Rotary Club Telemedicine Project Questionnaire

The goal in Rotary clubs providing equipment is to enable telemedicine to work well and as soon as possible. Key success factors are:

1. An Internet connection
2. Electricity (Generator or solar array may need to be part of the project)
3. An ICU or critical care ward
4. A doctor who wants to work with us and who speaks English
5. A Rotary Club that wants to help the hospital and sees telemedicine as a good project

    Your Name (required)

    Your Email (required)

    Name of Hospital (required)

    Hospital City and Country (required)

    Number of beds at hospital (required)

    Number of computers presently available at hospital (required)

     

    Hospital Assessment

    (Please explain “no” answers)

    Does the lead physician speak English?
    NoYes
    Comment

    What wards does the hospital have?

    Does the hospital have an Intensive Care Unit (ICU)?
    NoYes
    Comment

    How many doctors are on staff?

    How many nurses are on staff?

    Is the hospital a teaching hospital?
    NoYes
    If “yes”, is the hospital associated with a medical school? If so, which one?

    Would you like to explore having this project becoming the basis for a regional hub for telemedicine with a panel of specialists of its own?
    NoYesMaybe later

    Is there any form of electronic medical records?
    NoYes
    If “yes”, what is the format?

    Are patient records electronic?
    NoYes
    Comment

    Are medical supplies accounted for electronically?
    NoYes
    Comment

    Who on staff at the hospital will lead the telemedicine project? Name the leader and two other people who will support adoption of telemedicine at the hospital. The leader must be a doctor.

    Hospital Staff Name 1

    Mobile 1

    Email 1

    Hospital Staff Name 2

    Mobile 2

    Email 2

    Hospital Staff Name 3

    Mobile 3

    Email 3

     

    Technical Assessment

    Are computers used in business accounting and/or billing?
    NoYes
    Comment

    Are computers used in clinical work?
    NoYes
    Comment

    Is there a wired network in place?
    NoYes
    Comment

    Is there a wireless (WiFi) network in place?
    NoYes
    Comment

    Is there someone on the hospital staff who performs technical support for the network(s)?
    NoYes

    If “yes” please provide name, phone number and for that person below:


    Hospital Tech Support Staff Name

    Mobile

    Email

    Are electrical outages a problem?
    NoYes
    If “yes”, how many took place last week?

    What was the usual duration of the outages?

    How about last month?

    Does the hospital have a generator or solar power for when the electrical grid is down?
    NoYes
    Comment

    Do you have an internet connection?
    NoYes
    If “yes”, what type(s) of internet connection(s) are available at the hospital?:
    DSLCableFMSatelliteISDNOther

    Please test the speed of your connection using a computer on your hospital network. Go to speedtest.net and click on Begin Test. Based on your speedtest.net test results, what is your download speed?


    What is your upload speed?

    Are internet connection outages a problem?
    NoYes
    Comment

    If “yes”, how many took place last week?

    What was the usual duration of the outages?

    How about last month?

     

    Financial Assessment

    Does the hospital have a connection to a Rotary club in the community?
    NoYes

    Club Name

    Club Location:

    Name the Rotarians who will lead the host club team to support the telemedicine project and two other members who will support the project. (Note: One of the team members needs to be the President Elect)

    Rotarian Name 1

    Mobile 1:

    Email 1

    Rotarian Name 2

    Mobile 2

    Email 2

    Rotarian Name 3

    Mobile 3

    Email 3

    What hospital or other funds are available for this project?

    Source

    Amount

    Any additional comments?

    Thank you for taking the time to complete this questionnaire. We will be in touch as soon as possible.