Freestanding ASC Induction Form

ATTACHMENT K:
NHAMCS Freestanding ASC Induction Form

OMB No. 0920-0278; Exp. Date: ________ Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). Notice – Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
INTRO_SCR
	Hello (Respondent's name), This is ... from the U.S. Census Bureau.  I'm calling for the Centers for Disease Control and Prevention concerning their study of ambulatory surgery in freestanding ambulatory surgery centers and in hospitals.  You should have received a letter from Dr. Edward J. Sondik, the Director of the National Center for Health Statistics, describing the study.  You've probably also received a letter from the U.S. Census Bureau which is collecting the data for this study. Did you receive our letter(s)        If "No" or "DK", offer to send or deliver another copy.
1.	Yes
2.	No
3.	Unknown
INTRO_IND
Text:	DO NOT READ AS WORDED BELOW  o  Identify yourself - show I.D. o  Ask to speak to:  (Respondent's name)     (Press ALT-F9 to update Administrator/Alternate contact information) o  Introduce survey, as necessary
1.	Continue
2.	Reluctant Respondent
3.	Inconvenient time
4.	Other Outcome
5.	Conduct/continue induction by phone
HELLO
Text:	Hello.  This is . . . . from the U.S. Census Bureau. May I speak to (Respondent's name)?          If call is transferred, repeat this screen when phone is answered
1.	Correct person, Correct person called to the phone, or call is transferred to correct person
2.	Unknown/no longer there
3.	Reached on a different number
4.	Not available now, not at desk, etc.
5.	On vacation or otherwise temporarily away from work
6.	Other outcome or problem interviewing respondent
TRY_BACK
Text:	Do you want to callback later to try and speak to (Respondent's name)     or do you want to continue with a new/different respondent?     REPORTING PERIOD:  (Reporting period begin date) - (Reporting period end date)
1.	Callback later
2.	Continue with new/different respondent
KNOWL_RESP
Text:	Perhaps you can help me.  I am calling on behalf of the National Center for Health Statistics.  May I speak to someone who can answer questions about ambulatory surgery?
1.	Person you are speaking with can help
2.	Someone else can help
NEW_CONTACT
Text:	Enter 1 to record a new contact information      If necessary, explain survey to new respondent
1.	New contact
2.	Continue interview
REACHED_ON
Text:	What phone number should I use to reach (Respondent's name)?                 Press ALT-F9 To update Phone number(s)                 (When done updating phone(s), enter 1 to continue)
TRANSFER
Text:	Can you transfer me?
1.	Yes
2.	No
INTROB
Text:	( (Hello, this is . . . from the U.S. Census Bureau./ ) Is respondent ready to complete the interview?)
1.	Continue
2.	Reluctant Respondent
3.	Inconvenient time
4.	Other Outcome
NAMECHEK
Text:	Let me verify that I have the correct name and address for your ASC. Is the correct name (facility name)?
1.	Yes
2.	No
ASC_NAME
Text:	What is your ASC's name?      Enter 1 to update the ASC's name
1.	Enter 1 to update information
2.	Continue
ADDCHEK
Text:	Is your ASC located at (Facility Address)
1.	Yes
2.	No
ASC_ADDRESS
Text:	What is the correct address?         Enter 1 to update the ASC's address
1.	Enter 1 to update information
2.	Continue
MAILADD
Text:	Is this the mailing address?       (Facility Mailing Address)
1.	Yes
2.	No
MASC_STRET
Text:	What is the correct mailing address?         Enter the number and street or press enter if same
INTRO_AB
Text:	(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it. The National Center for Health Statistics of the Centers for Disease Control and Prevention is conducting an annual study of ambulatory care.  The study began data collection in 1992. CDC has contracted with the U.S. Census Bureau to collect the data.  (facility name) has been selected to participate in the study. I am calling to arrange an appointment to discuss your participation. The study is authorized under the Public Health Service Act and the information will be held strictly confidential.  Participation is voluntary. Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this ASC in the study.
PRFMSURG
Text:	Do not ask item if facility is an eye surgery center. Is ambulatory (outpatient) surgery or ambulatory diagnostic or therapeutic procedures currently performed in this facility?
1.	Yes
2.	No
3.	Eye surgery center
THANK_B1
Text:	Thank you (Respondent's name) but it seems that our information is incorrect. Since (facility name) does not perform ambulatory surgery, it should not have been chosen for our study. Thank you very much for your cooperation.
INELSPEC
Text:	In this study we are excluding facilities that are exclusively dedicated to family planning, birthing, abortion, podiatry or dentistry. Is (facility name) exclusively one of these?
1.	Yes
2.	No
THANK_B2
Text:	Thank you (Respondent's name), but it seems that our information is incorrect. Since (facility name)'s specialty is out-of-scope for our study, it should not have been chosen for our study.  Thank you very much for your cooperation.
LICASC
Text:	Is this facility currently licensed by the state?
1.	Yes
2.	No
PRNTLIC
Text:	It is important for us to determine whether or not your facility operates under the license or Provider of Services (POS) number of a parent facility. Does your ASC operate under the license of a parent facility?
1.	Yes
2.	No
PRNTPOS
Text:	It is important for us to determine whether or not your facility operates under the license of Provider of Services (POS) number of a parent facility. Does your ASC operate under the Provider of Services (POS) number of a parent facility?
1.	Yes
2.	No
PARFAC_NAME
Text:	What is the name of the parent facility?
PARFAC_STRET
Text:	What is the address of (Parent Facility Name)?
PFNC_THANK
Text:	Thank you for your time and assistance. We may contact you again in a few days regarding participation in this study.        Hang up
OWNASC
Text:	Is this facility owned, operated, or managed by -         Read answer categories
1.	A hospital
2.	One or more physicians
3.	Health maintenance organization
4.	Another health care provider
5.	A health care corporation that owns multiple health care facilities (e.g., HCA or Health South)
6.	Other
ONESPEC
Text:	Is the ambulatory (outpatient) surgery performed here primarily one specialty?
1.	Yes
2.	No
SPECNAME
Text:	What is the specialty?
1.	General Surgery
2.	Gastroenterology
3.	Ophthalmology
4.	Orthopedics
5.	Plastic Surgery
6.	Pain Block
7.	Urology
8.	Pediatric Surgery
9.	Obstetrician/Gynecology
10.	Other
SPECNAME_SP
Text:	What is the specialty?
MULTSPEC
Text:	Is the ambulatory (outpatient) surgery performed here multi-specialty?
1.	Yes
2.	No
STUDY_DESC
Text:	Thank you.  Now I would like to provide you with further information on the study.         Provide the administrator or other facility representative with a brief description of the study          Cover the following points -          (1)    NHAMCS is the only source of national data on health care provided in hospital emergency and outpatient departments and ambulatory surgery centers.         (2)    NHAMCS is endorsed by the:                        Ambulatory Surgery Center Association, American College of Surgeons, American Health Information Management Association, American Academy of Ophthalmology, Society for Ambulatory Anesthesia, American College of Emergency Physicians, Emergency Nurses Association, Society for Academic Emergency Medicine, American College of Osteopathic Emergency Physicians          (3)  Nationwide sample of about 600 hospitals and 246 freestanding ambulatory surgery centers.          (4)  Four-week data collection period          (5) Brief form completed for a sample of patient visits. As one of the ASC's that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory surgery.
INDUCTION_APPT
Text:	I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you?              Record day, date and time of appointment               ( Enter 999 to start the induction now)
SCREENER_THK
Text:	Thank you (Respondent's name) for your cooperation.  I am looking forward to our meeting.
ELIGREQ
Text:	** NOT DISPLAYED **
REVIEW
Text:	? [F1] I would like to begin with a brief review of the background for this study.           Provide the administrator or other facility representative with a brief introduction to the study and a general overview of procedures             Press F1 for points to be covered
PERMPART
Text:	As I mentioned earlier, I would like to discuss the plan for conducting the study.  This ASC has been assigned to a 4-week data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for this study. Are there any additional steps needed to obtain permission for the ASC to participate in the study?
1.	Yes
2.	No
PERMPART_SP
Text:	Please specify the necessary steps.           Be sure to ask for the name, title, address and phone of the person(s) able to grant permission
PERM_THANK
Text:	Thank you for your time
RO_PERMISSION
Text:	Call your regional office and inform them of the situation.     Await guidance before continuing with the case.
VSREPPER
Text:	Now I would like to make arrangements to obtain the information needed for sampling.  I will need to (verify/know) how your ambulatory surgery center is organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period.  Would you prefer I (verify/get) this information from you or someone else?
1.	Respondent
2.	Someone Else
CINFO
Text:	What is the name of the person I should talk to?      Enter 1 to enter/update contact person information or change respondent                                       Alternate Contacts
1.	New contact
2.	Continue interview
THANK_RESP
Text:	Thank you for your time and cooperation.
REACH_CPERSON
Text:	Are the new contacts available to answer the questions at this time?      If unavailable, press F10 to set an appointment
1.	Yes
NEWC_INTRO
Text:	Read if necessary Now I would like to obtain the information needed for sampling.  I will need to (verify/know) how your ambulatory surgery center is organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period.
ASL_INTRO
Text:	To develop the sampling plan, I would like to (collect/verify) more specific information about this facility's ambulatory surgery (centers/locations). We are only interested in the following types of (centers/locations): General or main operating rooms                 Endoscopy rooms Dedicated ambulatory surgery rooms          Cardiac catheterization labs Satellite operating rooms                               Laser procedures rooms Cystoscopy rooms                                           Pain block rooms
1.	Continue
2.	No in-scope ^centerslocations
ASL_NUM
Text:	** SHOW ONLY **
DEL_ASL
Text:	(Does (ASL name) still exist and is it still operational?)   (Enter 97 to delete this (ASC/ASL)/(ASC/ASL) entered by mistake/ If Yes, Press ENTER to move to the next row If No, Enter 97 to delete )
ASL_NAME
Text:	( What is the name of the (first/next) ambulatory surgery (center/location)? /Are there any other ambulatory surgery (center/locations)?)        Enter only IN_SCOPE (ASC/ASL)'s   (Press F1 for in-scope locations)          Enter 999 for no more
ASL_SPEC_GRP
Text:	What is (name)'s specialty group?
1.	General
2.	Multi-specialty
3.	Gastroenterology
4.	Ophthalmology
5.	Orthopedics
6.	Pain Block
7.	Plastic Surgery
8.	Ear, Nose and Throat
9.	Obstetrics - Gynecology
10.	Urology
11.	Other specialty
ASL_EVISITS
Text:	What is the expected number of ambulatory (outpatient) surgery cases for (name) from (Reporting period begin date) to (Reporting period end date)?
CHECK_EVISITS
Text:	You have indicated that none of your ambulatory surgery (centers/locations) will be seeing patients from (Reporting period begin date) to (Reporting period end date). Is that correct?
1.	Yes
2.	No
THANK_INELIG
Text:	Since there are no in-scope ambulatory surgery (centers/locations) for (facility name), it should not have been chosen for our survey. Thank you very much for your cooperation.
ASCLISTA
Text:	Now I have some questions about generating a report for all ambulatory surgery patients for sampling. Would you or your IT staff be able to generate a single list of ambulatory surgery cases for any of the following (centers/locations)? (Name of all ASLs)
1.	Yes - All
2.	Yes - Some Locations
3.	No
ASCLISTB
Text:	For which of these (centers/locations) can lists be combined?          Enter all that apply, separate with commas
1.	ASL_NAME [1]
2.	ASL_NAME [2]
3.	ASL_NAME [3]
4.	ASL_NAME [4]
5.	ASL_NAME [5]
6.	ASL_NAME [6]
7.	ASL_NAME [7]
8.	ASL_NAME [8]
9.	ASL_NAME [9]
10.	ASL_NAME [10]
11.	ASL_NAME [11]
12.	ASL_NAME [12]
13.	ASL_NAME [13]
14.	ASL_NAME [14]
15.	ASL_NAME [15]
IT_CNAME
Text:	What is the name of the IT contact?
IT_CTITLE
Text:	What is (IT contact name)'s title?
IT_CSTRET
Text:	What is (IT contact name)'s address?          Enter number and street or press enter if same
IT_CPHONE
Text:	What is (IT contact name)'s phone number?
AU_NUMBER
Text:	Assign AU number     If you can do abstractions for multiple offices in one (center/location), then assign the same AU number to each of those (centers/locations).
EBILLRECA
Text:	Does your (ASC/ambulatory surgery location) submit any CLAIMS electronically (electronic billing)?
1.	Yes
2.	No
3.	Unknown
EINSELIGA
Text:	Does your (ASC/ambulatory surgery location) verify an individual patient's insurance eligibility electronically, with results returned immediately?
1.	Yes, with a stand-alone practice management system
2.	Yes, with an EMR/EHR system
3.	Yes, using another electronic system
4.	No
5.	Unknown
EMEDRECA
Text:	Does your (ASC/ambulatory surgery location) use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
1.	Yes, all electronic
2.	Yes, part paper and part electronic
3.	No
4.	Unknown
EHRINSYRA
Text:	In which year did your (ASC/ambulatory surgery location) install your EMR/EHR system?
EHRNAMA
Text:	What is the name of your current EMR/EHR system?
1.	Allscripts
2.	Cerner
3.	eClinicalWorks
4.	Epic
5.	GE/Centricity
6.	Greenway Medical
7.	McKesson/Practice Partner
8.	NextGen
9.	Sage
10.	Other - Specify
11.	Unknown
EHRNAMA_SP
Text:	What is the name of your current EMR/EHR system?
EHRINSA
Text:	Does your (ASC/ambulatory surgery location) have plans for installing a new EMR/EHR system within the next 18 months?
1.	Yes
2.	No
3.	Maybe
4.	Unknown
EDEMOGA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Recording patient history and demographic information?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EPROLSTA
Text:	Does this include a patient problem list?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EPNOTESA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Recording clinical notes?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EALLERGA
Text:	Do they include a comprehensive list of the patient's medications and allergies?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ECPOEA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Ordering Prescriptions?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ESCRIPA
Text:	Are prescriptions sent electronically to the pharmacy?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EWARNA
Text:	Are warnings of drug interactions or contraindications provided?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EREMINDA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Providing reminders for guideline-based interventions or screening tests?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ECTOEA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Ordering lab tests?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EORDERA
Text:	Are orders sent electronically?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ESETSA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Providing standard order sets related to a particular condition or procedure?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ERESULTA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Viewing lab results?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EIMGRESA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Viewing imaging results?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EQOCA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Viewing data on quality of care measures?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EIMMREGA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Electronic reporting to immunization registries?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
ESUMA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Providing patients with clinical summaries for each visit?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EMSGA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for: Exchanging secure messages with patients?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	No
4.	Unknown
EHRWHOA
Text:	At your (ASC/ambulatory surgery location), if orders for prescriptions or lab tests are submitted electronically, who submits them?   Enter all that apply, separate with commas, Read answer categories out loud
1.	Prescribing practitioner
2.	Other
3.	Prescriptions and lab test orders are not submitted electronically
4.	Unknown
EXCHSUMA
Text:	Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?                Read answer categories
1.	Yes
2.	No
EXCHSUMMCA
Text:	How do you electronically share patient health information?           Read answer categories, Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method: ___________________
PAYHITA
Text:	Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?
1.	Yes, we already applied
2.	Yes, we intend to apply
3.	Uncertain whether we will apply
4.	No, we will not apply
PAYDRA
Text:	In which year did you first apply for meaningful use payments?
1.	2011
2.	2012
PAYYRA
Text:	In which year do you expect to apply for the meaningful use payments?
1.	2012
2.	2013 or later
3.	Unknown
ASL_SPEC_GRP
Text:	** SHOW ONLY **
1.	General
2.	Multi-specialty
3.	Gastroenterology
4.	Ophthalmology
5.	Orthopedics
6.	Pain Block
7.	Plastic Surgery
8.	Ear, Nose and Throat
9.	Obstetrics - Gynecology
10.	Urology
11.	Other specialty
ASL_STRET
Text:	What is (name)'s address or the address where the abstractions will be done?            (Abstractions can be done at one location for multiple ASL's)                Enter number and street.
ASL_PHONE
Text:	What is (name)'s telephone number or the telephone number where the abstractions will be done?
ASL_CONTACT
Text:	Enter ambulatory surgery (center/location) contact person's name
TE
Text:	Take Every Number ** NOT DISPLAYED **
RS
Text:	Random Start Number ** NOT DISPLAYED **
TOTAL_VISITS
Text:	** NOT Displayed **
PRF_WKLD
Text:	** NOT DISPLAYED **
MULTIASCFLAG
Text:	** Not Displayed **
EXIT_REFUSAL
Text:	Are you exiting this case because of a refusal?
1.	Yes, potential refusal
2.	No
CALLBACKNOTES
Text:	I'd like to schedule a DATE to (conduct the interview/complete the interview/follow-up on missing items) the interview. What DATE AND TIME would be best to visit again?            Today is:  ^IntDate
THANKCB
Text:	Thank you. I will call/come back at the time suggested   Revisit   (Appointment information)
DK_CHECK
Text:	Are there any Don't Know items that you need to callback for?
1.	Yes
2.	No
CALLBACKNOTES
Text:	I'd like to schedule a DATE to (conduct the interview/complete the interview/follow-up on missing items). What DATE AND TIME would be best to visit again?       Today is:  ^IntDate
THANKCB
Text:	Thank you. I will call/come back at the time suggested       Revisit   (Appointment information)
THANKYOU
Text:	This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.
ELIGFS
Text:	Does this facility have an eligible ASC?
1.	Yes
2.	No
VSFS101
Text:	How many visits are expected during the reporting period?
VSFSLY
Text:	How many visits were there to this ASC last year?
REFUSE
Text:	** Not Displayed **
WHOMAS
Text:	By Whom?
1.	ASC administrator
2.	ASC Director
3.	Approval board or official
4.	Other ASC official
TELPERAS
Text:	Was the refusal by telephone or in person?
1.	Telephone
2.	In Person
REASONAS
Text:	What reason was given?
CONVAS
Text:	Was conversion attempted?
1.	Yes
2.	No

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