National Ambulatory Medical Care Survey
Nonsubstantive Change to
OMB No. 0920-0234
(Expires 12/31/2014)
Contact Information:
David A. Woodwell, M.P.H.
Lead Statistician, Ambulatory and Hospital Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics/CDC
3311 Toledo Road, Room 3323
Hyattsville, MD 20782
301-458-4592
301-458-4032 (fax)
October 2, 2012
National Ambulatory Medical Care Survey (NAMCS)
This request is for a nonsubstantive change to an approved data collection (OMB No. 0920‑0234) (expires 12/31/2014), the National Ambulatory Medical Care Survey (NAMCS). On December 13, 2011, OMB approved the NAMCS including the shift from the basic survey to electronic data collection in 2012. The approved supporting statement included permission to modify selected sections of the 2012-2014 surveys through a nonsubstantive change clearance request. Some questions change on a periodic basis to collect new and/or updated information as needed. No change in burden is requested.
This document proposes some new, reinstated, and modified questions to the prior approved NAMCS data collection content by survey form. New and modified content for 2013 is presented in the included attachments highlighted below and described in more detail in section A2.
Physician Induction Interview (NAMCS-1A)
Attachment A is a draft of the 2013 NAMCS-1A including all proposed question changes. As in 2012, the 2013 NAMCS-1A questions will be collected on a computerized instrument.
Reinstate the collection of Federal Tax ID for each sampled office location;
Expand a question that asks about the number of physicians associated with the practice where the sampled physician is connected;
Expand the staffing questions to better capture the sampled physician’s workforce at the location where they see the most patients;
Modify electronic health record (EHR) items to mimic changes to the proposed 2013 National Electronic Health Records Survey (NEHRS);
Cycle out the Asthma supplement and delete applicable screener question in the induction instrument; and
Delete complementary and alternative medicine (CAM) questions.
Patient Record Form (PRF) and Lookback Module (LM)
Minor changes are proposed for these two forms. Attachment B is a draft of the 2013 NAMCS PRF, and Attachment C is a draft of the 2013 LM. All proposed question changes are highlighted in each attachment. As in 2012, the 2013 PRF and LM questions will be collected on a computerized instrument. For ease of presentation, a paper version is also provided.
Delete Cancer Stages;
Add an “STD prevention” checkbox to the Health Education/Counseling grouping under the Services section;
Add Current Procedural Terminology (CPT) codes; and
Add serum creatinine to the existing list of lab tests collected on both the PRF and LM
National Electronic Health Record Survey (NEHRS)
The draft paper-based 2013 NEHRS is Attachment D with revisions highlighted in yellow. As in 2012, the 2013 NEHRS is a mail survey with telephone follow-up.
Add a question on number of total physicians working at the sampled physician’s current reporting location
Slightly modify wording and change responses (from open-ended to six discrete categories) for practice size question;
Add question on meaningful use criteria;
Add response choices for name of EHR system;
Modify selected choices for the reporting location’s computerized capabilities; and
Improve flow of skip pattern for questions on referral and discharge follow-up.
Physician Workflow Survey (PWS)
For the PWS, physicians are categorized into those who have adopted the use of electronic medical records and those who have not. The proposed paper-based 2013 PWS for EHR adopters is Attachment E, and the proposed paper-based 2013 PWS for EHR nonadopters is Attachment F. In both attachments, revisions are highlighted in yellow. An itemized list of modifications for both survey forms is Attachment G. All formal correspondence letters sent to respondents is Attachment H. As in 2012, the 2013 PWS is primarily a mail survey with telephone and web follow-up.
Slightly change the content on both versions of the survey (EHR adopters and EHR nonadopters) as highlighted in the itemized list of question deletions, modifications, and additions; and
Add an on-line option for the respondents to participate in addition to the current options of mail and phone follow-up.
The following section highlights modifications to the NAMCS-1A and can be reviewed on the draft 2013 NAMCS-1A (Attachment A). It should be noted that the proposed changes described below follow sequentially how the changes will be ordered on the 2013 NAMCS-1A, and thus are organized similarly in the attachment.
The first modification to the NAMCS-1A involves the reinstatement of a physician’s Federal Tax ID which is recorded for each sampled location. The Federal Tax Identification Number is a nine-digit number that the IRS assigns to business entities. The IRS uses this number to identify taxpayers. The Federal Tax ID question was collected as recently as 2011, but was replaced by a similar item asking for a physician’s National Provider Identifier (NPI). For 2013, both the Federal Tax ID and the NPI will be recorded for each sampled physician’s office location. It is beneficial for workforce analysis purposes to have both the provider's NPI and his or her Federal Tax ID number. The NPI is a unique identifier that can be used to distinguish among survey respondents and to link to provider characteristics available in other datasets including the National Plan and Provider Enumeration System (NPPES) which is a database of all clinical providers who utilize electronic billing for any type of insurance payment. NPPES is maintained by the Centers for Medicare and Medicaid Services (CMS). The Federal Tax ID number is a separate indicator that allows one to determine a provider's organizational affiliation including the number and types of physicians who work together in a group practice. Collecting the Federal Tax ID will support linkage with information captured in the CMS Provider Enrollment, Chain and Ownership System (PECOS) database which describes the characteristics of physicians' organizations. It is possible within CMS data to link the NPIs of physicians who participate in Medicare with the Federal Tax ID of their organization. However, some physicians, most notably pediatricians and obstetricians do not routinely bill Medicare and relying purely on CMS data to link a provider's NPI to a Federal Tax ID number would lead to incomplete data collection and therefore an inability to characterize all physicians in NAMCS into groups. In the introductory letter send to sampled physicians, we mention that their Federal Tax ID will be linked to other health-care related data.
The next modification to the NAMCS-1A is the addition of a staffing question assessing the total number of physicians associated with the sampled physician at the location where they see the most patients. This question represents a slight modification to the current question which asks about the number of other physicians working with the sampled physician each sampled office location. Both questions will be retained on the 2013 survey form.
A set of questions examining physician workforce issues is also proposed for 2013. Specifically, these questions expand on the current question which simply asks about the number of mid-level providers practicing at a sampled physician’s particular office location. Fueled in part by changes in the delivery system, demonstration programs in the Affordable Care Act, and the increasing emphasis on Patient-Centered Medical Homes (PCMH), within the Department of Health and Human Services, there is strong interest in understanding the dynamics of practice redesign and how team-based care is actually delivered. A related interest is how Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs) are utilized and whether they are used to the full extent of their licenses and training. Adding questions to the NAMCS-1A would provide a description of the composition of the practice team and the roles/responsibilities of its respective members for preventive services. Issues to be explored include the composition of the professional staff in the physician’s office, including whether it includes non-physician providers; which staff, if any provide counseling, take vitals, etc. This exploration of provider types would go beyond physicians, APRNs and PAs, and could include registered nurses, community health workers, behavioral health providers, and others. The expansion is sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE).
Fourth, NCHS proposes to modify the current series of electronic health record (EHR) questions on the NAMCS-1A for 2013 so they mimic the proposed changes to 2013 NEHRS, as detailed below. Having all of the EHR items on both the 2013 NAMCS-1A and NEHRS will allow researchers to combine data from both surveys. Being able to combine data allows for more reliable estimates to be obtained regarding the adoption and use of electronic health records in office-based physician practices.
The asthma supplement is being cycled out for 2013 due to funding issues. The supplement was originally sponsored by individual Institutes within the National Institutes of Health and various Centers within the Centers for Disease Control and Prevention. Since there was no longer a supplement, the screener question assessing if the physician saw patients with asthma was also removed.
Finally, the complementary and alternative medicine (CAM) questions have been completed. These questions were only on the survey for 2012.
The following section highlights changes to the PRF and can be reviewed on the draft 2013 PRF (Attachment B), and the changes to the LM can be reviewed in Attachment C. It should be noted that the proposed changes described below follow sequentially how the changes will be ordered on the 2013 PRF and LM, and thus are organized similarly in the attachment.
First, the cancer stages (e.g., in situ, stage 1, stage 2, etc.) on the PRF will be removed. These variables were added with funding from CDC’s National Center for Chronic Disease Prevention Health Promotion (NCCDPHP) for a predetermined period of time in an effort to obtain more complete data on visits made to oncologists. NCCDPHP did not fund any additional data collection past 2012.
Second, NCHS proposes to add a checkbox titled “STD prevention” to the “Health Education/Counseling” sub-section under the main “Services” section. These diseases still remain a major public health challenge in the United States. Because one of CDC’s missions is to conduct research on STD prevention, including this checkbox will assist researchers examine patient education on STDs that is provided in physician offices and thus inform strategies that support STD prevention programs.
Third, NCHS proposes to collect up to 15 Current Procedural Terminology (CPT) codes in 2013. NAMCS staff conducted a pilot test earlier in 2012 and is currently wrapping-up a pretest funded by ASPE to assess the feasibility of developing nationally-representative estimates of payments for care in physician offices using the CPT codes. Based on the positive results of the pilot test and what we have learned so far from the pretest, NCHS would like to move forward and add the collection of these codes to the PRF in 2013. Collection of this information will allow tracking payments to physicians by patient attributes. The NCHS project team has consulted with outside experts including Dr. Ciaran Phibbs of Stanford University and Dr. Mark Hornbrook of Kaiser Permanente's Center for Health Research in developing this plan. Results from the pilot test indicate that collection of the CPT codes provides an important benefit to the NAMCS survey – that of obtaining a more comprehensive picture of the services provided or ordered by physicians. Although NAMCS also collects information on whether specific services were ordered or provided (e.g., mammograms, X-rays, etc.), by having CPT codes in the survey, researchers will have the potential of analyzing physician service use in a more complete and systematic way.
Finally, at the request of the American Society of Nephrology (ASN), NCHS proposes to add the collection of serum creatinine to the lab test on the PRF and to the LM. This addition will allow researchers to better understand and effectively treat kidney disease, which is the 8th leading cause of death in the United States. Approximately 26 million, or 1 in 9, Americans have some evidence of kidney disease, making it a significant public health issues in the United States. In addition, chronic kidney disease (CKD) disproportionately affects racial/ethnic minorities, who are 1.5 to 4 times more likely to develop kidney failure, also known as end-stage renal disease (ESRD), than white CKD patients.
Early identification and treatment of kidney disease can slow the loss of kidney function, prevent or delay CKD complications, and prevent or delay kidney failure. Measuring creatinine is a simple test that is the most common measure of kidney function. A standard bundle of blood tests routinely reports the amount of creatinine in the blood. Collecting data on creatinine measurement in NAMCS will generate a critical resource for investigators studying the management and treatment of kidney disease in patients within community settings. This information can be used to better understand practice patterns in order to enhance understanding of kidney disease.
National Electronic Health Records Survey (NEHRS) Revisions
To assist in measuring the progress of meeting the President’s goal for most Americans to have access to an interoperable electronic health record (EHR) by 2014, NCHS will continue to field the NEHRS for 2013. The 2013 draft NEHRS (Attachment D) has a few changes and modifications as described below in sequential order.
Specifically, we are no longer giving participants the ability to report in an open-ended question the number of physicians at their current practice. For 2013 the form will have six discrete categories that range from 1 to more than 100 additional physicians. A simple yes-no question was added to determine if a physician’s current EHR system meets meaningful use criteria. Four new response categories were added that expand the possible types of EHR systems a physician may own. The final proposed change to the form involves a question matrix that is used to identify specifics of the sampled physician’s EHR system.
All of the new questions on the 2013 NEHRS will help guide the policymaking process surrounding Stage II meaningful use. A few EHR functionality questions that were not deemed as important to ONC were deleted. The proposed questions will not increase the survey burden for physicians; that is, for each question that will be added, we have removed or modified an existing question in order to keep the survey length constant.
Physician Workflow Survey (PWS) Revisions
The two 2013 draft PWSs are Attachment E (current EHR adopters) and Attachment F (current EHR nonadopters).
Like the NEHRS, the PWS is a mail survey sponsored by ONC. To assist in measuring the progress of meeting the President’s goal for most Americans to have access to an interoperable EHR by 2014, ONC has funded NCHS to follow from 2011-2013 an eligible cohort of physicians selected from the original 2011 NEHRS through the PWS in years 2011 through 2013.
For 2013, all physicians still eligible from the 2012 PWS cohort will be contacted again to further gather information that ONC requires on the costs, benefits, and barriers associated with the use of EHRs at various levels of adoption. This information helps ONC measure the progress towards HITECH program goals and provides insight into where scarce resources need to be devoted to help physicians achieve Stage 1 and Stage 2 meaningful use of certified EHR technology. The longitudinal nature of this physician workflow survey will also provide insight into physician investment behavior, intent to meet HHS’ meaningful use criteria, and barriers that physicians face at various stages of EHR adoption. ONC is using this information to inform policy-making around Stage 2 meaningful use criteria. The meaningful use rule is part of a coordinated set of regulations to help create a private and secure 21st century electronic health information system. ONC’s criteria for meaningful use will be implemented in three stages. The information obtained from the workflow survey will provide great value to ONC and NHCS. Together with the NEHRS, the information obtained will help ONC monitor the effectiveness of federal programs and grants, and inform key policy decisions to develop criteria for successive stages.
Current modifications include similar changes to practice and office characteristics items as described above for the 2013 NEHRS. Additionally, content on physician attitudes about privacy and security were added, as well as unintended consequences of using EHR systems. Items were also added to measure how physician workflows are impacted by EHRs. Lastly, content on barriers to health information exchange (HIE) is also added to understand more about physician attitudes towards HIE.
NCHS proposes adding an additional option for physicians to respond to the PWS on-line (in addition to the current options of mail and phone). The questionnaire content would be the same across modes. The modification to current procedures would be that respondents would receive an invitation by email or letter (Attachment H) inviting them to complete the survey on-line (E-mail address was requested in the 2012 PWS.). Additionally, in Attachment H, letters are updated to reflect the third year of the study. Those who do not respond would receive a mail questionnaire with telephone follow-up, as the survey is currently administered.
A3. Use of Improved Information Technology and Burden Reduction
No change.
A4. Efforts to Identify Duplication and Use of Similar Information
No change.
A5. Impact on Small Businesses or Other Small Entities
No change.
A6. Consequences of Collecting the Information Less Frequently
No change.
A7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
No change.
A8. Comments in response to the Federal Register Notice and Efforts to Consult Outside the Agency
New Consultations:
Andrew Bindman, MD
Senior Advisor
HHS/ASPE/Health Policy
200 Independence Ave, SW
Washington, DC 20201
(202) 401-8398
Michael Furukawa, Ph.D.
Director, Office of Economic Analysis and Modeling
Office of the National Coordinator for Health Information Technology
(202) 690-3950
Mark Hornbrook, PhD
Chief Scientist
The Center for Health Research
Northwest/Hawaii/Southeast Kaiser Permanente Northwest
3700 North Interstate Avenue
Portland, OR 97227-1110
Vaishali Patel, Ph.D., M.P.H.
Health Services Researcher
Office of Economic Analysis, Evaluation, and Modeling
Office of the National Coordinator for Health Information Technology
(202) 690-3912
Ciaran Phibbs
Health Economics Resource Center (152)
VA Medical Center, 795 Willow Road
Menlo Park, CA 94025
Caroline Taplin
ASPE
Acting Director, Division of Public Health Services
200 Independence Ave, SW
Washington, DC 20201
(202) 690-6870
A9. Explanation of Any Payment or Gift to Respondents
No change.
A10. Assurance of Confidentiality Provided to Respondents
No change.
A11. Justification for Sensitive Questions
No change.
A12. Estimates of Annualized Burden Hours and Costs
Although there is no change to the burden hours, a number of forms have been slightly modified and are attached. Specific forms that have changed include the Physician Induction Interview (line 1) (Attachment A); the Patient Record form (line 3) (Attachment B); the Lookback module (line 5) (Attachment C); the National Electronic Health Record Survey (line 7) (Attachment D); and the Physician Workflow Survey (line 8) now two versions based on EHR adoption (Attachments E & F).
Table of Estimated Annualized Burden Hours
Type of Form |
Type of Respondent
|
Form Name |
Number of Respondents |
Number of Responses per Respondent |
Hours per Response |
Total Burden (Hours) |
Core NAMCS Forms |
Office-based physicians/CHC providers |
Physician Induction Interview (NAMCS-1) |
17,034 |
1 |
35/60 |
9,937 |
Community Health Center Directors |
Community Health Center Induction Interview (NAMCS-201) |
2,008 |
1 |
20/60 |
669 |
|
Office-based physicians/CHC providers |
Patient Record form (NAMCS-30) |
3,407 |
30 |
14/60 |
23,849 |
|
Office/CHC staff |
Pulling, re-filing medical record forms |
13,627 |
30 |
1/60 |
6,814 |
|
Office-based physicians/CHC providers |
Lookback module |
1,192 |
15 |
10/60 |
2,980 |
|
Office-based physicians/CHC providers |
Asthma Supplement |
11,072 |
1 |
20/60 |
3,691 |
|
National Electronic Health Records Survey (NEHRS) |
Office-based physicians |
NEHRS form |
4,344 |
1 |
20/60 |
1,448 |
Physician Workflow Survey (PWS) |
Office-based physicians |
PWS form |
2,645 |
1 |
30/60 |
1,323 |
Pretest NAMCS Forms |
Office-based physicians |
Physician Induction Interview (NAMCS-1) |
17 |
1 |
35/60 |
10 |
Office-based physicians |
Patient Record form (NAMCS-30) |
17 |
30 |
14/60 |
119 |
|
Re-abstraction Study |
Office/CHC staff |
Pulling, re-filing medical record forms |
500 |
10 |
1/60 |
83 |
|
Total |
|
|
|
|
50,923 |
A13. Estimates of Other Total Annual cost Burden to Respondents or Records Keepers
No change.
A14. Annualized Cost to the Government
No change.
A15. Explanation for Program Changes or Adjustments
Although there were slight changes to some questionnaires, there were no changes to the burden.
A16. Plans for Tabulation and Publication and Project Time Schedule
No change.
A17. Reason(s) Display of OMB Expiration Date is Inappropriate
No change.
A18. Exceptions to Certification for Paperwork Reduction Act Submissions
No change.
Supporting Statement
List of Attachments involved in change
National Ambulatory Medical Care Survey 2013: NAMCS-1A
National Ambulatory Medical Care Survey 2013: Patient Record Form
National Ambulatory Medical Care Survey 2013: Lookback Module
National Electronic Health Records Survey (NEHRS) 2013
Physician Workflow Survey Year 2013 (EHR adopters)
Physician Workflow Survey Year 2013 (EHR nonadopters)
Physician Workflow Survey Year 2013: Changes to 2013 Survey
Physician Workflow Survey Year 2013: Physician Letters
| File Type | application/msword |
| File Title | Supporting Statement |
| Author | Donald Cherry |
| Last Modified By | Gissendaner, Petunia (CDC/OD/OADS) |
| File Modified | 2012-10-17 |
| File Created | 2012-10-02 |