increase in the use of health IT to 

capture patient reporting of medical 

histories, symptoms, results of selftesting (e.g., blood glucose levels, blood 

pressure), weight questions and 

concerns, over-the-counter medication 

use, and other information that patients 

need to share with their care providers. 

Health IT can elicit such information 

from patients, and help incorporate it 

into the flow of information within a 

physician’s practice so that the 

information is detailed, actionable, 

timely, and can be used to meet 

patients’ treatment goals. Gathering and 

integrating information from patients 

using health IT can include patient 

surveys and other pre-formatted 

information collection mechanisms (eforms), secure messaging (email) 

between patients and their providers 

(Byrne, Elliott, and Firek, 2009; Bergmo, 

Kummervold, Gammon et al., 2005); and 

patient portals (sometimes referred to as 

[electronic] personal health records or 

PHRs, patient portals allow patients to 

view portions of their medical records 

[e.g., view laboratory test results] and 

support other health-related tasks such 

as making appointments or requesting 

medication refills). The use of patientreported information is not yet widely 

integrated into health IT. 

This project will fill the gaps in the 

current literature by exploring the 

influence of sociotechnical factors—for 

clinicians and their office staff, and for 

patients—in capturing and using 

patient-reported information in 

ambulatory health IT systems and 

associated workflows. The goal of the 

project is to answer the following 

research questions: 

• How does the use of health IT to 

capture and use patient-reported 

information support or hinder the 

workflow from the viewpoints of 

clinicians, office staff, and patients? 

• How does the sociotechnical 

context influence workflow related to 

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10176 Federal Register / Vol. 78, No. 30 / Wednesday, February 13, 2013 / Notices 

the capture and use of patient-reported 

information? 

• How do practices redesign their 

workflow to incorporate the capture and 

use of patient-reported information? 

The study will consist of rigorous 

mixed-methods case studies of six 

ambulatory care physician practices 

including three small practices (1–3 

physicians and the other clinicians and 

office staff in their practices) and three 

medium-sized practices (4–10 

physicians, and the other clinicians and 

office staff in their practices). These case 

studies will be conducted during 

multiday (3 to 4 days) site visits to 

collect information for this exploratory 

research. The multiple case study 

research approach of Eisenhardt and 

colleagues (Brown & Eisenhardt, 1997; 

Eisenhardt, 1989) will guide data 

collection and data analysis, to 

elucidate health IT workflows and 

important sociotechnical factors (for 

patients, clinicians, and office staff) in 

the capture and use of patient-reported 

information. 

A focus of the case studies will be to 

identify current workflows related to 

patient-reported information, and 

determine the work system factors that 

influence workflows (barriers and 

facilitators). In particular, data collected 

from the six practices will help identify 

bottlenecks and sources of delay, 

unnecessary steps or duplication, 

rework to correct errors or 

inconsistencies, role ambiguity, missing 

information, and lack of data quality 

controls or reconciliation of 

inconsistencies. The focus is not on the 

content of information reported by 

patients, or how it alters clinicians’ 

diagnostic or treatment decisions. 

Rather, the focus is on the workflows 

required to capture, process, and make 

use of information that patients report to 

their care providers. 

This study is being conducted by 

AHRQ through its contractor, Abt 

Associates Inc., and subcontractors 

University of Wisconsin-Madison and 

University of Alabama-Birmingham, 

pursuant to AHRQ’s statutory authority 

to conduct and support research on 

health care and on systems for the 

delivery of such care, including 

activities with respect to health care 

technologies and the quality, 

effectiveness, efficiency, 

appropriateness and value of health care 

services including quality measurement 

and improvement. 42 U.S.C. 299a(a)(1), 

(2) and (5). 

Method of Collection 

To achieve the goal of this project the 

following activities will be conducted at 

each of six participating ambulatory 

physician practices (referred to herein 

as ‘study sites’): 

(1) Preliminary Conference Call: The 

Practice Manager (the individual in each 

practice who manages day-to-day 

operations) and the Physician Leader 

(the physician in each practice who is 

most knowledgeable about health IT and 

health IT implementation) will be asked 

to participate in a preliminary 

conference call to learn about the study 

site and what will be expected of their 

practice as a study site. This call will 

last approximately one hour and will be 

completed by up to 2 participants per 

site for a total of up to 12 participants 

across sites. 

(2) Pre-Visit Questionnaire: The 

Practice Manager will be asked to 

complete a brief questionnaire prior to 

the site visit, describing the practice 

size, health IT installed, patient 

population served, and other general 

contextual information about the 

practice and use of health IT. The PreVisit Questionnaire will take 

approximately one hour to complete 

and will be completed by up to one 

respondent per study site. 

(3) Practice Tour: Each of the six site 

visits will begin with a one-hour tour of 

the practice and discussion with the 

Practice Manager to observe the 

physical layout and computer work 

stations, clarify the purpose of the study 

and the site visit, and clarify 

information from the Pre-Visit 

Questionnaire. 

(4) Interviews with Practice Manager 

and Physician Leader: Following the 

tour at each study site, the Practice 

Manager and Physician Leader will be 

asked to participate in a one hour 

interview. The interview with the 

Practice Manager will focus on the 

sociotechnical context of the practice, 

with an emphasis on the social context 

of the practice. The interview with the 

Physician Leader will also focus on the 

sociotechnical context of the practice, 

and, in particular, the technical aspects 

of clinicians using the health IT system. 

The focus will be on the workflow 

across the practice, not the workflow of 

these two individuals. This information 

will be used to create the basic outline 

or structure of a Workflow Process 

Map(s), a diagram that shows the 

temporal sequencing of tasks in relation 

to other work system elements (person, 

organization, environment, and tools 

and technologies). It will also be used to 

begin to identify potential variation or 

flexibility in individuals’ workflows, 

and provide context regarding multiple 

IT systems that may be in use in the 

practice. The information obtained from 

these interviews will be augmented by 

observation of workflows in the practice 

and interviews with others in the 

practice, as described in #5 and #6. 

(5) Observations of Clinicians and 

Office Staff: Researchers will observe 

between 7 to 20 clinicians (including 

physicians, nurse practitioners, 

physician assistants, nurses, medical 

assistants, and ancillary staff) and 

between 3 to 7 office staff (including the 

front desk receptionist, IT staff, clerks, 

and other non-clinical staff) per study 

site, depending on site size for a total of 

up to 81 clinicians and up to 30 office 

staff observations across the study sites. 

Observations will take place as 

clinicians and office staff work to elicit, 

integrate and work with patientreported information. Each clinician 

will be observed for up to two hours and 

each office staff person will be observed 

for up to 30 minutes. These observations 

periods are different because clinicians’ 

work is more complex and varies more 

from one patient to the next, while 

office staff work varies less. 

Observations will focus on processes, 

bottlenecks, facilitators, workarounds, 

and points in the workflow when paper 

information supplements electronic 

information. Observations of both 

clinicians and office staff will be 

recorded on the Observation Form. The 

observations will be used to create a 

detailed Workflow Process Map(s). This 

data collection will not burden the 

clinic staff and is not included in the 

burden estimates in Exhibit 1. 

(6) Interviews with Clinicians and 

Office Staff: Following observations of 

the workflow, each clinician and office 

staff person who was observed will be 

interviewed for up to one hour, for a 

total of up to 81 clinicians and up to 30 

office staff interviews. If there are more 

clinicians or office staff than can be 

interviewed during the site visit, those 

with the most extensive experience with 

patient-reported information will be 

selected for interviews. These 

interviews will include discussion 

about the sociotechnical context, the 

workflow observed (see above), 

facilitators and barriers to capturing and 

using patient-reported information, and 

whether there are uncommon workflow 

patterns that arise occasionally but were 

not observed. Unlike the interviews 

with the Physician Leader and Practice 

Manager, these interviews will focus on 

the workflow of each individual, not the 

workflow across the entire practice. The 

same interview guide will be used for 

both clinician and office staff 

interviews. 

(7) Survey of Clinicians and Office 

Staff: All clinicians and office staff in 

the six study sites will be invited to 

respond to a survey. Although there 

may not be sufficient time on site to 

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Federal Register / Vol. 78, No. 30 / Wednesday, February 13, 2013 / Notices 10177 

observe and interview every clinician 

and office staff person in the mediumsized practices, all of them will be asked 

to complete the survey questionnaire. 

Therefore, the number of survey 

respondents is greater than the number 

of observed and interviewed 

individuals. Up to 10 surveys will be 

completed at each small-sized study site 

and up to 35 surveys will be completed 

at each medium-sized study site, for a 

total of up to 135 respondents across the 

six sites. The surveys will be used to 

collect data regarding attitudes about 

and perceptions of the health IT 

workflows staff engage in related to 

patient-reported information and the 

impact of health IT on workload, stress, 

and job satisfaction, because workflow 

can impact workload and job 

satisfaction which have been shown to 

impact quality of care. The survey will 

also be used to collect data on barriers 

and facilitators associated with 

capturing and using patient-reported 

information. 

(8) Patient Interviews: Patients will be 

interviewed to understand the workflow 

of entering or reporting information 

from the patient’s perspective; the 

extent and adequacy of training or 

instruction patients received in using 

the health IT; attitudes about the time it 

takes to report information; and whether 

there are challenges, barriers, 

facilitators, or workarounds commonly 

used by patients as they report 

information requested by their care 

providers. Five patients will be 

interviewed at each small practice and 

up to seven at each medium-sized 

practice, for a total of up to 36 across the 

six study sites. More patients will be 

interviewed in the medium-sized 

practices because there are more 

clinicians in these practices, and each 

may have different patterns of 

interacting with their patients. 

Interviewing more patients will enhance 

the ability to capture information about 

variation in the clinician-patient 

information sharing and interaction. 

These interviews will help researchers 

understand the range of patient 

experiences. 

(9) Post-Visit Follow-up to Review the 

Workflow Process Map(s): Following 

each site visit, researchers will complete 

the Workflow Process Map(s) for the 

study site and send it to the Practice 

Manager and Physician Leader, 

requesting confirmation that the 

understanding of their workflows is 

correct. 

The lessons learned from this research 

may be used in a variety of ways: 

(1) To identify additional workflow 

components that ambulatory practices 

should consider when implementing 

health IT to capture and use patientreported information; 

(2) To identify issues relevant to best 

practice guidelines for health IT 

implementation; 

(3) To identify issues for 

consideration in the design and 

evaluation of other patient-centered 

health IT tools. 

The study findings will be widely 

disseminated to health IT researchers 

and implementers via AHRQ’s National 

Resource Center for Health IT Web site. 

The study will enhance the existing 

knowledge about sociotechnical factors 

that impact health IT workflow, and 

how small and medium-sized 

ambulatory practices employ health IT 

to capture and use patient-reported 

information as they redesign their 

workflow to deliver patient-centered 

care. 

Estimated Annual Respondent Burden 

Exhibit 1 shows the estimated annual 

burden hours for the respondents’ time 

to participate in this research. The 

Preliminary Conference Call with each 

site will involve two people, the 

Practice Manager and the Physician 

Leader, and will require up to one hour 

per site. A total of 12 people across the 

six study sites will be involved. The 

Pre-Visit Questionnaire and the Practice 

Tour will be completed by the Practice 

Manager at each site and will require up 

to one hour each. The Practice Manager 

and the Physician Leader at each site 

(12 individuals in total across the 6 

sites) will be separately interviewed to 

gather in depth information about the 

sociotechnical context of the practice. 

The interviews will each take up to one 

hour to complete. Interviews with 

Clinicians and Office Staff will be 

completed with a maximum of 111 

clinicians and office staff across the six 

study sites, and each interview will last 

up to one hour. A maximum of 135 

clinicians and office staff combined (up 

to 10 for each of three small-sized sites 

and 35 for each of 3 medium-sized sites) 

will be asked to complete the clinician 

and office staff survey, which will take 

approximately 15 minutes for each 

respondent to complete. Up to 36 

patients will be interviewed (5 in each 

of the small sites and up to 7 in each 

of the medium-sized sites). Each 

interview will take no more than 30 

minutes to complete. A total of 12 

persons (the Practice Manager and the 

Physician Leader at each site) will be 

involved in the Post-Visit Follow-up to 

Review the Workflow Process Map(s), 

which will take one hour. The total 

annual burden hours, is estimated to be 

211 hours. 

Exhibit 2 shows the estimated annual 

cost burden associated with the study 

sites’ time to participate in the research. 

The total annual cost burden is 

estimated to be $11,031. 

EXHIBIT 1—ESTIMATED ANNUALIZED BURDEN HOURS

Form name Number of 

respondents 

Number of 

responses per 

respondent 

Hours per 

response 

Total burden 

hours 

Preliminary Conference Call ............................................................................ 12 1 1 12 

Pre-Visit Questionnaire .................................................................................... 6 1 1 6 

Practice Tour ................................................................................................... 6 1 1 6 

Interviews with Practice Manager and Physician Leader ................................ 12 1 1 12 

Interviews with Clinicians and Office Staff ...................................................... 111 1 1 111 

Survey of Clinicians and Office Staff ............................................................... 135 1 15/60 34 

Patient Interviews ............................................................................................ 36 1 30/60 18 

Post Visit Follow-up to Review the Workflow Process Map(s) ....................... 12 1 1 12 

Total .......................................................................................................... 330 N/A N/A 211 

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10178 Federal Register / Vol. 78, No. 30 / Wednesday, February 13, 2013 / Notices 

EXHIBIT 2—ESTIMATED ANNUALIZED BURDEN HOURS

Form name Number of 

respondents 

Total burden 

hours 

Average 

hourly wage 

rate* 

Total cost 

burden 

Preliminary Conference Call ............................................................................ 12 12 a$67.15 $806 

Pre-Visit Questionnaire .................................................................................... 6 6 b46.17 277 

Practice Tour ................................................................................................... 6 6 b46.17 277 

Interviews with Practice Manager and Physician Leader ................................ 12 12 a67.15 806 

Interviews with Clinicians and Office Staff ...................................................... 111 111 c55.00 6,105 

Survey of Clinicians and Office Staff ............................................................... 135 34 d45.98 1,563 

Patient Interviews ............................................................................................ 36 18 e21.74 391 

Review of the Workflow Process Map(s) ........................................................ 12 12 a67.15 806 

Total .......................................................................................................... 330 196 N/A 11,031 

*Based upon the mean of the average hourly wages, National Compensation Survey: Occupational wages in the United States May 2011, 

‘‘U.S. Department of Labor, Bureau of Labor Statistics.’’ aThe average wage for Practice Managers ($46.17 per hour) and Physician Leaders ($88.12 per hour) [$88.12 reflects the average for Family 

and General Practitioners ($85.26 per hour) and Internists, General ($90.97 per hour)]. bThe average U.S. wage for Practice Managers is $46.17 per hour. 

cThe weighted average wage for physicians ($88.12 per hour) [$88.12 reflects the average for Family and General Practitioners ($85.26 per 

hour) and Internists, General ($90.97 per hour)], nurse practitioners and physician assistants ($41.63 per hour) [$41.63 reflects the average for 

Physician Assistants ($43.01 per hour) and Health Diagnosing and Treating Practitioners, All ($40.24 per hour)], nurses ($33.23 per hour), and 

Office Staff ($17.94) [reflects the average for Receptionists and Information Clerks ($12.85 per hour), Office and Administration Support Workers, 

All Other ($16.07 per hour), and Computer Support Specialists ($24.91 per hour)]. dThe weighted average wage for physicians ($88.12), nurse practitioners and physician assistants ($41.63), nurses ($33.23) and office staff 

($17.94). eThe average U.S. hourly wage ($21.74). 

Request for Comments 

In accordance with the Paperwork 

Reduction Act, comments on AHRQ’s 

information collection are requested 

with regard to any of the following: (a) 

Whether the proposed collection of 

information is necessary for the proper 

performance of AHRQ health care 

research and health care information 

dissemination functions, including 

whether the information will have 

practical utility; (b) the accuracy of 

AHRQ’s estimate of burden (including 

hours and costs) of the proposed 

collection(s) of information; (c) ways to 

enhance the quality, utility, and clarity 

of the information to be collected; and 

(d) ways to minimize the burden of the 

collection of information upon the 

respondents, including the use of 

automated collection techniques or 

other forms of information technology. 

Comments submitted in response to 

this notice will be summarized and 

included in the Agency’s subsequent 

request for OMB approval of the 

proposed information collection. All 

comments will become a matter of 

public record. 

Dated: February 6, 2012. 

Carolyn M. Clancy, 

Director. 

[FR Doc. 2013–03217 Filed 2–12–13; 8:45 am] 

BILLING CODE 4160–90–M 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Submission for OMB Review; 

Comment Request 

Title: Tribal TANF Financial Report 

(ACF–196T). 

OMB No.: 0970–0345. 

Description: Tribes use Form ACF– 

196T to report expenditures for the 

Tribal TANF grant. Authority to collect 

and report this information is found in 

the Personal Responsibility and Work 

Opportunity Reconciliation Act of 1996 

(PRWORA), Public Law 104–193. Tribal 

entities with approved Tribal plans for 

implementation of the TANF program 

are required by Section 412(h) of the 

Social Security Act to report financial 

data. Form ACF–196T provides for the 

collection of data regarding Federal 

expenditures. Failure to collect this data 

would seriously compromise the 

Administration for Children and 

Families’ (ACF) ability to monitor 

expenditures. This information is also 

used to estimate outlays and may be 

used to prepare ACF budget 

submissions to Congress. Financial 

management of the program would be 

seriously compromised if the 

expenditure data were not collected. 45 

CFR part 286 subpart E requires the 

strictest controls on funding 

requirements, which necessities review 

of documentation in support of Tribal 

expenditures for reimbursement. 

Comments received from previous 

efforts to implement a similar Tribal 

TANF report Form ACF–196T were 

used to guide ACF in the development 

of the product presented with this 

submittal. 

The American Recovery and 

Reinvestment Act (ARRA) of 2009, 

Public Law 111–5 has authorized 

emergency TANF funds to be awarded 

to States, Tribes, and Territories who 

meet certain eligibility requirements 

written in the legislation. TANF Policy 

Announcement TANF–ACF–PA–2009– 

01 provides additional guidance on 

eligibility requirements. Recipients of 

ARRA funds are to report spending and 

performance data to Federal agencies 

quarterly for posting on the public Web 

site, ‘‘Recovery.gov’’. Federal agencies 

are required to collect ARRA 

expenditures data and the data must be 

clearly distinguishable from the regular 

TANF (non-ARRA) funds. Therefore, in 

order to meet this data collection 

requirement, the ACF–196T has been 

modified with the addition two line 

items and a column to report ARRA 

expenditures. The collection and 

posting of this data is to allow the 

public to see where their tax dollars are 

spent. 

Respondents: All Tribal TANF 

Agencies. 

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