As mentioned in section A1, the questions that will be asked of the additional physicians in the pilot as well as those in the “live” data collection will be the same as those in the Physician Induction Interview (PII) of the core NAMCS. Slight changes will be made to account for the different collection method (mail versus personal interview). The mail version is, by design, self administered, where as the core NAMCS questions are asked via a personal interview. As also mentioned before, only a subset of the questions from the PII will be used as they relate to the characteristics of the physician’s practice.
The subgroup of questions from the PII are as follows and may be further modified to account for self-reporting by physicians:
1. Is your specialty ___________________?
1 □ Yes – SKIP to item 8
2 □ No – What is your specialty (including general practice)?
_________________________________________
2. Which of the following categories best describes your professional activity?
1 □ Patient care
2 □ Research
3 □ Teaching
4 □ Administration
5 □ Other - Specify ____________________________
3. Do you directly care for any ambulatory patients in your work?
1 □ Yes – SKIP to item 4a
2 □ No
3 □ No longer in practice – SKIP to closing
3c. Are you employed by the Federal Government or do you work in a hospital emergency or outpatient department?
1 □ Yes
2 □ No – SKIP to item 4a
3d. In addition to working in any of these settings, do you also see any ambulatory patients?
1 □ Yes
2 □ No – SKIP to closing
The following questions are concerned with the private patients.
4a. We have your office address as:
[PRE-PRINTED ADDRESS WILL BE PLACED HERE].
Is this correct?
1 □ Yes – SKIP to item 14
2 □ No, incorrect address – Ask item 4b
4b. What is the (correct) address and telephone number of your office?
Number and Street ________________________________________
City __________________________ State ____ Zip Code _____
Telephone (Area Code and number) __________________________
5a. Overall, at how many office locations do you see ambulatory patients? ___________________
5b. In a typical year, about how many weeks do you NOT see any ambulatory patients because of such events as conferences, vacations, etc.? _____________
If the number of weeks is greater than 26, go to item 5c.
If the number of weeks is equal to 0, SKIP to item 5d.
If the number of weeks is greater than 1, but less than 26, SKIP to item 6a.
5c. Based on your answer to item 5b, is it true you typically see patients fewer than half of the weeks in each year?
1 □ Yes – SKIP to item 6
2 □ No – Please explain ________________________ SKIP to item 6
5d. Based on your answer to item 5b, is it true that you typically see patients all 52 weeks of the year?
1 □ Yes
2 □ No – Please explain _______________________________________
6a. Of the office types listed below, please circle the location where you have the most ambulatory care visits,
If none of your practice locations are one of the types shown below please go to the closing [this will be updated])–
If the location where you see most ambulatory care visits is not located at the address where this survey was sent, that’s fine, please still report on the location where you see the most ambulatory care visits.
If you work at only one location, report on that one location.
Private solo or group practice
Freestanding clinic/urgicenter (not part of a hospital outpatient department)
Community health center (e.g., Federally Qualified Health Center (FQHC), federally funded clinic or “look alike” clinic)
Mental health center
Non-federal government clinic (e.g., state, county, city, material and child health, etc.)
Family planning clinic (including Planned Parenthood)
Health maintenance organization or other prepaid practice (e.g., Kaiser Permanente)
Faculty Practice Plan
INSTRUCTION: For questions 7a through 8f, please answer as it applies to the location where you see the most ambulatory care visits even if it is not the location where this survey was sent.
7a. During your last normal week of practice, approximately how many office visit encounters did you have at the location where you see the most ambulatory care visits? ___________ NOTE: If you are in a group practice, only report on your visits.
8a. Is the location where you see the most ambulatory care visits a solo practice, or are you associated with other physicians in a partnership, in a group practice, or in some other way?
Solo…………….1 □ SKIP to item 8d
Nonsolo………...2 □
8b. How many physicians are associated with you at the location where you see the most ambulatory care visits? _________________
8c. Is the location where you see the most ambulatory care visits a single- or multi-specialty (group) practice
Multi………… 1 □
Single………… 2 □
8d. How many mid-level providers (i.e., nurse practitioners, physician assistants, and nurse midwives) are associated with you at the location where you see the most ambulatory care visits? ___________________
8e. At the location where you see the most ambulatory care visits, are you a full- or part-owner, employee, or an independent contractor?
Owner……………1 □
Employee………..2 □
Contractor………...3 □
INSTRUCTION: If “Owner” is marked then automatically mark“Physician or physician group” in item 18f.
8f. Who owns the practice at the location where you see the most ambulatory care visits?
Physician or physician group…….. 1 □
HMO……………………………... 2 □
Community Health Center……….. 3 □
Medical/ Academic health center… 4 □
Other hospital…………………….. 5 □
Other health care corp……………. 6 □
Other……………………………… 7 □
9. During your last normal week of practice, about how many encounters of the following type did you make with patients?
Nursing home visits…………………………. ____________
Other home visits……………………………. ____________
Hospital visits……………………………….. _____________
Telephone consults………………………….. _____________
Internet/e-mail consults……………….…….. _____________
10. At the location where you see the most ambulatory care visits, does your practice submit claims electronically (Electronic billing)?
1 □ Yes, all electronic
2 □ Yes, part paper and part electronic
3 □ No
4 □ Don’t know
11a. At the location where you see the most ambulatory care visits, does your practice use electronic MEDICAL RECORDS (not including billing records)?
1 □ Yes, all electronic
2 □ Yes, part paper and part electronic
3 □ No
4 □ Don’ know
11b. At the location where you see the most ambulatory care visits, does your practice have a computerized system for…
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Yes |
No |
Unknown |
Turned off |
1. Patient demographic information? |
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If yes, does this include patient problem list? |
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2. Orders for prescriptions? |
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If yes, (a) Are there warnings of drug interactions or contraindications provided? |
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(b) Are prescriptions sent electronically to the pharmacy? |
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3. Orders for tests? |
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If yes, are orders sent electronically? |
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4. Viewing Lab results? |
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If yes, are out range levels highlighted? |
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5. Viewing Imaging results? |
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If yes, are electronic images returned? |
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6. Clinical notes? |
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If yes, (a) do they include medical history and follow up notes? |
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(b) Reminders for guideline-based interventions and/or screening tests? |
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7. Public health reporting? |
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If yes, are notifiable diseases sent electronically? |
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12. Are there any of the above features of your system that you do NOT use or have turned off?
1 □ Yes – Please specify _____________________________________
2 □ No
3 □ Unknown
13. At the location where you see the most ambulatory care visits, are there plans for installing a new EMR system or replacing the current system within the next 3 years?
1 □ Yes
2 □ No
3 □ Maybe
4 □ Unknown
14a. At the location where you see the most ambulatory care visits, roughly, what percent of your patient care revenue comes from?
Medicare? ________ %
Medicaid? ________ %
Private insurance? ________ %
Patient payments? _________ %
Other (including charity, research, CHAMPUS, VA, etc.) _______%
14b. At the location where you see the most ambulatory care visits, roughly, how many managed care contracts does this practice have such as HMOs, PPOs, IPAs, and point-or-service plans?
1 □ None
2 □ Less than 3
3 □ 3 to 10
4 □ More than 10
14c. At the location where you see the most ambulatory care visits, roughly, what percentage of the patient care revenue received by this practice comes from (these) managed care contracts? _________ %
15a. At the location where you see the most ambulatory care visits, which of the following factors are taken into account for your patient care compensation (e.g., base pay, bonuses, or withholds)?
Your productivity (e.g., number of cases seen per time period)?
1 □ Yes
2 □ No
3 □ Don’t know
Patient satisfaction (e.g., results of patient surveys)?
1 □ Yes
2 □ No
3 □ Don’t know
Quality of care (e.g., rates of preventive care services)?
1 □ Yes
2 □ No
3 □ Don’t know
Practice profiling (patterns of using certain services, e.g., laboratory tests, imaging, referrals, etc.)?
1 □ Yes
2 □ No
3 □ Don’t know
15b. At the location where you see the most ambulatory care visits, are performance measures on your practice available to the public?
1 □ Yes
2 □ No
3 □ Don’t know
16. At the location where you see the most ambulatory care visits, what percent of your patient care revenue is based on bonuses, returned withholds, or other performance-based payments? _____________ %
17. At the location where you see the most ambulatory care visits, roughly, what percent of your patient care revenue comes from each of the following methods of payment?
(1) Usual, customary and reasonable fee-for-service? _________ %
(2) Discounted fee for service? _________ %
(3) Capitation? _________ %
(4) Case rates (e.g., package pricing/episode of care)? __________ %
(5) Other? __________ %
| File Type | application/msword |
| Author | ziy6 |
| Last Modified By | ziy6 |
| File Modified | 2007-08-22 |
| File Created | 2007-08-22 |