Form 6 NAMCS EMR/EHR Mail Survey (Line 6)

ATTACHMENT T
NAMCS EMR Supplement 2010

OMB No. 0920-0234: Approval expires 08/31/2009
NOTICE - Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the 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 currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this 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 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).

National Ambulatory Medical Care
Survey (NAMCS):
Electronic Medical Records Supplement 2010
The purpose of the National Study of Electronic Medical Records/Electronic Health Records (EMR/EHR) is to collect
information about physician office practices and the adoption of electronic medical records in ambulatory care settings.
Your participation is greatly appreciated. Your answers are completely confidential. Participation in this survey is
voluntary. If you have questions or comments about this survey, please call 866-635-4515.
1. We have your specialty as
Is that correct?

□1
□2

Yes
No → What is your specialty? _______________________________________

The following questions ask about ambulatory patients. We define ambulatory patients as any patients
coming to see you for personal health services who are not currently on the premises.

2. Do you directly care for any ambulatory patients in
your work?

□1
□2
□3

Yes

Continue to Question 3.

No

Please stop here and
return the questionnaire
in the envelope provided.
Thank you for your time.

I am no longer
in practice

}

3. In a typical year, about how many weeks do you NOT
see any ambulatory patients because of such events
as conferences, vacations, illness, etc.?
__________ weeks

The next set of questions asks about a normal week.
We define a normal week as a week with a normal
case load, no holidays, vacations, or conferences.
4. Overall, at how many office locations do you see
ambulatory patients in a normal week?
__________ locations
5. During your last normal week of practice how
many patient visits did you have at all locations?
__________ visits
6. During your last normal week of practice, about
how many encounters of the following type did
you make with patients?
1. Nursing home visits

__________

2. Other home visits

__________

3. Hospital visits

__________

4. Telephone consults

__________

5. Internet / e-mail consults

__________

7. Do you see ambulatory patients in any of the
following settings? CHECK ALL THAT APPLY.

For the remaining questions, please answer regarding
the reporting location indicated in question 9 even if
it is not the location where this survey was sent.

□1

Private solo or group practice

□2

Freestanding clinic/urgicenter (not part of a
hospital outpatient department)

□3

Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or “look alike” clinics)

□4

Mental Health Center

State

□5

Non-federal Government clinic (e.g., state,
county, city, maternal and child health, etc.)

Zip Code

□6

Family planning clinic (including Planned
Parenthood)

□7

Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)

□8

Faculty Practice Plan

□9

Hospital emergency department

□10

Hospital outpatient department

□11

Ambulatory surgicenter

□12

Institutional setting (school infirmary, nursing
home, prison)

□13

Industrial outpatient facility

□14

Federal Government operated clinic (e.g., VA,
military, etc.)
Laser vision surgery

9. At which of the settings in question 7 do you see the
most ambulatory patients? WRITE THE NUMBER
LOCATED NEXT TO THE BOX YOU CHECKED.
__________

□16

Country

USA

County

Telephone

(

)

-

11. During your last normal week of practice,
approximately how many office visits did you have
at the reporting location? (A normal week would
be one with a normal case load, no holidays,
vacations or conferences.)
Note: Please only include visits where you personally
saw the patient.

8. Do you see ambulatory patients in any of the
following settings? CHECK ALL THAT APPLY.

□15

10. What are the county, state, zip code and telephone
number of the reporting location?

Did not check any boxes
in question 7

__________ office visits
12. Is the reporting location a solo practice, or are you
associated with other physicians in a partnership,
in a group practice or in some other way?

□1
□2

Solo → SKIP to Question 15
Associated with others

13. How many physicians are associated with you at
the reporting location?
__________ physicians
14. Is the reporting location a single- or multispecialty (group) practice?

□1
□2

Single
Multi

15. How many mid-level providers (i.e., nurse
practitioners, physician assistants, and nurse
midwives) are associated with the reporting
location?
__________ mid-level providers

If you only see patients in a reporting location
checked in question 8, please mark box 16 above,
stop and return the questionnaire in the envelope
provided. Thank you for your time.

16. Does the reporting location submit claims
electronically (electronic billing)?

□1
□2
□3
□4

Yes, all electronic
Yes, part paper and part electronic
No
Unknown

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

□1
□2
□3
□4

Yes, all electronic
Yes, part paper and part electronic
No
Unknown

}

Go to Question 17a.

}

Skip to Question 18.

17a. Which year did you install your EMR/EHR system? __________
17b. What is the name of your current EMR/EHR system? CHECK ONLY ONE BOX. IF OTHER IS CHECKED,
PLEASE SPECIFY THE NAME.

□1 Allscripts
□2 Cerner
□3 eClinicalWorks
□4 Eclipsys

□5 Epic
□6 eMDs
□7 GE Centricity
□8 Greenway Medical

□9 HealthPort
□10 McKesson
□11 NextGen
□12 Praxis

□13 Practice One
□14 Sage Intergy
□15 Other______________
□16 Unknown

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

□1Yes □2 No □3 Maybe □4 Unknown
19. Please indicate whether the reporting location has each of the computerized capabilities listed below. CHECK
NO MORE THAN ONE BOX PER ROW. Does the reporting location have a computerized system for:

Yes

19a. Patient history & demographic information?
19a1. If yes, does this include a patient problem list?
19b. Clinical notes?

1
Go to 19a1

□

2
Skip to 19b

□
1□

□
2□

1

Go to 19b1

19b1. If yes, do they include a list of medications that the
patient is taking?
19b2. If yes, does this include a comprehensive list of the
patient’s allergies (including allergies to
medication)?
19c. Orders for prescriptions?

2

Skip to 19c
2

□

2

1

□

1
Go to 19d1
1

19c2. If yes, are prescriptions sent electronically to the
pharmacy?

1

19d1. If yes, are orders sent electronically?

□

□

1

19c1. If yes, are warnings of drug interactions or
contraindications provided?

19d. Orders for lab tests?

Yes, but
turned off
or not
used

4
Skip to 19b

□
3□

□
4□

3

Skip to 19c

3

□

2
Skip to 19e

2

□

□

□

□

1

3
Skip to 19b

3

2

□

Unknown

□

□

1
Go to 19d1

No

□

4

□

3
Skip to 19e

□

3

□

2

Skip to 19c
4

3

□

4

□

□

2
Skip to 19e

□

□
□
□

4
Skip to 19e

□

4

□

4

□

3
Skip to 19e

□

3

□
□
□

4
Skip to 19e

□

4

Yes

□

1
Go to 19e1

19e. Viewing lab results?
19e1. If yes, are results incorporated into EMR/EHR?

19f. Viewing imaging results?

□
1□
1□

2

□

2

□

2

19g. Reminders for guideline-based interventions or
screening tests?

1

19h. Electronic reporting to immunization registries?

1

□1
□2
□3
□4
□5
□6

Prescribing practitioner
Other clinician (including RN)
Lab technician
Administrative personnel
Prescriptions and lab test orders not submitted

electronically
21. Beginning in 2011, Medicare and Medicaid will
offer incentives to practices that have “meaningful
use of Health IT”. At the reporting location, are there
plans to apply for Medicare or Medicaid incentive
payments for meaningful use of Health IT?
Yes, we intend to
apply

□2

Uncertain whether
we will apply

□3

No, we will not
apply

Go to Question 21a.

}

Skip to Question 22.

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

□1
□2
□3
□4

2011
2012

Medicaid
Unknown

□

4
Skip to 19f

3
Skip to 19f

□
2□
2□

3

□

3

□

3

□1
□2
□3

□

□
3□
3□

4

□
4□
4□

□

4

□

4

□
□

Owner (full or part)
Employee
Contractor

□1
□2
□3
□4
□5
□6
□7

Physician or physician group
HMO
Community health center
Medical / academic health center
Other hospital
Other health care corporation
Other

24. At the reporting location, what percent of your
patient care revenue comes from the following?
1. Medicare

%

2. Medicaid

%

3. Private insurance

%

4. Patient payments
5. Other

%

(including charity, research, CHAMPUS,
VA, etc.)

Unknown

Medicare

Unknown

22. Are you a full- or part-owner, employee, or
independent contractor of the reporting
location? CHECK ONE.

After 2012

21b. What incentive payment do you plan to apply
for? CHECK ONE.

□1
□2
□3

No

23. Who owns the reporting location? CHECK ONE.

Other

□1

□

2
Skip to 19f

1

19e2. If yes, are out of range levels highlighted?

20. At the reporting location, if orders for
prescriptions or lab tests are submitted
electronically, who submits them? CHECK ALL
THAT APPLY.

Yes, but
turned off
or not
used

TOTAL

%
100%

25. Who completed this survey?

□1
□2
□3

The physician to whom it was addressed
Office staff
Other

Thank you for your participation. Please return your survey in the envelope provided.
If you have misplaced this envelope, please send the EMR survey to the following address:
2605 Meridian Parkway, Suite 200, Durham, NC 27713-5254