Physician Questionnaire - cpso.on.ca

1 Physician Questionnaire The purpose of this Questionnaire is to provide the Methadone Committee with the most current information about you and your practice. The information enclosed will be reviewed by the Committee and individuals appointed, to discuss and/or review your practice, and by staff who support the Committee. NAME:: CPSO#: DATE OF BIRTH: SEX: MEDICAL SCHOOL: YEAR OBTAINED: SPECIALTY: YEAR OBTAINED: ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------- PLEASE PRINT LEGIBLY USING BLACK INK ONLY I. What is your practice status? What type of methadone exemption have you received from Health Canada?

2 General Exemption for MMT for Opioid Dependence 1 year General Exemption for MMT for Opioid Dependence 3 year General Exemption for MMT for Opioid Dependence with the added delegation privilege Mailing Address Phone 1: Phone 2: Fax Number: Email Address: Primary Practice Address (location in which you see the majority of your methadone patients) Phone 1: Phone 2: Fax Number: Email Address: Secondary Practice Address Phone 1: Phone 2: Fax Number: Email Address: Updated: March 30, 2010 Physician Questionnaire BEST Contact Information for CPSO Staff and Assessors: Office backline: (_____ ) _____ - _____ Cell: (_____ ) _____ - _____ Pager: (_____ ) _____ - _____ Home: (_____ ) _____ - _____ Other: (_____ ) _____ - _____ E-mail: Please indicate your preference (1st, 2nd, 3rd) to arrange the assessment.

3 It is occasionally possible for a weekend assessment. Please indicate if you would be interested in this option. MON. TUES. WED. THURS. FRI. SAT. SUN. b. Do you have Internet access in your office practice? No Yes Cable (High Speed) DSL (High Speed) T1 connection T3 connection Dial-up Other _____ c. Some of our assessors use laptops to complete the assessment process. Is there an available phone plug/outlet in your office practice that the assessor could use to connect to the Internet? Please note that no costs would be incurred for this activity. Yes No II.

4 What does your practice structure look like? (Please help us to match an appropriate assessor to your practice by providing us with a description of your practice.) Who do you work with in your office practice? 1. Please indicate the number of full-time and part-time personnel that you work with on a regular basis (daily/weekly) within your office practice: FOR OFFICE PRACTICE # FT #PT Physicians Registered Nurses/RPNs Nurse Practitioners Administrative Staff Case Managers Counsellors Updated: June 2011 Page 2 of 9 Physician Questionnaire Tell us what you share with other physicians in your office practice 2.

5 A. YES NO Staff Office Space Patient Records b. Please briefly describe your arrangements to ensure care for your patients in your absence ( cross-coverage, vacations etc.) _____ _____ c. Please indicate the number of hours in a typical week (i) are available while being on call: _____ (ii) attend to patients during the time you are on call: _____ Where do you work? 3. Please indicate which location you see patients, the number of patients seen and the number of hours spent in direct patient contact in a typical work-week. Please do not provide a range, but indicate the upper limit of the number of patients you see and the number of hours you spend in direct patient contact.

6 Facility # patients seen # hrs spent in direct patient contact #hrs spent utilizing telemedicine? A. Office Practice: a) Private Office b) Community Health Centre c) Clinic d) Locum B. Long-term Care Facility/Nursing Home etc. C. Government Facility (jail, army, etc.) D. Telemedicine _____ Telemedicine 1. Is telemedicine done through Ontario Telehealth Network? YES NO 2. Please identify the sites (locations) you provide MMT utilizing telemedicine services? Updated: June 2011 Page 3 of 9 Physician Questionnaire 3. According to your records, list the number of patients in each site location that are currently being treated using this method of practice?

7 Telemedicine Site Location # of Patients 4a) Is there a nurse/counsellor/case manager available at the site when you are conducting the interview with the patient? YES NO b) If yes, what are their roles and responsibilities? 5. What percentage of patients is seen on the initial visit with the results of a focused physical assessment available prior to initiation of MMT? 6. What percentage of patients is initiated to MMT treatment via telemedicine? 7a) Describe your activities in relation to interaction with clinic staff at the site locations? b) Is there a Physician available between clinic visits? YES NO c) Are you accessible via telephone or e-mails?

8 YES NO Updated: June 2011 Page 4 of 9 Physician Questionnaire 8. How are prescriptions issued and transmitted? Shared EMR Fax Other: _____ Urine Collection 1. Is there a drug urine screen collection area within your institution/clinic/office? YES NO 2. How is privacy/security for patients respected? 3. Are the urines supervised? YES NO If yes, how is supervision provided?

9 If not supervised, what measures are you taking to improve reliability of the urine specimen (for example, methadone metabolite detection, temperature monitoring, specific gravity, etc.)? 4. How frequently are the urines collected? 5. Please describe what laboratory test is utilized for urine drug screens? Updated: June 2011 Page 5 of 9 Physician Questionnaire Dispensing/Administration 1. Is there an on-site pharmacy? Yes No 2. Is the pharmacy open on Sunday? Yes No If no, what arrangements are made to ensure a patient receives their methadone dose? 3. Are patients required to go to any particular pharmacy?

10 If yes, please explain why? 4. Is methadone administered to the patient by a: pharmacist trained laboratory technician trained regulated health professional (please describe) 5. If methadone is administered by a non-pharmacist, is the methadone dose been prepared and dispensed by the pharmacist? YES NO 6. Please describe your method of securing and storing methadone in your clinic/institution/office? 7. If methadone is administered in your clinic/institution/office, are records maintained for the following: Amount of methadone received from the pharmacy YES NO Amount of methadone that is administered to each patient YES NO Amount of methadone discarded/returned to pharmacy YES NO Community Services YES NO 1.