Form 0920-0234 Att C3- 2016 NAMCS 1 CHC 122115

1/24/2021

Attachment C3: 2016 NAMCS-1 List of all proposed questions for CHC Providers

This table lists all proposed 2016 survey questions in the order that they would appear in the survey. Additions and modifications for 2016 are indicated in red font. Several blocks of questions have been moved to the NAMCS 201 (CHC Providers only). These changes are indicated in blue.

OMB No. 0920-0234 Exp. Date xx/xx/20xx

Notice-Public reporting burden for this collection of information is estimated to average 45 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 (0920-0234).

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 the 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).

Variable

Name

CHC Providers

SPECVER

N/A

PRV_SPEC

N/A

PRV_SPEC_SP

N/A

PRVETHN

What is (your/Provider name's) ethnicity?

1. Hispanic or Latino

2. Not Hispanic or Latino Same

RACE

What is (your/Provider name's) race?  

         Enter all that apply, separate with commas

1. White

2. Black or African-American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

PROFACT

Which of the following categories best describes (your/Provider name's) professional activity -
patient care, research, teaching, administration, or something else?

1. Patient Care

2. Research

3. Teaching

4. Administration

5. Something else – Specify PROFACT_SP

AMBCARE

(Do/Does) (you/provider's name) directly care for any ambulatory patients in (Your/ his/her) work?

1. Yes

2. No - does not give direct care

3. No longer in practice (i.e., retired, not licensed)

4. Temporarily not practicing (refers to duration of 3 months or more)

Skip Instructions:

1: If CHCPROV (flag for CHC providers) = 1, goto ADDCHECK
2: Goto VERIF9A
3: Goto THANK_OOS

4: Goto THANK_OOS

VERIF9A

We include as ambulatory patients, individuals receiving health services without admission to a hospital or other facility.  Does (your/Provider name's) work include any such individuals?

1. Yes, cares for ambulatory patients

2. No, does not give direct care

Specify reason VERIF9a_SP

Skip Instructions:

1: If CHCPROV (flag for CHC providers) =1, goto ADDCHECK
2: Goto VERIF9A_SP

FED

N/A

Skip Instructions:

N/A

PRIVPAT

N/A

Skip Instructions:

N/A

HOSPRIVPAT

N/A

Skip Instructions:

N/A

REMINDER

N/A

ADDCHECK

We have (your/Provider name's) address as
( Address)

Is that the correct address for the CHC?

1. Yes

2. No, update address

NEW_PINFO

What is the correct address and phone number of your current CHC location?

THANK_OOS

Thank you, (Respondent's name/Provider’s name), but since you are not currently practicing, our questions would not be appropriate for you.
I appreciate your time and interest.

Skip Instructions:

IF AMBCARE = 3 goto WHYNO_PRACT
IF AMBCARE = 4 goto WHY_UNAVAIL

WHYNO_PRACT

  Why isn't the doctor practicing?

1. Retired

2. Not licensed

3. Other

WHY_OOS

Describe the provider's practice or medical activities which define him/her as ineligible or out-of-scope.

Enter all that apply, separate with commas

1. Federally employed

2. Radiology, anesthesiology or pathology specialist

3. Administrator

4. Work in institutional setting

5. Work in hospital emergency department, hospital outpatient department, or community health center at a site not at this location.

6. Work in industrial setting

7. Ambulatory surgicenter

8. Laser vision surgery

9. Other – Specify WHY_OO_SP

WHY_UNAVAIL

Why is provider temporarily not practicing?

Verbatim response

INDUCT_APPT

I would like to arrange an appointment with you within the next week or so to discuss the study.
It will take about 30 minutes.  What would be a good time for you, before Friday, (last Friday before the assigned reference week)?

I appreciate that you choose not to participate in the study, but I would like to ask a few short questions about the CHC at this location so we can make sure responding providers do not differ from nonresponding providers.

“Providers” filled for CHC Providers

NUMLOCR

Overall, at how many different office locations do you see ambulatory patients? Do not include settings such as EDs, outpatient departments, surgicenters, Federal Clinics, and community health centers.

NUMLOCR_CHC

Overall, at how many different CHC locations do you see ambulatory patients?

NOPATSENR

In a typical year, about how many weeks do you NOT see ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALFR

LTHALFR_SP

You typically see patients fewer than half the weeks in each year. Is that correct?

1. Yes

2. No – Please explain LTHALFR_SP

ALLYEARR

ALLYEARR_SP

You typically see patients all 52 weeks of each year. Is that correct?

1. Yes

2. No – Please explain ALLYEARR_SP

NUMVISR

During your last normal week of practice how many patient visits did you have at all CHC locations?

WKHOURSR

During your last normal week of practice, how many hours of direct patient care did you provide?

NOTE – Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services. Do not include hours from EDs, outpatient departments, surgicenters, or Federal clinics.

NUMBPAR

At the current CHC location:

How many physicians are associated with you?

SINGSPCR

At the current CHC location:

Is this a single- or multi-specialty CHC at this location?

OWNERSHR

At the current CHC location:

Are you a full- or part-owner, employee, or an independent contractor?

OWNSR

At the current CHC location:

Who owns the CHC at this location?

INDUCT_INTRO

Before we begin, I'd like to give you some background about this study.

Medical researchers and educators are especially interested in topics like medical education, health workforce needs, and the changing nature of health care delivery.  The National Ambulatory Medical Care Survey (or NAMCS) was developed to meet the need for such information.  

The Centers for Disease Control and Prevention works closely with members of the medical profession to design the NAMCS each year.  The NAMCS supplies essential information about how ambulatory medical care is provided in the United States, and how it is utilized by patients.  

Your part in the study is very important and should not take much of your time.  It consists of your participation during a specified 7-day period.  During that time, you would supply a minimal amount of information about the patients you see.

First, I have some questions to ask about the CHC at this location.  Your answers will only be used to provide data on the characteristics of office-based practices in the U.S.  Any and all information you provide for this study will be kept confidential.

NUMLOC

Overall, at how many different office locations, (do/does) (you/physician's name) see ambulatory patients?  Do not include settings such as EDs, outpatient departments, surgicenters, Federal clinics, and community health centers.

NOPATSEN

In a typical year, about how many weeks (do/does) (you/physician's name) NOT see any ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALF

LTHALF_SP

(You/provider’s name) typically (see/sees) patients fewer than half the weeks in each year.
Is that correct?

1. Yes

2. No Please explain LTHALF_SP

ALLYEAR

ALLYEAR_SP

(You/provider’s name) typically (see/sees) patients all 52 weeks of the year.
Is that correct?

1. Yes

2. No Please explain ALLYEAR_SP

SEEPAT

WHYNOPAT

This study will be concerned with the AMBULATORY patients (you/provider’s name) will see at this CHC location during the week of Monday, (Reporting period begin date) through Sunday, (Reporting period end date).

(Are/Is) (you/provider’s name) likely to see any ambulatory patients at the current CHC location during that week?

  For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks, and so forth will be provided by staff in physician's absence, enter "Yes."

1. Yes

2. No Why is that?
    Enter verbatim response

(12b) WHYNOPAT

CHECK_BACK

Since it’s very important that we include any ambulatory patients that you might see at this CHC location during that week, I’ll check back with you just before (starting date) to make sure your plans have not changed.

  Even though the physician/provider is not available during the reporting week, continue with the induction

OFFSTRET

N/A

OFFICE_CITY

N/A

OFFICE_ST

N/A

OFFICE_ZIP

N/A

LOCTYPE

N/A

CUR_OFFICE

N/A

CUR_CHC_ADD

What does the current address below represent?

[Fill with original or updated CHC address]

1. Sampled CHC location-goto OTHLOC

2. Sampled CHC that moved-goto OTHLOC

3. Not sampled CHC location-goto CALL_RO_PHYS

CALL_RO_PHYS

Call your RO and inform them of the situation. Await resolution from the RO before continuing with this case.

OFFICETYP

Choice #5 will be automatically populated:

(5) Community Health Center (e.g., Federally Qualified Health Center (FQHC), federally funded clinics or ‘look alike’ clinics)

FREESTAND_PROBE

N/A

FAMPLAN_PROBE

N/A

OTHLOC

Are there other CHC locations where (you/physician's name) NORMALLY would see patients, even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting period? 

1. Yes Go to OTHLOC_NUM

2. No Skip to ESTDAYS

OTHLOC_NUM

In how many other CHC locations do you NORMALLY see patients?

______ Number of locations

OTHLOCVS

Of these CHC locations where (you/physician's name) will not be seeing patients during (Your/ his/her) 7-day reporting period, how many total office visits did (you/physician's name) have during (Your/ his/her) last week of practice at these CHC locations?

ESTDAYS

During the week of Monday, [Fill Date] through Sunday, [Fill Date] how many days do you expect to see any ambulatory patients at this CHC location?

ESTVIS

During (Your/ his/her) last normal week of practice, approximately how many office visit encounters did (you/provider’s name) have at this CHC location?

Only include the visits to the sampled CHC provider.

          If physician is in group practice, only include the visits to sampled physician.

SAME

During the week of Monday, (fill) through Sunday (fill), do you expect to have about the same number of visits as you saw during your last normal week at the current CHC location taking into account time off, holidays, and conferences?

1. Yes

2. No

ESTVISP

Approximately how many ambulatory visits do you expect to have at this CHC location?

ESTTOTVS

Tally of estimated number of visits

SOLO

Now, I'm going to ask about the CHC at [Pre-fill location].

Do you work solo at this CHC, or are you associated with other physicians in a partnership, in a group at this CHC, or in some other way at this location?

1. Solo

2. Nonsolo

OTHPHY

How many physicians are associated with (you/provider’s name) at (Office location)?

MULTI

Is this a single- or multi-specialty CHC at [Pre-fill location]?

1. Multi

2. Single

MIDLEV

How many mid-level providers (i.e., nurse practitioners, physician assistants, and nurse midwives) are associated with (you/physician's name) at (Office location)?

OWNERSH

(Are/Is) (you/provider’s name) a full- or part-owner, employee, or an independent contractor at (Office location)?

1. Full-owner

2. Part-owner

3. Employee

4. Contractor

OWNS

Who owns the CHC at (Office location)?

1. Physician or Physician group

2. Insurance company, health plan, or HMO

3. Community Health Center

4. Medical/Academic health center

5. Other hospital

6. Other health care corporation

7. Other

ONSITE_EKG

ONSITE_PHLEB

ONSITE_LAB

ONSITE_SPIRO

ONSITE_ULTRA

ONSITE_XRAY

Does the CHC have the ability to perform any of the following on site at (Office location)?

1. EKG/ECG

2. Phlebotomy

3. Lab testing (not including urine dipstick, urine pregnancy, fingerstick blood glucose, or rapid swab testing for infectious diseases)

4. Spirometry

5. Ultrasound

6. X-ray

1. Yes

2. No

3. Don’t know

PATEVEN

(Do/Does) (you/provider’s name) see patients in the CHC during the evening or on weekends at (Office location)?

1. Yes

2. No

3. Don’t know

NPI

What is (your/Provider name's) National Provider Identifier (NPI) at (Office location)?

FEDTXID

What is your Federal Tax ID, also known as an Employer Identification Number (EIN), at (Office location)?

WKHOURS

During (your/Provider name's) last normal week of practice, how many hours of direct patient care did (you/provider’s name) provide?

Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services.

NHVISWK

HOMVISWK

HOSVISWK

TELCONWK

ECONWK

During (Your/ his/her) last normal week of practice, about how many encounters of the following type did (you/provider’s name) make with patients:

1. Nursing home visits

2. Other home visits

3. Hospital visits

4. Telephone consults

5. Internet/e-mail consults

STD-PrEP Questions

STD_INTRO

The following question set asks about policies, services, and experiences related to the prevention and treatment of sexually transmitted infections (STIs) and HIV prevention.

1. Enter 1 to Continue-SKIP to STIADOLPOL

STIADOLPOL

◊The next 5 questions refer to the currently sampled CHC which is (fill address of sampled CHC).

Does the current sampled CHC have a written policy that asks parents, relatives or guardians of an adolescent patient to leave the room during any part of the visit?

1. Yes-go to STIADOLPOL_ASK

2. No-go to STIEVAL

3. Don’t know—go to STIEVAL

STIADOLPOL_ASK

When does the CHC policy require that I/Dr. X (fill last name or greet name) ask relatives or guardians of adolescent patients to leave the room during part of the visit?

1. Always

2. Depending on the circumstance

3. Don’t know

STIEVAL

Do you/Does Dr. X (fill last name or use greet name) evaluate patients for sexually transmitted infections or treat patients with sexually transmitted infections at the current CHC location?

1. Yes-SKIP to STINJABX

2. No-SKIP to STIRSKEVAL

STINJABX

Which of the following injectable antibiotics are provided onsite at the current CHC location for same-day treatment for patients diagnosed with gonorrhea or syphilis? (Mark all that apply)

1. Benzathine penicillin G (bicillin) 2.4 million units IM

2. Ceftriaxone 250 mg IM

3. Other injectable cephalosporin

4. None of the above

For patients with vaginal discharge or urethritis, which of the following point-of-service tests does the current CHC location provide onsite? (Mark all that apply)

1. Dipstick urinalysis

2. KOH (whiff) test

3. pH test

4. Rapid Bacterial vaginosis test

5. Rapid Trichomonas test

6. Stained microscopy using either gram stain, methylene blue stain, or gentian violet stain

7. Standard (unstained) microscopy of urine sediment

8. Wet mount microscopy (wet prep)

9. None of the above

STIRSKEVAL

◊The next question asks about STI and HIV-related risk assessment and services that you/Dr. X (fill last name or greet name) provide(s).

Do you/Does Dr. X (fill last name or use greet name) document any of the following about your/their patients on at least an annual basis? [Mark all that apply]

1. Any substance abuse or injection drug use

2. Condom use

3. HIV status of their sex partners

4. Number of sex partners they have

5. Patients’ sexual orientation or the sex of their sex partners

6. Types of sex that they have (vaginal, anal, oral)

PRP_INTRO

The next questions must be answered by Dr. X (fill last name or greet name) who is the sampled CHC provider. They ask specifically about Dr. X’s (fill last name or greet name) experience with HIV-prevention using PrEP (pre-exposure prophylaxis).

1. Enter 1 to Continue-SKIP to PRPHRD

PRPHRD

◊ (The following question must be answered by the sampled CHC provider.)

Have you heard of PrEP (pre-exposure prophylaxis) to prevent HIV infection?

1. SKIP to PRPEFF

2. No-SKIP to CLASTRAIN [end section]

◊ (The following question must be answered by the sampled CHC provider.)

Please indicate whether you agree or disagree with the following statements about PrEP.

	1. Disagree	2. Agree	3. Don’t know
PrEP is effective for HIV prevention. [PRPEFF]
PrEP use will result in an increase in risky sexual behavior and sexually transmitted infections. [PRPRSB]
PrEP will lead to drug resistance if a patient gets infected while taking PrEP. [PRPDR]
Most patients will have difficulty affording PrEP regardless of their insurance status. [PRPAFF]
Most patients will have difficulty adhering to daily dosing of PrEP. [PRPADH]

	1. Yes		2. No
One or more of my patients have asked for PrEP. [PRPASK]
One or more of my patients have declined PrEP [PRPDEC]

PRPRX

◊ (The following question must be answered by the sampled CHC provider.)

Have you prescribed PrEP?

1. Yes CLASTRAIN [end section]

2. No-Go to PRPWHY

PRPWHY

◊ (The following question must be answered by the sampled CHC provider.)

Why have you not prescribed PrEP? (Mark all that apply):

1. I do not have any patients at high risk of acquiring HIV infection.

2. Prescribing PrEP is outside my scope of practice.

3. I do not have enough information about PrEP to prescribe it.

4. I am uncomfortable prescribing antiretroviral medications.

5. I refer my patients to another provider or clinic for PrEP.

6. My patients have not asked for PrEP.

7. I have offered PrEP to one or more of my patients but they have declined.

8. PrEP is not effective for HIV prevention.

9. PrEP use will cause an increase in risky sexual behavior and sexually-transmitted infections in my patients.

10. PrEP will lead to drug resistance if my patients get infected while taking PrEP.

11. My patients will have difficulty affording PrEP, regardless of their insurance status.

12. My patients will have difficulty adhering to daily dosing of PrEP.

13. Other (Prompt text field for response)

National CLAS Standards Questions

CLASTRAIN

(The following two questions must be answered by the sampled provider.) Within the past 12 months, have you participated in any cultural competence training?

1. Yes

2. No

CLASKNOW

(The following question must be answered by the sampled provider.) How familiar are you with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards)?

1. Never heard of it

2. Heard of it but do not know much about it

3. Know something about it

4. Very familiar with it

ALCOHOL_INTRO

The next set of questions are only administered to primary care providers and seeks to determine the extent to which alcohol screening and brief intervention (SBI) is being conducted within their practices.

ALCSCREEN

Screening for alcohol misuse (excessive consumption and alcohol-related problems) is often conducted in clinical settings. How do you screen for alcohol misuse?

1. I don’t screen

2. T-ACE

3. TWEAK

4. CAGE

5. CRAFFT

6. AUDIT

7. Ask number of drinks per occasion

8. Ask frequency of drinking

9. Ask binge question

10. I don’t use a formal screening instrument

11. Other (specify) ALCSCREENOTH

ASCREENOFT

How often do you screen for alcohol misuse?

1. At every health maintenance visit (annually)

2. At every health care visit

3. When I suspect a patient has a substance/alcohol-related problem

4. Almost never or never

ASCREENADM

How are screening question(s) administered?

3. Interview

4. Patient completes a form

5. Electronic

6. Other (specify) ASCREENADMOTH

ASCREENWHO

If patient is interviewed, who administers the screening?

1. Physician, nurse practitioner, physician assistant

2. Nurse, excluding nurse practitioner

3. Medical assistant

4. Administrative staff

5. Other (specify) ASCREENWHOTH

ABRFINTERV

Brief interventions for risky alcohol use are short discussions with patients who drink too much or in ways that are harmful. These interventions typically include some of the following elements:

• Feedback on screening results

• Gathering further information on drinking patterns, alcohol-related harm, or symptoms of alcohol dependence

• Discussing the risks and consequences of drinking too much

• Providing advice about cutting back or stopping

Among patients who screen positive for risky alcohol use, how often are brief interventions conducted?

1. Never

2. Sometimes

3. Often

4. Always

ARESOURCE

What resources would be helpful in implementing alcohol/substance screening and intervention in primary care settings? (Select all that apply)

1. Implementation guide for alcohol screening and intervention

2. Training on how to conduct alcohol screening

3. Training on how to conduct intervention

4. Office-based mentoring

5. Access to patient education materials

6. Scripts on what to say to patients

7. Information about reimbursement for services

8. Information about where or how to refer for additional services

9. Other (specify) ARESOURCEOTH

MOSTVIS_INTRO

The next section refers to characteristics of the sampled CHC.

NUMPH

(one location listed)

The next questions are about the CHC that is associated with [Pre-fill location].

How many physicians, including you are associated with this CHC?

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

NUMPH

(two or more locations listed)

N/A

PCMH

Is the CHC at this location certified as a patient-centered medical home?

1. Yes

   1. If yes, by whom CERT_WHO

      1. The Accreditation Association for Ambulatory Health (AAAH)

      2. The Joint Commission

      3. The National Committee for Quality Assurance (NCQA)

         1. [If yes:]  What level of certification? NCQAlevel

            1. Level 1

            2. Level 2

            3. Level 3

      4. Utilization Review Accreditation Commission (URAC)

      5. Other – Specify PCMH_OTH____________

      6. Unknown

2. No

3. Unknown  

ACCESS

Is it possible within the CHC at this location to access patient medical records using an electronic health record (EHR) system 24 hours a day?

1. Yes ACCESS_PH

   1. [If yes:] Is this access available to physicians only, or is it also available to other non-physician clinicians? 

1. Physicians (MD/DO) only.

2. All Physicians and non-physician Clinicians.

3. Unknown

2. No

3. Unknown

PMETHOD

What is the primary method by which the CHC at this location receives information about patients in this CHC when they have been seen in the emergency department or hospitalized? (Mark only one box)

1. Electronic transmission (i.e., EHR or EMR)

2. Fax

3. Email

   1. [If yes:] Was this email sent over a secure network? SECNET

1. Yes

2. No

3. Unknown

4. Telephone or in-person communication with provider

5. Paper copy

6. Other PMETHOD_SP

TRANS

Is someone in the CHC at this location responsible for assisting patients to safely transition back to the community within 72 hours of being discharged from a hospital or nursing home?

1. Yes

2. No

3. Unknown

PROTO

Does the CHC at this location have written protocols for providing chronic care services that are used by all members of the care team?

1. Yes

2. No

3. Unknown

QUAL

Does the CHC at this location report any quality measures or quality indicators to either payers or to organizations that monitor health care quality?

1. Yes

2. No

3. Unknown

DIFTIN

Do all other locations or offices associated with the CHC at this location use the same Federal Tax ID, also known as an Employer Identification Number (EIN), or do any locations or offices associated with the CHC at this location use a different Federal Tax ID or EIN?

1. All use the same Federal Tax ID or EIN

2. Some use a different Federal Tax ID or EIN

3. Unknown 

Staffing Types

(34 variables)

The next set of questions refer to the types of providers who work at [Pre-fill location].

How many of the following full-time and part-time providers are on staff at [Pre-fill location]?

Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.

Please provide the total number of full-time and part-time providers.

Please include the sampled provider in the total count of staff below.

Type of Provider	Number Full-time (≥30 hours)	Number Part-time (<30 hours)
Physicians (MD and DO)	MD_DO_FT	MD_DO_PT
Non-Physician Clinicians
Physician Assistants (PA)	PA_FT	PA_PT
Nurse Practitioners (NP)	NP_FT	NP_PT
Certified Nurse Midwives (CNM)	CNM_FT	CNM_PT
Clinical Nurse Specialist	CNS_FT	CNS_PT
Nurse Anesthetists	NA_FT	NA_PT
Other Nursing Care
Registered nurses (RN) (not an NP or CNM)	RN_FT	RN_PT
Licensed Practical Nurses (LPN)	LPN_FT	LPN_PT
Certified Nursing Assistants/Aides (CNA)	CNA_FT	CNA_PT
Allied Health
Medical Assistants (MA)	MA_FT	MA_PT
Radiology Technicians (RT)	RT_FT	RT_PT
Laboratory Technicians (LT)	LT_FT	LT_PT
Physical Therapists (PT)	PT_FT	PT_PT
Pharmacists (Ph)	PH_LT	PH_PT
Dieticians/Nutritionists (DN)	DN_FT	DN_PT
Other
Mental Health Providers (MH)	MH_FT	MH_PT
Health Educators/Counselors (HEC)	HEC_FT	HEC_PT
Case Managers (not an RN)/Certified Social Workers (CSW)	CSW_FT	CSW_PT
Community Health Workers (CHW)	CHW_FT	CHW_PT

Tasks performed (13 variables)

At [Pre-fill location], which type of provider most commonly performs the following tasks?  Enter all that apply.

The providers listed are generated from the previous staffing question. If any providers in your office are missing, please go back to the staffing question and check the appropriate box(es).

Based on the staff selected in Question 32, a checkbox answer list of staffing types will be made available for each of the following questions A-M, but will only contain those selected providers as well as “Task is not performed in this office” and “Unknown”.
A.      Records body measurements (such as height and weight) and vital signs (such as BP, temperature, heart rate)	Task_Body
B.      Performs office-based testing such as EKG and hearing/vision testing (do not include laboratory testing)	Task_Test
C.      Draws blood for lab testing	Task_Blood
D.      Provides immunizations (includes both childhood and adult)	Task_Immun
E.       Conducts cancer screenings ( such as breast, cervical, and prostate screenings)	Task_Screen
F.       Provides behavioral health screenings (such as depression, alcohol and substance abuse)	Task_Behav
G.      Provides counseling services (such as diet/nutrition, weight reduction, tobacco cessation, stress management)	Task_Counsel
H.      Manages the routine care of patients with chronic conditions (such as hypertension, asthma, diabetes)	Task_Rout
I.        Writes refill prescriptions for medications	Task_Refill
J.        Enters patient information into medical/billing records	Task_Enter
K.      Performs imaging tests (such as X-rays and ultrasounds)	Task_Image
L.       Make referrals (for example, to specialty care, or to community-based services)	Task_Ref
M.     Contacts patients, who are transitioning from hospital or nursing home back to the community	Task_Contacts

Autonomy of PAs, NPs, and CNMs (15 variables)

The following questions concern the PAs, NPs, and CNMs practicing at [Pre-fill location].

A.      Physician Assistant	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are PA(s) supervised by someone on-site? PA_SUP
Do you sign-off on the medical records of the patients the PA(s) see(s)? PA_SIGN
Do the PA’s patients have a separate log from your patients? PA_LOG
Is your approval required before the PA(s) prescribe(s) medication? PA_APPROVAL
Do/does the PA(s) bill for services using their own NPI number? PA_BILL
B.      Nurse Practitioner	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are NP(s) supervised by someone on-site? NP_SUP
Do you sign-off on the medical record of the patients the NP(s) see(s)? NP_SIGN
Do the NP’s patients have a separate log from your patients? NP_LOG
Is your approval required before the NP(s) prescribe(s) medication? NP_APPROVAL
Do/does the NP(s) bill for services using their own NPI number? NP_BILL
C.      Certified Nurse Midwife	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are CNM(s) supervised by someone on-site? CNM_SUP
Do you sign-off on the medical record of the patients the CNM(s) see(s)? CNM_SIGN
Do the CNM’s patients have a separate log from your patients? CNM_LOG
Is your approval required before the CNM(s) prescribe(s) medication? CNM_APPROVAL
Do/does the CNM(s) bill for services using their own NPI number? CNM_BILL
D. Clinical Nurse Specialist	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Do the CNS's patients have a separate log from your patients? CNS_LOG
Do/Does the CNS(s) bill for services using their own NPI number? CNS_BILL
E. Nurse Anesthetists	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Do the NA's patients have a separate log from your patients? NA_LOG
Do/Does the NA(s) bill for services using their own NPI number? NA_BILL

ELECTRONIC HEALTH RECORDS QUESTIONS

EMR_INTRO

Answer ALL remaining questions for the current CHC location, which is [Pre-fill].

EBILLREC

Does the CHC reporting location submit any claims electronically (electronic billing)?

1. Yes

2. No

3. Unknown

EMEDREC

Does the CHC reporting location use an electronic health record (EHR) or electronic medical record (EMR) system? Do not include billing record systems.

1. Yes, all electronic

2. Yes, part paper and part electronic

3. No

4. Unknown

EHRINSYR

In which year did the CHC install your current EHR/EMR system?

HHSMU

Does the CHC’s current system meet meaningful use criteria as defined by the Department of Health and Human Services?

1. Yes

2. No

3. Unknown

EHRNAM

What is the name of the CHC’s current EHR/EMR system?

1. Allscripts

2. Amazing Charts

3. athenahealth

4. Cerner

5. eClinicalWorks

6. e-MDs

7. Epic

8. GE/Centricity

9. Greenway Medical

10. McKesson/Practice Partner

11. NextGen

12. Practice Fusion

13. Sage/Vitera

14. Other-Specify EHRNAMOTH

15. Unknown

SECURCHCK

Has the CHC made an assessment of the potential risks and vulnerabilities of your electronic health information within the last 12 months? This would help identify privacy or security related issues that may need to be corrected.

1. Yes

2. No

3. Unknown

DIFFEHR

Does the CHC’s EHR have the capacity to electronically send health information to another provider whose EHR system is different from the CHC’s system?

1. Yes

2. No

3. Unknown

EMRINS

At the CHC reporting location are there plans for installing a new EHR/EMR system within the next 18 months?

1. Yes

2. No

3. Maybe

4. Unknown

MUINC

Medicare and Medicaid offer incentives to CHCs that demonstrate “meaningful use of health IT.” At the CHC reporting location, are there plans to apply for Stage 1of these incentive payments?

MUSTAGE2

Are there plans to apply for Stage 2 incentive payments?

1. Yes

2. No

3. Maybe

4. Unknown

EDEMOG EPROLST

EVITAL

ESMOKE

EPNOTES

EMEDALG

EMEDID

EREMIND

ECPOE

ESCRIP

EWARN

ECONTRSUB

EFORMULA

ECONTRSUBS

ECTOE

EORDER

ERESULT

EGRAPH

ERADI

EIMGRES

EPTEDU

ECQM

EIDPT

EGENLIST

EIMMREG

EDATAREP

ESUM

EMSG

EPTREC

Please indicate whether the CHC reporting location has each of the following computerized capabilities and how often these capabilities are used.

These 5 answer choices are for each of the following items a-u.

1. Yes, used routinely

2. Yes, but NOT used routinely

3. Yes, but turned off or not used

4. No

5. Unknown

1. Recording patient history and demographic information?

2. Recording patient problem list?

3. Recording and charting vital signs?

4. Recording patient smoking status

5. Recording clinical notes?

6. Recording patient’s medications and allergies?

7. Reconciling lists of patient medications to identify the most accurate list?

8. Providing reminders for guideline-based interventions or screening tests?

9. Ordering prescriptions?

1. If Yes, ask – Are prescriptions sent electronically to the pharmacy?

2. If Yes, ask – Are warnings of drug interactions or contraindications provided?

3. If Yes, ask – Are drug formulary checks performed?

10. Do you prescribe controlled substances?

1. If Yes, ask Are prescriptions for controlled substances sent electronically to the pharmacy?

11. Ordering lab tests?

1. If Yes, ask – Are orders sent electronically?

12. Viewing lab results?

1. If yes, ask – Can the EHR/EMR automatically graph a specific patient’s lab results over time?

13. Ordering radiology tests?

14. Viewing imaging results?

15. Identifying educational resources for patients’ specific conditions?

16. Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

17. Identifying patients due for preventive or follow-up care in order to send patients reminders?

18. Providing data to generate lists of patients with particular health conditions?

19. Electronic reporting to immunization registries? Providing data to create reports on clinical care measures for patients with specific chronic conditions (e.g. HbA1c for diabetics)?

20. Providing patients with clinical summaries for each visit?

21. Exchanging secure messages with patients?

22. Providing patients the ability to view online, download, or transmit information from their medical record?

REFOUT

Do you refer any of your patients to providers outside of the CHC? Electronic does not include fan, eFax, or mail.

1. Yes

2. No

REFOUTHOW

How do you send patient health information to them?

1. Electronically

2. Via paper-based methods

3. We do not send patient health information to the provider

REFOUTS

^DoDoes (you/physician's name) send the patient's clinical information to the other providers?

1. Yes, routinely

2. Yes, but not routinely

3. No

REFOUTSE

^DoDoes (you/physician's name) send it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

REFIN

^DoDoes (you/provider’s name) see patients from providers outside of the CHC? Electronic does not include fan, eFax, or mail.

1. Yes

2. No

REFINHOW

How do you receive patient health information from them? Check all that apply.

1. Electronically

2. Via paper-based methods

3. Do not send patient health information to the provider

REFINS

^DoDoes (you/physician's name) send a consultation report with clinical information to the other providers?

1. Yes, routinely

2. Yes, but not routinely

3. No

REFINSE

^DoDoes (you/physician's name) send it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

INPTCARE

^DoDoes (you/physician's name) take care of patients after they are discharged from an inpatient setting?

1. Yes

2. No

DISSUM

^DoDoes (you/physician's name) receive a discharge summary with clinical information from the hospital?

1. Yes, routinely

2. Yes, but not routinely

3. No

DISSUME

Do you receive it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

INCORINFO

Can you automatically incorporate the received information into the CHC’s EHR system without manually entering the data?

1. Yes

2. No

3. Not applicable, I do not have an EHR system

ESHARE

The next questions are about sharing (either sending or receiving) patient health information.

Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

Electronically does not include scanned or pdf documents, fax, eFax, or mail.

1. Yes

2. No

ESHARES

Do you electronically send patient health information to another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

ESHARER

Do you electronically receive patient health information from another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

ESHAREHOW

How do you electronically share patient health information?

       Enter all that apply, separate with commas

1. EHR/EMR

2. Web portal (separate from EHR/EMR)

3. Other electronic method (not fax) ESHAREHOWOTH

EDISCHSR

Do you electronically send or receive hospital discharge summaries to or from providers outside of your medical organization? Check all that apply.
    

1. Send electronically

2. Receive electronically

3. Do not send or receive

EEDSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of your medical organization? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

ESUMCSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of your medical organization? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

PTONLINE

Can patients seen at the reporting location do the following online activities? Check all that apply.
    

1. View their medical record online

2. Download and transmit health information in the electronic medical record to their personal files

3. Request corrections to their electronic medical record

4. Enter their health information online (e.g. weight, symptoms)?

5. Upload their data from self-monitoring devices (e.g. blood glucose readings)?

EHRTOEHR

Is the patient health information that you share electronically sent directly from the CHC’s EHR system to another EHR system?

[Pre-filled location is displayed.]

1. Yes, routinely

2. Yes, but not routinely

3. No

4. Unknown

ESHAREPROV

With what types of providers do you electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)?

1. Ambulatory providers inside your office/group

2. Ambulatory providers outside your office/group

3. Hospitals with which you are affiliated

4. Hospitals with which you are not affiliated

5. Behavioral health providers

6. Long-term care providers

7. Home health providers

EOUTINFO

Are you/your staff able to electronically find health information (e.g. medications, outside encounters) from sources outside of the CHC for your patients? Please reference (fill location), which is the current CHC location.

Enter all that apply.

1. Yes routinely

2. Yes, but not routinely

3. No

4. Unknown

EOUTHOW

EOUTOSP

If Yes to EOUTINFO, How do you look up patient health information from sources outside of the CHC? Please reference (fill location), which is the current CHC location.

Enter all that apply.

1. Through your EHR/EMR

2. Web portal (separate from EHR/EMR)

3. View only or restricted access to other providers’ EHR system

4. Other electronic method (not fax) EOUTOSP

EOUTYP

EOUTYPSP

What types of information do you routinely look up?

Enter all that apply.

1. Lab results

2. Imaging reports

3. patient problem lists

4. Medication lists

5. Other EOUTYPSP

EOUTINCORP

Do you or your staff routinely incorporate the information you look up into your EHR?

1. Yes, via manual entry or scanned copy

2. Yes, automatically able to incorporate without manual entry or scanning

3. No, we do not routinely incorporate into our EHR

EDISCHSR

Do you electronically send or receive hospital discharge summaries to or from providers outside of the CHC? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

EEDSR

Do you electronically send or receive Emergency Department notifications to or from providers outside of the CHC? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

ESUMCSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of the CHC? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

PTONLINE

Can patients seen at the CHC do the following online activities? Check all that apply.

1. View their medical record online

2. Download and transmit health information in the electronic medical record to their personal files

3. Request corrections to their electronic medical record

4. Enter their health information online (e.g. weight, symptoms)?

5. Upload their data from self-monitoring devices (e.g. blood glucose readings)?

Revenue & Contracts, Compensation, New Patients

PRMCARE PRMAID

PRPRVT

PRPATPAY

PROTH

Please remind physician/provider that the remaining questions refer to the current CHC location, which is [Pre-fill-in location].

I would like to ask a few questions about the current CHC’s revenue and contracts with managed care plans.

Roughly, what percent of (your/Physician name's) patient care revenue comes from –

1. Medicare?

2. Medicaid?

3. Private insurance?

4. Patient payments

5. Other (including charity, research, Tricare, VA, etc.)?

PCTRVMAN

Roughly, what percent of the patient care revenue received by this CHC comes from managed care contracts?

REVFFS

REVCAP

REVCASE

REVOTHER

Roughly, what percent of (your/Physician name's) patient care revenue comes from each of the following methods of payment?

1. Fee-for-service?

2. Capitation?

3. Case rates  (e.g., package pricing/episode of care)?

4. Other?

ACEPTNEW

(Are/Is) (you/physician's name) currently accepting "new" patients into the CHC at [Fill-in location]?

1. Yes

2. No

3. Don’t know

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those "new" patients, which of the following types of payment (do/does) (you/physician's name) accept at [Fill-in location]?

1. Capitated private insurance?

2. Non-capitated private insurance?

3. Medicare?

4. Medicaid?

5. Workers’ compensation?

6. Self-pay?

7. No charge?
   
   

The following answer choices are used for each of the above seven payment types:

1. Yes

2. No

3. Don’t know

PHYSCOMP

Which of the following methods best describes your basic compensation?

Bold answer choices & add FR instruction to prompt them to read answers aloud.

1. Fixed salary

2. Share of practice billings or workload

3. Mix of salary and share of billings or other measures of performance (e.g., your own billings, practice's financial performance, quality measures, practice profiling)

4. Shift, hourly or other time-based payment

5. Other

COMP

CHCs may take various factors into account in determining the compensation (salary, bonus, pay rate, etc.) paid to the physicians/providers in the CHC.  Please indicate whether the CHC explicitly considers each of the following factors in determining your compensation. 
  Enter all that apply, separate with commas

1. Factors that reflect your own productivity

2. Results of satisfaction surveys from your own patients

3. Specific measures of quality, such as rates of preventive services for your patients

4. Results of practice profiling, that is, comparing your pattern of using medical resources with that of other physicians

5. The overall financial performance of the practice

SASDAPPT

Does the CHC set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

Skip Instructions:

1. Goto SDAPPT

2. SKIP to APPTTIME

SDAPPT

Roughly, what percent of (your/Physician name's) daily visits are same day appointments?

APPTTIME

On average, about how long does it take to get an appointment for a routine medical exam?

1. Within 1 week

2. 1 - 2 weeks

3. 3 - 4 weeks

4. 1 - 2 months

5. 3 or more months

6. Do not provide routine medical exams

7. Don't know

PRVBYEAR

What is (your/Physician name's) year of birth?

PRVSEX

What is (your/Physician name's) sex?

1. Female

2. Male

PRVDEGR

What is (your/Physician name's) highest medical degree?

1. MD

2. DO

3. Nurse practitioner

4. Physician assistant

5. Nurse midwife

6. Other

PRVPSPEC PRVPSPEC_SP

What is (your/Physician name's) primary specialty?

Enter verbatim response for specialty

PRVSSPEC PRVSSPEC_SP

What is (your/Physician name's) secondary specialty?
Enter verbatim response for specialty

PRVPBC

What is (your/Physician name's) primary board certification?

PRVSBC

What is (your/Physician name's) secondary board certification?

PRVYRGRD

What year did (you/physician's name) graduate from medical school?

PRVFMS

Did (you/physician's name) graduate from a foreign medical school?

1. Yes

2. No

PHY_UNAVAIL

Thank you for your time and cooperation ^RESPNAME_FILL.  The information you provided will improve the accuracy of the NAMCS in describing office-based patient care in the United States.

I will call you on Monday, (Reporting period begin date) to see if your plans have changed.
If you have any questions (Hand respondent your business card) please feel free to call me.

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