NAMCS - EMR Supplement 2011

Attachment D: NAMCS Electronic Medical Records Supplement 2011

OMB No. 0920-0234: Approval expires 02/28/2013

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 2011

The purpose of the National Study of Electronic Medical Records/Electronic Health Records (EMRs/EHRs) 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 866-966-1473.

1. We have your specialty as

Is that correct?

□1 Yes

□2 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 Yes □2 No □3 I am no longer in practice

}

Continue to Question 3. Please stop here and return the questionnaire in the envelope provided. Thank you for your time.

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, with 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.

□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

□5 Non-federal government clinic (e.g., state,

county, city, maternal and child health, etc.)

□6 Family planning clinic (including Planned

Parenthood)

□7 Health maintenance organization or other

prepaid practice (e.g., Kaiser Permanente)

□8 Faculty practice plan

□9 None of the above

PLEASE READ

• If you answered none of the above in question 7, skip to question 27.

• If you checked any of the boxes 1-8 in question 7, continue to question 8, below.

8. 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.

__________

For the remaining questions, please answer regarding the reporting location indicated in question 8 even if it is not the location where this survey was sent.

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

Country	USA
County
State
Zip Code
Telephone	( ) -

10. 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, with no holidays, vacations or conferences.)

Note: Please only include visits where you personally saw the patient.

__________ office visits

11. 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 Solo → SKIP to Question 14
□2 Associated with others

12. How many physicians are associated with you at the reporting location? __________ physicians

13. Is the reporting location a single- or multi-specialty (group) practice?
□1 Single □2 Multi

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

__________ mid-level providers

15. Does the reporting location submit any claims

electronically (electronic billing)?

□1 Yes
□2 No

□3 Unknown

16. Do you or your staff 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

17. Does the reporting 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

} }

Go to Question 17a. Skip to Question 18.

17a. In which year did you install your EMR/EHR system?

Year: ___________

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 CHARTCARE

□4 eClinicalWorks □5 Epic □6 eMDs

□7 GE/Centricity □8 Greenway Medical □9 MED3000

□10 NextGen □11 Sage □12 SOAPware

□13 Practice Fusion □14 Other________ □15 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	Yes, but turned off or not used	No	Unknown
19a. Recording patient history and demographic information?	1□ Go to 19a1 a1	2□ Skip to 19b	3□ Skip to 19b	4□ Skip to 19b
19a1. If yes, does this include a patient problem list?	1□	2□	3□	4□
19b. Recording clinical notes?	1□ Go to 19b1 19b1	2□ Skip to 19c	3□ Skip to 19c	4□ Skip to 19c
19b1. If yes, do they include a comprehensive list of the patient’s medications and allergies?	1□	2□	3□	4□
19c. Ordering prescriptions?	1□ Go to 19c1	2□ Skip to 19d	3□ Skip to 19d	4□ Skip to 19d
19c1. If yes, are prescriptions sent electronically to the pharmacy?	1□	2□	3□	4□
19c2. If yes, are warnings of drug interactions or contraindications provided?	1□	2□	3□	4□
19d. Providing reminders for guideline-based interventions or screening tests?	1□	2□	3□	4□
19e. Ordering lab tests?	1□ Go to 19e1	2□ Skip to 19f	3□ Skip to 19f	4□ Skip to 19f
19e1. If yes, are orders sent electronically?	1□	2□	3□	4□
19f. Providing standard order sets related to a particular condition or procedure?	1□	2□	3□	4□
19g. Viewing lab results?	1□ Go to 19g1	2□ Skip to 19h	3□ Skip to 19h	4□ Skip to 19h
19g1. If yes, are results incorporated into EMR/EHR?	1□	2□	3□	4□
19h. Viewing imaging results?	1□	2□	3□	4□
19i. Viewing data on quality of care measures?	1□	2□	3□	4□
19j. Electronic reporting to immunization registries?	1□	2□	3□	4□
19k. Public health reporting?	1□ Go to 19k1	2□ Skip to19l	3□ Skip to 19l	4□ Skip to19l
19k1. If yes, are notifiable diseases sent electronically?	1□	2□	3□	4□
19l. Providing patients with clinical summaries for each visit?	1□	2□	3□	4□
19m. Exchanging secure messages with patients?	1□	2□	3□	4□

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

□1 Prescribing practitioner

□2 Other

□3 Prescriptions and lab test orders not submitted

Electronically

□4 Unknown

21. Do you exchange patient clinical summaries electronically with any other providers?

□ 1 Yes, send summaries only Go to

□2 Yes, receive summaries only Question

□3 Yes, send and receive summaries 21a

□

Skip to Question 22

4 No

□5 Unknown

21a. How do you electronically send or receive patient clinical summaries? CHECK ALL THAT APPLY

□1 Through EMR/EHR vendor

□2 Through hospital-based system

□3 Through Health Information Organization

or state exchange

□4 Through secure email attachment

□5 Other/Unknown

22. Beginning in 2011, Medicare and Medicaid will offer incentives to practices that demonstrate “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?

□1 Yes, we intend to apply □2 Uncertain whether we will apply □3 No, we will not apply

}

Go to Question 22a. Skip to Question 23.

22a. In which year do you expect to apply for the meaningful use payments?

□1 2011
□2 2012
□3 After 2012

□4 Unknown

23. Who owns the reporting location? CHECK ONE.

□1 Physician or physician group

□2 HMO

□3 Community health center

□4 Medical/academic health center

□5 Other hospital

□6 Other health care corporation

□7 Other

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

1. Medicare	%
Medicaid/CHIP	%
Private insurance	%
Patient payments	%
Other (including charity, research, CHAMPUS, VA, etc.)	%
TOTAL	100%

25. At the reporting location, are you currently accepting new patients?

□

Go to Question 26

1 Yes Go to Question 25a.
□2 No

□3 Unknown

25a. From those new patients, which of the following types of payment do you accept?

	Yes	No	Unknown
1. Private insurance
a. Capitated	□1	□2	□3
b. Non-capitated	□1	□2	□3
2. Medicare	□1	□2	□3
3. Medicaid/CHIP	□1	□2	□3
4. Worker’s compensation	□1	□2	□3
5. Self-pay	□1	□2	□3
6. No charge	□1	□2	□3

26. At the reporting location, what percent of your current patients have Medicaid/CHIP?

_________%

27. Who completed this survey?

□

Box for Admin Use

1 The physician to whom it was addressed
□2 Office staff
□3 Other

Boxes for Admin Use

Thank you for your participation. Please return your survey in the envelope

p rovided. If you have misplaced this envelope, please send the EMR survey to

the following address: 2605 Meridian Parkway, Suite 200, Durham, NC 27713

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