Namcs 10-12 OMB Att V

ATTACHMENT V
Justification for Changes to NAMCS Annual
Survey to Collect State-level EMR/EHR data
for ONC

Justification for Changes to NAMCS Annual Survey
To Collect State-level EMR/EHR data for ONC

The Office of the National Coordinator for Health Information Technology (ONC) relies on the
National Center for Health Statistics’ (NCHS) National Ambulatory Medical Care Survey
(NAMCS) data to measure the annual rate of adoption of electronic medical records
(EMRs)/electronic health records (EHRs) by United States physicians.
NCHS and ONC work closely each year to include a subset of questions on the NAMCS that
ONC uses to estimate the national rate of adoption. A core set of questions helps to measure
adoption of key functionalities of an EMR/EHR system. Each year, a small subset of questions
on the survey is modified or revised to improve question wording as well as address relevant
policy issues such as the major barriers to EHR adoption. This information provides a critical
national picture of physician attitudes and behavior regarding health information technology.
Although NAMCS is nationally representative and conducted through in-person interviews, the
annual sample size of NAMCS is not sufficient for ONC to estimate national EMR/EHR
adoption. Therefore, for the past couple of years, NCHS has supplemented the data collected by
the core NAMCS with a mail survey of additional physicians. The mail supplement has been
funded by ONC through an Interagency Agreement. By combining the results of the mail survey
and the in-person core NAMCS, NCHS provides ONC with national EMR/EHR adoption rate
estimates. However, because of the need to merge these disparate data sources, the final results
are not available until approximately 12 months after the end of the calendar year for the year in
which the data are collected. In other words, the 2008 data results were not final until late 2009.
With the implementation of the Health Information Technology for Economic and Clinical
Health (HITECH) Act, ONC requires a faster turn around to calculate the national rate of
adoption. In addition, HITECH requires ONC to initiate a number of local and state programs
including grants to states to support information exchange and the funding of extension centers,
which will provide hands-on technical assistance regarding adoption of EHRs in a defined
geographic area. The extension centers have been directed to prioritize their efforts to focus on
primary care providers. With the implementation of these new programs, it is important that
ONC be able to look at rates of adoption by state and provider specialty. These data will help
identify which regional extension center programs have been successful in getting more
providers to adopt EMR/EHR, and in measuring adoption among primary care physicians. This
will be useful both in accomplishing program goals as well as identifying which strategies
employed by extension centers have been most successful.
In order to address these needs, ONC asked NCHS to increase the sample size to allow for state
and provider specialty estimates of EMR/EHR adoption. NCHS conducted power analyses and
determined that a mail survey of approximately 10,300 physicians (a five-fold increase from the
2009 sample) would allow ONC to conduct the types of analyses required to monitor the impact
of HITECH programs on adoption by provider specialty and state. Therefore, employing such a
significantly larger sample for the mail survey eliminated the need to rely on the results of the
core survey. The NAMCS mail survey is planned to be in the field by February 2010, or as soon

as NCHS receives clearance to begin. The data will provide the baseline data needed to monitor
conversion to EMR/HER after the implementation of state grants and regional extension
programs. NCHS has shortened the time frame to produce the data by improving some
procedures for data processing, including receiving survey data on a flow basis from the
contractor. As a result, the projected data release date has changed from fall to late summer.
The distribution of the first grant funds is not dependent on these data, but the earliest provision
of estimates is still important. It is anticipated that increases in the use of EMR/EHR might be
seen as early as the 4th quarter of 2010. ONC has already put a line item into its budget for the
next several years to continue to support NCHS in conducting a mail survey of the NAMCS to
monitor trends in the uptake of physician’s use of electronic records. Thus, the clearance will
represent three mail surveys between 2010 and 2012.
NAMCS data will not be used to inform the distribution of grant funds. However, these data will
be extremely valuable in measuring the progress of the grant programs and evaluating their
impact on state, region and national level. This will be the first state and nationwide estimate of
the types of systems office-based physicians have purchased, the major functionalities of EHRs
available in physician offices, and whether physicians intend to seek eligibility for Medicare or
Medicaid incentive payments. These data will complement rather than duplicate the data that
will be collected by the awardees of the major grant programs.
The regional extension center program will collect data throughout the year, but these data will
be limited because they will only be collected from providers who have agreed to work with the
extension centers, and will present an in-depth but limited view of provider adoption and use of
EHRs. Providers who are not interested in adopting an EHR are unlikely to sign up to work with
an extension center. Likewise, providers who are fairly advanced in their adoption may decide
they do not require the services of an extension center in order to become meaningful users.
Extension center marketing efforts may result in an uneven distribution of providers seeking
services across the service area (for example, targeting small provider practices or those located
in specific suburbs or metropolitan areas). Providers who are not eligible for incentive payments
due to low volume of Medicare or Medicaid patients are also unlikely to seek the services of an
extension center, although they may be using EHRs in some capacity. Extension centers have
also been directed to target primary care physicians, which may limit the number of non-primary
care practices that can receive extension center services.
Another issue raised by the implementation of HITECH was the definition of “Meaningful Use”
of an Electronic Health Record. The definition of “Meaningful Use” will be established in a
Notice of Proposed Rule Making scheduled for publication in December 2009 and a Final Rule
due in late Spring 2010. The rule will be published by Centers for Medicare & Medicaid
Services (CMS), which is working closely with ONC on its development.
Although CMS will be able to measure the percentage of providers who are meaningful users
beginning in 2011, there will be a gap between the publication of the rule and CMS’s data on
which providers have adopted EMR/EHR but not yet achieved meaningful use. It is critical to
obtain baseline estimates in 2010 on the adoption of electronic health records, as this information
will help develop programs and approaches to support providers to become meaningful users in
2011 and beyond. This information will be needed on an annual basis moving forward.

The sampling framework of NAMCS guarantees a representative view of adoption that properly
reflects all physicians regardless of practice size, location, or specialty. It will also provide
national information on adoption levels by primary care versus specialty physician which are not
currently available.
State programs as well as the regional extension center program will begin in January 2010 and
continue for several years. Concurrently the NAMCS 2010 mail survey will be conducted. By
December 2009, there will be a Federal Register Notice of Proposed Rulemaking on the
definition of “meaningful use” and by June 2010, we will have the final definition. Within seven
months of this definition being published, ONC expects to field a second NAMCS mail survey to
document the movement of physicians to adoption of a broader set of electronic medical record
functionalities. The figure below illustrates the general timeline.
Regional Extension Centers
State Grants

ARRA
published

Draft
definition
of 2011
meaningful
use

Final
definition
of 2011
meaningful
use

2010 NAMCS

Proposed
definition
of
meaningful
use for
2013

2011 NAMCS

2012 NAMCS

ONC also identified questions that would gauge provider’s interests in applying for meaningful
use incentive payments, as this information will help inform policy and predict programmatic
input on future rates of adoption. The table below outlines each of the new questions proposed to
be included in the 2010 NAMCS survey, ONC’s rationale/justification for each question, and the
internal goals that the new questions will answer.
The core questions that are used to measure adoption (e.g., questions 19a-h) will not change from
year to year. This will allow us to measure adoption in a standardized format ongoing. Questions
not related to core adoption may change from year to year depending on new policies such as
any legislation related to health IT that may become part of health reform. For example, in
December 2009, the draft definition of meaningful use will be published in the federal register.
It will be valuable to monitor provider adoption in light of the draft definition. In June 2010, the
final definition will be published as a result of public comment. The 2011 NAMCS will help
identify whether changes from the draft to final definition had any impact on provider attitudes
and approaches to health IT adoption. In late 2011, it is likely that a draft definition for 2013
meaningful use (which is expected to be even more advanced than the 2011 definition) will be

released. Providers will need to start addressing these new requirements in 2012. The 2012
NAMCS will help capture physician behavior in response to the revised draft definition.

2010 NAMCS Survey
Question
17a. What year did you
install your EMR/EHR
system?
17b. What is the name of
your current EMR/EHR
system?

19b1. Do clinical notes
include a list of medications
that patient is taking?

19b2. Do clinical notes
include a list of patient
allergies (including allergies
to medications)?

19e1. Are lab results
incorporated into
EMR/EHR?

Rationale for Question

Specific Goal

Will enable retrospective
cohort analysis, and provide
a proxy for reconstructing
adoption velocity
Will provide first definitive
transparency on market
penetration of different
EMR/EHR products, and
permit cross-tabs to examine
whether certain products are
associated with higher levels
of adoption and utilization of
more functionalities
Will help understand which
features of clinical notes are
being used by the provider.
Medication lists are a critical
feature of EMRs/EHRs as
they can be used to look for
potential drug interactions or
use of inappropriate
medications, both associated
with clinical quality
Will help to understand
whether physician is using
clinical notes to document
allergies. This information is
critical to providing quality
care, and is especially
relevant as medication
allergies can be crossreferenced against the list of
current medications to avoid
adverse allergic reactions.
In many cases lab results are
stored separately from the
electronic medical record. A
functional EHR should
incorporate lab results as part
of the comprehensive

Quantify the rate of
adoption

Identify dominant
products in marketplace

Identify critical feature of
EMR/EHR related to
quality of care

Identify critical feature of
EMR/EHR related to
quality

Identify critical feature of
EMR/EHR related to
quality

2010 NAMCS Survey
Question

19h. Electronic reporting to
immunization registries?

20. At the reporting
location, if orders for
prescriptions or lab tests are
submitted electronically,
who submits the order?

21. At the reporting
location, are there plans to
apply for Medicare or
Medicaid incentive
payments for meaningful
use of health IT?

21a. What year do you
expect to apply for the
meaningful use incentive
payments?

21b. What incentive
payment do you plan to

Rationale for Question
medical record. This helps
eliminate errors and
streamlines workflow
processes for the practitioner.
Rewords a previous question
about public health reporting,
but more accurately captures
the intent of the reporting
and which entity receives the
data.
Asks about a critical
EMR/EHR function called
Computerized Provider
Order Entry (CPOE). The
literature has clearly linked
effective use of CPOE with
improved quality.
Will help measure the
potential impact of the
incentive payments by
providing a preliminary
estimate of the number of
providers who are likely to
apply for incentive payments,
as well as the characteristics
of those who are likely to be
left behind.
The incentive payments
decrease over time as the
requirements to be a
meaningful user increase
with each subsequent year.
This question will help us
understand which providers
are seeking the maximum
incentives (beginning in
2011) and which ones are
willing to forgo the earlier
incentives in order to have
more time to implement their
systems.
Physicians can be eligible for
either Medicare or Medicaid

Specific Goal

Identify critical feature of
EMR/EHR related to
public health

Identify critical feature of
EMR/EHR related to
quality

Estimate future levels of
adoption

Estimate future levels of
adoption

Estimate future levels of
adoption

2010 NAMCS Survey
Question
apply for?

Rationale for Question
incentive payments but not
both. Although the Medicaid
incentives will be higher, the
requirements to be a
meaningful user under
Medicaid will be stricter. It
will be useful to know what
percent of providers will seek
Medicaid versus Medicare
incentive payments,
especially for those eligible
for either.

Specific Goal