NAMCS-1 Induction Interview

National Ambulatory Medical Care Survey

Attachment C1

NAMCS-1 Physician Induction Interview (Line 1)

OMB: 0920-0234

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Attachment C1-2014 NAMCS Induction Interview
A. Telephone Screener Questions
SPECVER
(your/Physician name's) specialty is (Specialty)
Is that right?
1. Yes
2. No

PRV_SPEC
What is your (your/Physician name's) specialty (including general practice)?
Enter "XXX" if specialty not found

PRV_SPEC_SP
Enter verbatim response for specialty

PRVETHN
What is (your/Physician name's) ethnicity?
1. Hispanic or Latino
2. Not Hispanic or Latino

RACE
What is (your/Physician name's) race?
Enter all that apply, separate with commas
1. White
2. Black/African-American
3. Asian
4. Native Hawaiian/Other Pacific Islander
5. American Indian/Alaska Native

PROFACT
Which of the following categories best describes (your/Physician name's) professional activity patient care, research, teaching, administration, or something else?
1. Patient Care
Page 1 of 5

2. Research
3. Teaching
4. Administration
5. Something else - Specify

PROFACT_SP
Specify

AMBCARE
? [F1]
(Do/Does) (you/physician's name) directly care for any ambulatory patients in (Your/ his/her)
work?
1. Yes
2. No - does not give direct care
3. No longer in practice

VERIF9A
? [F1]
We include as ambulatory patients individuals receiving health services without admission to a
hospital or other facility. Does (your/Physician name's) work include any such individuals?
1. Yes, cares for ambulatory patients
2. No, does not give direct care

VERIF9a_SP
Specify

FED
? [F1]
(Do/Does) (you/physician's name) work as an employee or a contractor in a federally operated
patient care setting (e.g., VA, military, prison) or in a hospital emergency or outpatient
department?

Page 2 of 5

1. Yes
2. No

PRIVPAT
? [F1]
In addition to working in a federally operated patient care setting, hospital emergency or
outpatient
department, (do/does) (you/physician's name) also see any ambulatory patients in another
setting (e.g., office based practice or community health center)?
1. Yes
2. No

HOSPRIVPAT
(do/does) (you/physician's name) work in an office-based practice owned by a hospital?
1. Yes
2. No

REMINDER
Although the provider works in a federal patient care setting, please make sure the respondent is
aware that all of the following questions are concerned with their private patients.

1. Enter 1 to Continue

ADDCHECK
We have (your/Physician name's) address as
( Address)
Is that the correct address for your office?
1. Yes
2. No, update address

NEW_PINFO
What is the correct address and phone number?
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Enter 1 to update the address and phone
1. Enter 1 to update information
2. Continue

THANK_OOS
Thank you, (Respondent's name/Physician's name), but I believe that since (you/physician's
name) (do/does) not (practice any longer/see any ambulatory patients),
our questions would not be appropriate for you.
I appreciate your time and interest.

1. Enter 1 to Continue

WHYNO_PRACT
Why isn't the doctor practicing?
1. Retired
2. Not licensed
3. Temporarily not practicing
4. Other

INDUCT_APPT
I would like to arrange an appointment with you within the next week or so to discuss the study.
It will take about 30 minutes. What would be a good time for you, before Friday, (Friday before
the reference week)?
( Enter 999 to start the induction now)

INDUCT_RESP
Did the physician give you an alternate contact for the induction interview?
1. Yes
2. No

WHO_RESP
Who?
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Enter 1 to enter alternate contact information
1. Record new contact person
2. Continue interview

SCR_THANK
Thank you, (Respondent's name/Physician's name).

1. Enter 1 to Continue

PHYSCHEDULE
Press ALT-F11 to enter/update physician's schedule
1. Enter 1 to Continue

PIISPEC
** NOT DISPLAYED **

PIISPECB
** NOT DISPLAYED **

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B. Induction Interview Questions
INDUCT_INTRO
Before we begin, I'd like to give you some background about this study.
Medical researchers and educators are especially interested in topics like medical education,
health workforce needs, and the changing nature of health care delivery. The National
Ambulatory Medical Care Survey (or NAMCS) was developed to meet the need for such
information.
The Centers for Disease Control and Prevention works closely with members of the medical
profession to design the NAMCS each year. The NAMCS supplies essential information about
how ambulatory medical care is provided in the United States, and how it is utilized by patients.
Your part in the study is very important and should not take much of your time. It consists of
your participation during a specified 7-day period. During that time, you would supply a minimal
amount of information about the patients you see.
First, I have some questions to ask about your practice. Your answers will only be used to
provide data on the characteristics of office-based practices in the U.S. Any and all information
you provide for this study will be kept confidential.

1. Enter 1 to Continue

NUMLOC
Overall, at how many office locations, (do/does) (you/physician's name) see ambulatory
patients? Do not include settings such as EDs, outpatient departments, surgicenters, and
Federal clinics.

NOPATSEN
In a typical year, about how many weeks (do/does) (you/physician's name) NOT see any
ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALF
(You/physician's name) typically (see/sees) patients fewer than half the weeks in each year.
Is that correct?
1. Yes
2. No

LTHALF_SP
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Please explain

ALLYEAR
(You/physician's name) typically (see/sees) patients all 52 weeks of the year.
Is that correct?
1. Yes
2. No

ALLYEAR_SP
Please explain

SEEPAT
? [F1]
This study will be concerned with the AMBULATORY patients (you/physician's name) will see in
(Your/ his/her) (office/offices) during the week of Monday, (Reporting period begin date) through
Sunday, (Reporting period end date).
(Are/Is) (you/physician's name) likely to see any ambulatory patients in (Your/ his/her)
(office/offices) during that week?
For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks,
and
so forth will be provided by staff in physician's absence, enter "Yes."
1. Yes
2. No

WHYNOPAT
? [F1]
Why is that?
Enter verbatim response

CHECK_BACK
? [F1]
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Since it's very important that we include any ambulatory patients that (you/physician's name)
might see in (Your/ his/her) office during that week, I'll check back with your office just before
(Reporting period begin date) to make sure (Your/ his/her) plans have not changed.
Even though the physician/provider is not available during the reporting week, continue with the
induction
1. Enter 1 to Continue

FOLIO_NUM
Give the folio to the doctor and enter the folio number

OFFICE_NUM
** Show only **

DEL_OFFICE
Enter 97 to delete this office/Office entered by mistake

OFFSTRET
(At what office location(s) will you see ambulatory patients during your practice's 7-day reporting
period Monday, ^BEGIN_DATE through Sunday, ^END_DA
Enter 999 for no more

OFFICE_CITY
In what city is this office located?

OFFICE_ST
In what state is this office?

OFFICE_ZIP
What is the zip code for this office?

LOCTYPE
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Enter location/address type
1. Main Office address
2. Alternative/2nd office address
3. Home office
4. Home
5. Unknown

CUR_OFFICE
Which office is the current office?

1. ^OFF1
2. ^OFF2
3. ^OFF3
4. ^OFF4
5. ^OFF5

OFFICE_NUM
** Show only **

OFFSTRET
** Show only **

OFFICETYP
B
Looking at this list, choose ALL of the type(s) of settings that describe the office at (Office
location).
If in doubt about any clinic/facility/institution, PROBE Is this/that clinic/facility/institution part of a hospital emergency department or an outpatient
department?
If yes, select 2 or 4
Is this/that clinic/facility/institution part operated by the Federal Government?
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If yes, select 12

Enter up to 3, separate with commas
1. Private solo or group practice
2. Hospital emergency department
3. Freestanding clinic/urgicenter (not part of a hospital outpatient department)
4. Hospital outpatient department
5. Community Health Center (e.g. Federally Qualified Health Center (FQHC), federally funded clinics or 'look alike'
6. Ambulatory surgicenter
7. Mental health center
8. Institutional setting (school infirmary, nursing home, prison)
9. Non-federal Government clinic (e.g., state, county, city, maternal and child health, etc)
10. Industrial outpatient facility
11. Family planning clinic (including Planned Parenthood)
12. Federal Government operated clinic (e.g., VA, military, etc.)
13. Health maintenance organization or other prepaid practice (e.g., Kaiser Permanente)
14. Laser vision surgery
15. Faculty practice plan

FREESTAND_PROBE
Is this/that clinic in an institutional setting, in an industrial outpatient facility, or operated by the
Federal Government?
1. Yes
2. No

FAMPLAN_PROBE
Is this/that clinic operated by the Federal Government?
1. Yes
2. No

SCOPE
** Not displayed **

NUMOFFIN
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** Not displayed **

OTHLOC
Are there other office locations where (you/physician's name) NORMALLY would see patients,
even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting
period? Do not include settings such as EDs, outpatient departments, surgicenters, and Federal
clinics.
1. Yes
2. No

OTHLOCVS
Of these locations where (you/physician's name) will not be seeing patients during (Your/ his/her)
7-day reporting period, how many total office visits did (you/physician's name) have during (Your/
his/her) last week of practice at these locations?

CKITEMB
** NOT DISPLAYED **

OOS_THANK2
Thank you, (Respondent name) your practice is not within the scope of this study.
We appreciate your time and interest.
1. Enter 1 to Continue

ESTDAYS
ESTDAYS fill
In-scope locations
(In-scope locations)

OFFICE_NUM
** Show only **

Page 6 of 56

OFFSTRET
** Show only **

ESTVIS
? [F1]
During (Your/ his/her) last normal week of practice, approximately how many office visit
encounters did (you/physician's name) have at each office location?
If physician is in group practice, only include the visits to sampled physician.

SAME
During the week of Monday, (Reporting period begin date) through Sunday (Reporting period end
date), (do/does) (you/physician's name) expect to have about the same number of visits as
(you/physician's name) saw during (Your/ his/her) last normal week in each office taking into
account time off, holidays, and conferences?
1. Yes
2. No

ESTVISP
Approximately how many ambulatory visits (do/does) (you/physician's name) expect to have at
this office location?

ESTTOTVS
** NOT DISPLAYED **

ESTTOTVS_LW
** NOT DISPLAYED **

OFFICE_NUM
** Show only **

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OFFSTRET
** Show only **

SOLO
Now, I'm going to ask about (your/Physician name's) practice at (Office location).
(Do/Does) (you/physician's name) have a solo practice, or (are/is) (you/physician's name)
associated with other physicians in a partnership, in a group practice, or in some other way at
this location?
1. Solo
2. Nonsolo

OTHPHY
How many physicians are associated with (you/physician's name) at (Office location)?

MULTI
Is this a single- or multi-specialty (group) practice at (Office location)?
1. Multi-specialty practice
2. Single-specialty practice

MIDLEV
How many mid-level providers (i.e., nurse practitioners, physician assistants, and nurse
midwives) are associated with (you/physician's name) at (Office location)?

OWNERSH
(Are/Is) (you/physician's name) a full- or part-owner, employee, or an independent contractor at
(Office location)?
1. Full-owner
2. Part-owner
3. Employee
4. Contractor

OWNS
Page 8 of 56

A
Who owns the practice at (Office location)?

1. Physician or Physician group
2. Insurance company, health plan, or HMO
3. Community Health Center
4. Medical/Academic health center
5. Other hospital
6. Other health care corporation
7. Other

ONSITE_EKG
Does (your/Physician name's) practice have the ability to perform any of the following on site at
(Office location)?
EKG/ECG
1. Yes
2. No
3. Don't know

ONSITE_PHLEB
Does (your/Physician name's) practice have the ability to perform any of the following on site at
(Office location)?
Phlebotomy
1. Yes
2. No
3. Don't know

ONSITE_LAB
Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office
location)?
Lab testing (not including urine dipstick, urine pregnancy, fingerstick blood glucose, or
rapid swab testing for infectious diseases)
Page 9 of 56

1. Yes
2. No
3. Don't know

ONSITE_SPIRO
Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office
location)?
Spirometry
1. Yes
2. No
3. Don't know

ONSITE_ULTRA
Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office
location)?
Ultrasound
1. Yes
2. No
3. Don't know

ONSITE_XRAY
Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office
location)?
X-Ray
1. Yes
2. No
3. Don't know

PATEVEN
(Do/Does) (you/physician's name) see patients in the office during the evening or on weekends at
(Office location)?

Page 10 of 56

1. Yes
2. No
3. Don't know

NPI
? [F1]
What is (your/Physician name's) National Provider Identifier (NPI) at (Office location)?

FEDTXID
? [F1]
What is (your/Physician name's) Federal Tax ID Identifier at (Office location)?

WKHOURS
During (your/Physician name's) last normal week of practice, how many hours of direct patient
care did (you/physician's name) provide?
Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing
surgery/procedures, providing other related patient care services.

NHVISWK
During (Your/ his/her) last normal week of practice, about how many encounters of the following
type did (you/physician's name) make with patients:
Nursing home visits

HOMVISWK
During (Your/ his/her) last normal week of practice, about how many encounters of the following type did
(you/physician's name) make with patients:
Other home visits

HOSVISWK
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During (Your/ his/her) last normal week of practice, about how many encounters of the following type did
(you/physician's name) make with patients:
Hospital visits

TELCONWK
During (Your/ his/her) last normal week of practice, about how many encounters of the following type did
(you/physician's name) make with patients:
Telephone consults

ECONWK
During (Your/ his/her) last normal week of practice, about how many encounters of the following type did
(you/physician's name) make with patients:
Internet/e-mail consults

PRIMARY_OFFICE
There is more than 1 office with the same number of "most" visits.
Please ask which office the physician/provider routinely
has the most visits.
1. ^BlkInduction.TblOFFICE1.BlkOffice1.OFFSTRET[1]
2. ^BlkInduction.TblOFFICE1.BlkOffice1.OFFSTRET[2]
3. ^BlkInduction.TblOFFICE1.BlkOffice1.OFFSTRET[3]
4. ^BlkInduction.TblOFFICE1.BlkOffice1.OFFSTRET[4]
5. ^BlkInduction.TblOFFICE1.BlkOffice1.OFFSTRET[5]

MOSTVIS_INTRO
The next set of questions pertain to characteristics of the sampled physician's healthcare
workforce, including physicians and other allied health care providers.

1. Enter 1 to Continue

NUMPH
If one location listed, display the following:
Page 12 of 56

[NUMPH_FILL] How many physicians, including you, are associated with this practice? Please
include physicians at [OFFICE_MOST], and physicians at any other locations of this practice.
If two or more locations listed, display the following text and questions:
[NUMPH_FILL] The next questions are about the location where you have the most office visits.
How many physicians, including you, are associated with that practice? Please include
physicians at [OFFICE_MOST], and physicians at any other locations of that practice.]

1. 1 physician
2. 2-3 physicians
3. 4-10 physicians
4. 11-50 physicians
5. 51-100 physicians
6. More than 100 physicians

PCMH
Is your practice certified as a patient-centered medical home?

CERT_WHO
By whom is your practice certified as a patient-centered medical home?
Enter all that apply, separate with commas

NCQALEVEL
What is the level of certification for the National Committee for Quality Assurance (NCQA)?

PCMH_OTH
Please specify the name of the other organization that certifies your practice as a
patient-centered medical home.

MD_DO_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?

Page 13 of 56

Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time physicians (include MDs and DOs)?

MD_DO_PT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Part-time physicians (include MDs and DOs)?

PA_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Physician Assistants (PA)?

PA_PT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Part-time Physician Assistants (PA)?

NP_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
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Please include the sampled provider in the total count of staff below.
Full-time Nurse Practitioners (NP)?

NP_PT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Part-time Nurse Practitioners (NP)?

CNM_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Nurse Practiticioners (NP)?

CNM_PT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Part-time Certified Nurse Midwives (CNM)?

RN_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
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Full-time Registered Nurses (RN) (not an NP or CNM)?

RN_PT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Part-time Registered Nurses (RN) (not an NP or CNM)?

LPN_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Licensed Practical Nurses (LPN)?

CNA_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Certified Nursing Assistants/Aides (CNA)?

MA_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Medical Assistants (MA)?
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RT_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Radiology Technicians (RT)?

LT_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Laboratory Technicians (LT)?

PT_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Physical Therapists (PT)?

PH_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.

Full-time Pharmacists (PH)?

DN_FT
How many of the following full-time and part-time providers are on staff at the office location
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where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.

Full-time Dieticians/Nutritionists (DN)?

MH_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Mental Health Providers (MH)?

HEC_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Health Educators/Counselors (HEC)?

CSW_FT
How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Case Managers (not RNs)/Certified Social Workers (CSW)?

CHW_FT
H
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How many of the following full-time and part-time providers are on staff at the office location
where you have the most office visits?
Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.
Please provide the total number of full-time and part-time providers.
Please include the sampled provider in the total count of staff below.
Full-time Community Health Workers (CHW)?

TASK_BODY
At the office location where you see the most patients, which type of provider most commonly
performs the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Records Body Measurements (such as height and weight) and vital signs (such as blood
pressure, temperature, and heart rate)
1. Physicians (MD and DO)
2. Physician Assistants (PA)
3. Nurse Practiticioners (NP)
4. Certified Nurse Midwives (CNM)
5. Registered Nurses (RN)
6. Licensed Practical Nurses (LPN)
7. Certified Nursing Assistants/Aides (CNA)
8. Medical Assistants (MA)
9. Radiology Technicians (RT)
10. Laboratory Technicians (LT)
11. Physical Therapists (PT)
12. Pharmacists (PH)
13. Dieticians/Nutritionists (DN)
14. Mental Health Providers (MH)
15. Health Educators/Counselors (HEC)
16. Case Managers (not RNs)/Certified Social Workers (CSW)
17. Community Health Workers (CHW)
18. Task is not performed in this office
19. Reserved for future additions
20. Unknown

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TASK_TEST
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Office-based testing such as EKG and hearing/vision testing (do not include laboratory
testing)

TASK_BLOOD
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Draws blood for lab testing

TASK_IMMUN
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Provides immunizations (includes both childhood and adult)

TASK_SCREEN
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Conducts cancer screenings (such as breast, cervical, and prostate screenings)
Page 20 of 56

TASK_BEHAV
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Provides behavioral health screenings (such as depression, alcohol and substance abuse)

TASK_COUNSEL
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Provides counseling services (such as diet/nutrition, weight reduction, tobacco cessation,
stress management

TASK_ROUT
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Manages the routine care of patients with chronic conditions (such as hypertension, asthma,
diabetes)

TASK_REFILL
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Page 21 of 56

Writes refill prescriptions for medications

TASK_ENTER
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Enters patient information into medical/billing records

TASK_IMAGE
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Performs imaging tests (such as X-rays and ultrasounds)

TASK_REF
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Enter all that apply, separate with commas
Makes referrals (for example, to specialty care, or to community-based services)

TASK_CONTACTS
At the office location where you see the most patients, which type of provider most commonly performs
the following tasks?
The providers listed below are generated from the previous staffing question. If any providers in your
office are missing, please go back to the staffing question and check the appropriate box(es).
Page 22 of 56

Enter all that apply, separate with commas
Contacts patients, who are transitioning from the hospital or a nursing home back to the
community

PA_SUP
The following questions concern the mid-level providers practicing at the location where you
have the most office visits.
Physician Assistant
Are PA(s) supervised by someone on-site?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

PA_SIGN
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Physician Assistant
Do you sign-off on the medical records of the patients the PA(s) see(s)?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

PA_LOG
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Physician Assistant
Do the PA's patients have a separate log from your patients?
1. Yes, always
2. Yes, sometimes
Page 23 of 56

3. No
4. Unknown/Not Applicable

PA_APPROVAL
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Physician Assistant
Is your approval required before the PA(s) prescribe(s) medication?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

NP_SUP
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Nurse Practicioner
Are NP(s) supervised by someone on-site?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

NP_SIGN
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Nurse Practicioner
Do you sign-off on the medical record of the patients the NP(s) see(s)?
1. Yes, always
2. Yes, sometimes
3. No
Page 24 of 56

4. Unknown/Not Applicable

NP_LOG
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Nurse Practicioner
Do the NP's patients have a separate log from your patients?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

NP_APPROVAL
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Nurse Practicioner
Is your approval required before the NP(s) prescribe(s) medication?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

NP_BILL
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Nurse Practicioner
Do/does the NP(s) bill for services using their own NPI number?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable
Page 25 of 56

CNM_SUP
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Certified Nurse Midwife
Are CNM(s) supervised by someone on-site?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

CNM_SIGN
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Certified Nurse Midwife
Do you sign-off on the medical record of the patients the CNM(s) see(s)?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

CNM_LOG
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Certified Nurse Midwife
Do the CNM's patients have a separate log from your patients?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

CNM_APPROVAL
The following questions concern the mid-level providers practicing at the location where you have the
Page 26 of 56

most office visits.
Certified Nurse Midwife
Is your approval required before the CNM(s) prescribe(s) medication?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

CNM_BILL
The following questions concern the mid-level providers practicing at the location where you have the
most office visits.
Certified Nurse Midwife
Do/does the CNM(s) bill for services using their own NPI number?
1. Yes, always
2. Yes, sometimes
3. No
4. Unknown/Not Applicable

ACCESS
The remaining questions are to be answered for the practice that is associated with the location
where the physician sees the most patients. When defining this location, include only in-scope
locations previously listed.
Is it possible within your practice to access patient medical records using an electronic health
record (EHR) system 24 hours a day?
1. Yes
2. No
3. Unknown

ACCESS_PH
Is this access available to physicians only, or is it also available to other non-physician
clinicians?

Page 27 of 56

Enter all that apply, separate with commas

1. Physicians (MD/DO) only
2. All Physicians and Non-physician Clinicians
3. Unknown

PMETHOD
What is the primary method by which your practice receives information about patients in your
practice when they have been seen in the emergency department or hospitalized?

1. Electronic transmission (i.e., EHR or EMR)
2. Fax
3. Email
4. Telephone or in-person communication with provider
5. Paper copy
6. Other

PMETHOD_SP
Specify other method to receive information

SECNET
Was this email sent over a secure network?
1. Yes
2. No
3. Unknown

TRANS
Is someone in your practice responsible for assisting patients to safely transition back to the
community within 72 hours of being discharged from a hospital or nursing home?
1. Yes
2. No
3. Unknown
Page 28 of 56

PROTO
Does your practice have written protocols for providing chronic care services that are used by all
members of the care team?
1. Yes
2. No
3. Unknown

QUAL
Does your practice report any quality measures or quality indicators to either payers or to
organizations that monitor health care quality?
1. Yes
2. No

DIFTIN
Do all other locations or offices associated with this practice use the same Federal Tax ID or do
any locations or offices associated with this practice use a different Federal Tax ID?
1. All use the same Federal Tax ID
2. Some use a different Federal Tax ID
3. Unknown

EMR_INTRO
Office: (Office location with most visits)
Answer ALL remaining questions for the in-scope location with the most visits which is (Office
location with most visits)

1. Enter 1 to Continue

EBILLREC
Office: (Office location with most visits)
Does the reporting location submit any claims electronically (electronic billing)?
1. Yes
Page 29 of 56

2. No
3. Unknown

EMEDREC
Office: (Office location with most visits)
Does the reporting location use an electronic health record (EHR) or electronic medical record
(EMR) system? Do not include billing record systems.
1. Yes, all electronic
2. Yes, part paper and part electronic
3. No
4. Unknown

EHRINSYR
Office: (Office location with most visits)
In which year did you install your EHR/EMR system?

HHSMU
Does your current system meet meaningful use criteria as defined by the Department of Health
and Human Services?

EHRNAM
Office: (Office location with most visits)
What is the name of your current EHR/EMR system?
CHECK ONLY ONE BOX. IF OTHER IS CHECKED, PLEASE SPECIFY THE NAME.

1. Allscripts
2. Amazing Charts
3. athenahealth
4. Cerner
5. eClinicalWorks
6. e-MDs
7. Epic
8. GE/Centricity
Page 30 of 56

9. Greenway Medical
10. McKesson/Practice Partner
11. NextGen
12. Practice Fusion
13. Sage/Vitera
14. Other-Specify
15. Unknown

EHRNAMOTH
Specify the name of the EHR/EMR system.

SECURCHCK
Has your practice conducted or reviewed a security risk analysis of your EHR system? This
would help identify privacy or security related issues that may need to be corrected.

1. Yes
2. No
3. Unknown

DIFFEHER
Does your EHR have the capability to electronically send health information to another provider
whose EHR system is different from your system?

1. Yes
2. No
3. Unknown

EHRTOEHR
Is the patient health information that you share electronically sent directly from your EHR system
to another EHR system?
1. Yes, routinely
2. Yes, but not routinely
3. No
4. Unknown
Page 31 of 56

EMRINS
Office: (Office location with most visits)
At the reporting location, are there plans for installing a new EHR/EMR system within the next 18
months?
1. Yes
2. No
3. Maybe
4. Unknown

MUINC
Office: (Office location with most visits)
Medicare and Medicaid offer incentives to practices that demonstrate "meaningful use of health
IT." At the reporting location, are there plans to apply for Stage 1 of these incentive payments?
1. Yes, we already applied
2. Yes, we intend to apply
3. Uncertain if we will apply
4. No, we will not apply

MUSTAGE2
Office: (Office location with most visits)
Are there plans to apply for Stage 2 incentive payments?

1. Yes
2. No
3. Maybe
4. Unknown

EDEMOG
C-1