Namcs 1

Attachment C1: 2014 NAMCS-1
OMB No. 0920-0234: Expiration date 12/31/2014
NOTICE - Public reporting burden of this collection of information is estimated to average 35 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 current valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing 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 for statistical purposes 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).

NAMCS-1A

1. Physician’s address:

FORM
(4-22-2014)

Disclaimer – The following questionnaire is based on a
computer-based questionnaire. Thus, the following questions contain
the same content of the computer-based questionnaire, though the flow
of the paper-questionnaire questions does not necessarily represent the
flow of the computer-based questionnaire due to the limitations of a
paper questionnaire.

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

NATIONAL CENTER FOR HEALTH STATISTICS
CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL AMBULATORY
MEDICAL CARE SURVEY
2014 PANEL
2. Physician’s telephone and FAX numbers (Area code and number)
Office Telephone
1
FAX

Office
2

Telephone
FAX

3. Introduction
The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the National
Ambulatory Medical Care Survey (NAMCS). This annual study, which has been in the field since 1973, collects information about
the large portion of ambulatory care provided by physicians and midlevel providers throughout the United States. Research using
NAMCS helps to inform physicians, health care researchers, and policy makers about the changing characteristics of ambulatory
health care in this country. The information that we will request includes data about patient visits (e.g., demographics, diagnoses,
services, and treatments); physician practice characteristics (e.g., practice type), and use of electronic medical records.
Many organizations and leaders in the health care community, including those providing the enclosed letter of endorsement, have
expressed their support and join me in urging your participation in this meaningful study. You will be asked to complete a short
electronic questionnaire on a sample of about 30 patient encounters during a randomly assigned, 1-week reporting period.
Additionally, there is a short interview (approximately 35 minutes) with you about the nature of your practice. We intend to conduct
additional health care research by linking National Provider Identifiers (NPI) and Federal Tax Identification Numbers collected in
this study to health care-related data such as Medicare records. Participation is voluntary, and you or your staff may refuse to
answer any question or stop participating at any time without penalty or loss of benefits.
The following are some key points about the survey:
• Data collection for NAMCS is authorized by Section 306 of the Public Health Service Act (Title 42, U.S. Code, 242k).
• All information collected will be held in the strictest confidence according to Section 308(d) of the Public Health Service Act (Title
42, U.S. Code, 242m(d) and the Confidential Information Protection and Statistical Efficiency Act (Title 5 of PL 107-347). This
information will be used for statistical purposes only. No patient names, social security numbers, or addresses are collected.
• NAMCS conforms to the Privacy Rule as mandated by HIPAA because disclosure of patient data is permitted for public
health purposes, and the NCHS Research Ethics Review Board has approved NAMCS.
• U.S. Census Bureau employees, who administer the study, have taken an oath to abide by Title 13, U.S. Code, Section 9, which
requires them to keep all information about your practice and patients confidential.
A Census Bureau employee, acting as our agent, will call you to schedule an appointment regarding the details of your
participation. If you have any questions, please call a NAMCS representative at 1–800–392–2862. You can also find additional
information on the survey by visiting the NAMCS participant website at: http://www.cdc.gov/nchs/ahcd/namcs_participant.htm.
You may have questions about your rights as a participant in this research study. If so, please call the Research Ethics Review
Board at 1–800–223–8118. Please leave a brief message with your name and phone number and say that you are calling about
Protocol #2010-02. Your call will be returned as soon as possible.
We greatly appreciate your cooperation.
Sincerely,
Charles J. Rothwell, MS, MBA
Director

Section I – TELEPHONE SCREENER – Continued

4. Specialty
a. Your specialty is _______________________________ ,
1

is that right?

2

Yes – SKIP to item 4c
No

Edit

b. What is your specialty (including general
practice)?
(Name of specialty)
Code

Edit

Refer to the NAMCS-252, pages 9 and 10 for codes.

c. What is your ethnicity?

1
2

d. What is your race?
Enter (X) one or more.

1
2
3
4
5

5.

Which of the following categories best
describes your professional activity –
patient care, research, teaching,
administration, or something else?

1
2
3
4
5

6a. Do you directly care for any ambulatory
patients in your work?

1
2
3

b. PROBE: We include as ambulatory patients,
individuals receiving health services
without admission to a hospital or other
facility. Does your work include any such
individuals?

c. Do you 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?

d. In addition to working in a federally
operated patient care setting, hospital
emergency or outpatient department, do
you also see any ambulatory patients in
another setting (e. g., office based practice
or community health center)?

e. Do you work in an office-based practice
owned by a hospital?

f. 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.
Page 2

1
2

1
2

1
2

Hispanic or Latino
Not Hispanic or Latino
White
Black or African-American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Patient care
Research
Teaching
Administration
Something else – Specify

Yes – SKIP to item 6c
No – does not give direct care [6b PROBE]
No longer in practice – SKIP to item 8 on page 3
Yes, cares for ambulatory patients
No, does not give direct care –Specify reason,
then read item 8 on page 3

Yes
No – SKIP to item 6e

Yes
No – SKIP to item 8 on page 3

2

Yes
No – SKIP to item 7a on page 3

1

Continue

1

FORM NAMCS-1A (4-22-2014)

Section I – TELEPHONE SCREENER – Continued

7a. We have your address as (Read address shown
1

in item 1). Is that the correct address for your
office?

b. What is the correct address and phone

2

Yes – SKIP to item 9
No, incorrect address – Ask item 7b

Number and street

}

number of your office?

City

State

ZIP Code

Telephone (Area code and number)

8. Thank you, Dr. . . ., but I believe that since you do not (see any ambulatory

SKIP to
item 9

patients/practice any longer), our questions would not be appropriate for you. I
appreciate your time and interest.

9. 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,________________(last Friday before the assigned reporting week)?
Weekday

Month

Day

Year

Time
a.m.
p.m.

Physician refused to participate –Go to item 10a.
Thank you, Dr. . . .

FR, PLEASE READ
BEFORE CONTINUING

FR Instruction – COMPLETE QUESTIONS BELOW FOR ALL IN-SCOPE PHYSICIANS
WHO HAVE REFUSED TO PARTICIPATE.

I appreciate that you choose not to participate in the study, but I would like to ask a few
short questions about your practice so we can make sure responding physicians do not differ
from nonresponding physicians.

10a. At how many different office locations, do you
see ambulatory patients? Do not include
settings such as EDs, outpatient departments,
surgicenters, and Federal clinics.

Number of
office locations
Number of weeks

b. In a typical year, about how many weeks do
you NOT see ambulatory patients (e.g.,
conferences, vacations, etc.)?

c. You typically see patients fewer than half
the weeks in each year. Is that correct?

FORM NAMCS-1A (4-22-2014)

If > 26 weeks, ask item 10c.
If = 0, SKIP to item 10d.
If 1 to 26 weeks,
SKIP to item 10e.
1
2

Yes – SKIP to item 10e.
No – Please explain

}

SKIP to
item 10e

Page 3

Section I – TELEPHONE SCREENER – Continued

10d. You typically see patients all 52 weeks of
the year. Is that correct?
1
2

Yes
No – Please explain

e. During your last normal week of practice,
how many patient visits did you have at all
office locations?

Number of
patient visits

f. During your last normal week of practice,
how many hours of direct patient care did
you provide?
NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services. Do not include hours from EDs, outpatient
departments, surgicenters, or Federal clinics.

Number of
weekly hours

g. At the office location where you see the most
ambulatory patients:
(1) How many physicians are associated with
you?

(2) Is this a single- or multi-specialty group
practice?

Number of physicians
If number of other physicians
is 0, SKIP to item 10g(3).

1
2

(3) Are you a full- or part-owner, employee, or
an independent contractor?

1
2
3
4

Multi
Single

Full-owner – SKIP to exit items
Part-owner
Employee SKIP to item 10g(4)
Contractor

}

(4) Who owns the practice?
1
2

REFER TO FLASHCARD A.

3
4
5
6
7

Page 4

Physician or physician group
Insurance company, health plan, or HMO
Community Health Center
Medical/Academic health center
Other hospital
Other health care corporation
Other – Specify

FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW
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.

11a. Overall, at how many office locations do you see
ambulatory patients? Do not include settings such
as EDs, outpatient departments, surgicenters, and
Federal clinics.

b. In a typical year, aabout how many weeks do you

Number of locations

Number of weeks

NOT see any ambulatory patients (e.g.,
conferences, vacations, etc)?

c. You typically see patients fewer than half
the weeks in each year. Is that correct?

d. You typically see patients all 52 weeks of the year.
Is that correct?

If > 26 weeks, ask item 11c.
If = 0, SKIP to item 11d.
If 1 to 26 weeks,
SKIP to item 12a.
1
2

1
2

Yes – SKIP to item 12a
No – Please explain

}

SKIP to
item 12a

Yes
No – Please explain

12a. This study will be concerned with the AMBULATORY
patients you will see in your office(s) during the week
of Monday,
_______________ through Sunday,_______________.
Are you likely to see any ambulatory patients in your
office(s) 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, mark "Yes.")

1
2

Yes –SKIP to item 13a on page 6
No

b. Why is that? Record verbatim.
(If appropriate, read item 15c below and leave forms with physician. Otherwise, SKIP to item 16a on page 8.)
(If appropriate, read item 12c below. Otherwise, SKIP to item 13a on page 6.)

c. Since it’s very important that we include any ambulatory patients that you might see in your
office during that week, I’ll check back with your office just before (Starting date) to make sure your
plans have not changed.

FR, PLEASE READ
BEFORE CONTINUING
FORM NAMCS-1A (4-22-2014)

FR Instruction – Even though the physician/provider is not available during the reporting
week, continue with item 13a on page 6.
Page 5

Section II – INDUCTION INTERVIEW – Continued

13a. At what office location(s) will you

of settings that describe each location where you
work. For each location enter all setting types that apply. (If any
even numbered settings are entered, they are out-of-scope.)

see ambulatory patients during
your practice’s 7-day reporting
period Monday,
through Sunday,

?

(1) Are there any other office
locations at which you will see
ambulatory patients during that
7-day reporting period? (Up to 5
offices can be recorded).

(2) What is the street address?

(3) In what city is this office
located?

13b. Looking at FLASHCARD B below, choose ALL of the type(s)

If FLASHCARD number 3 (free-standing clinic/urgicenter) is
entered, ask –
Is this/that clinic in an institutional setting (#8), in an
industrial outpatient facility (#10), or operated by the
Federal Government (#12)?
If FLASHCARD number 11 (family planning clinic) is entered, ask –
Is this/that clinic operated by the Federal Government
(#12)?
If in doubt about any (clinic/facility/institution), PROBE –
(1) Is this/that clinic/facility/institution part of a
hospital emergency department or an outpatient
department? If yes, select 2 or 4.
(2) Is this/that clinic/facility/institution operated by
the Federal Government? If yes, select 12.

(4) In what state is this office?

(5) What is the zip code for this
office?
Edit

FLASHCARD B
(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’ clinics)

(6) Ambulatory surgicenter
(8) Institutional setting (school infirmary,
nursing home, prison)

(7) Mental health center

(10) Industrial outpatient facility

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

(12) Federal Government operated clinic
(e.g., VA, military, etc.)

(11) Family planning clinic (including Planned
Parenthood)

(14) Laser vision surgery

(13) Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)
(15) Faculty practice plan

13c. Are there other office locations where you NORMALLY
would see patients, even though you will not see any during
your 7-day reporting period? Do not include settings such
as EDs, outpatient departments, surgicenters, and Federal
clinics.

1
2

Yes – SKIP to item 13d
No – SKIP to item 14a

d. Of these locations where you will not be seeing patients during
your 7-day reporting period, how many total office visits did
you have during your last week of practice at these locations?
Page 6

Number of visits
FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued
Ask item 14a ONCE to obtain total for ALL in-scope locations.

14a. During the week of Monday, ____________ through Sunday, ___________ how many days do
you expect to see any ambulatory patients at the following locations? (Only include days
at in-scope locations.)
NOTE – NON-PARTICIPATING PHYSICIANS: If
refusal or unavailable, enter the number of days in a
normal week.

Edit

Estimated Number
of Days

Enter street name or town of in-scope location(s).
NOTE: Keep the location numbers the same as the office numbers in item 13a.
Office location No.

#1

#2

#3

#4

#5

b. During your last normal week of practice,
approximately how many office visit encounters
did you have at each office location?
NOTE: If physician is in group practice, only
include the visits to sampled physician.

Number
of visits

_____ _____

_____

_____ _____

Edit

c. During the week of Monday, ____________ through
Sunday ____________, do you expect to have about
the same number of visits as you saw during
your last normal week in each office taking into
account time off, holidays, and conferences?

Yes . . .
No . . . .

1

1

1

1

1

2

2

2

2

2

NOTE: Enter (X) response. If answer is "Yes", instrument
copies the number in 14b to 14d for that office location. If
answer is "No" then item 14d is ASKED for that office
location.

d. Approximately how many ambulatory visits do
you expect to have at this office location?

Number
of visits

_____

_____ _____ _____ _____

e. Tally of estimated number of visits
NOTE: To obtain the total number of estimated visits,
instrument adds the estimate for each office location in
14d.
Now, I’m going to ask about your practice at
(in-scope location).

15a. Do you have a solo practice, or are you

Number of visits
_____
Office Location

#1

#2

Solo . . . . . .

1

1

associated with other physicians in a
partnership, in a group practice, or in some
other way at (this/that in-scope location)?

#3
1

#4

#5

1

1

2

2

If Solo, SKIP to item 15d.
Nonsolo . . .

2

2

2

_____

_____

Multi . . . . . .

1

1

1

1

1

Single . . . . .

2

2

2

2

2

b. How many physicians are associated with you
at (this/that in-scope location)?
How many

c. Is this a single- or multi-specialty (group)
practice at (this/that in-scope location)?

FORM NAMCS-1A (4-22-2014)

_____ _____ _____

Page 7

Section II – INDUCTION INTERVIEW – Continued

15d. How many mid-level providers (i.e., nurse
practitioners, physician assistants, and
nurse midwives) are associated with you at
(this/that in-scope location)?

#1

#2

_____

_____

Office Location

How many

e. Are you a full- or part-owner, employee, or an Full-owner . . . . . . .
independent contractor at (this/that in-scope
location)? If "Owner" is marked then automatically
mark "Physician or physician group" in item 15f.

f. Give FLASHCARD A (p.1 Flashcard and
Job Aid Booklet) and ask:
Who owns the practice at (this/that in-scope
location)?

Part-owner . . . . . .
Employee . . . . . . .
Contractor . . . . . . .
Physician –
Physician group . . . .
Insurance company,
health plan, or
HMO . . . . . . . . . .
Community Health
Center . . . . . . . . .
Medical/ Academic
health center . . . . .
Other hospital . . . .
Other health care corp
Other . . . . . . . . . .

#3

#5

#4

_____ _____ _____

1

1

1

1

1

2

2

2

2

2

3

3

3

3

3

4

4

4

4

4

1

1

1

1

1

2

2

2

2

2

3

3

3

3

3

4

4

4

4

4

5

5

5

5

5

6

6

6

6

6

7

7

7

7

7

g. Does your practice have the ability to
perform any of the following on site at
(this/that in-scope location)?
1. EKG/ECG

1
2
3

2. Phlebotomy

1
2
3

3. Lab testing (not including urine dipstick,
urine pregnancy, fingerstick blood
glucose, or rapid swab testing for
infectious diseases)

1

4. Spirometry

1

2
3

2
3

5. Ultrasound

1
2
3

6. X-Ray

1
2
3

h. Do you see patients in the office during the
evening or on weekends at (this/that in-scope
location?

1
2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

Yes
No
DK

1

2
3

2
3

2
3

2
3

2
3

2
3

2
3

Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK

i. What is your National Provider Identifier
(NPI) at (this/that in-scope location?

j. What is your Federal Tax ID at (this/that
in-scope location?

Page 8

FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued

16a. During your last normal week of practice,
how many hours of direct patient care did
you provide?

Number of
weekly hours

NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.

b. During your last normal week of practice,

Number of encounters
per week

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

..............

The next set of questions pertain to characteristics of the sampled physician’s healthcare
workforce, including physicians and other allied health care providers.
IF ONE LOCATION LISTED IN NAMCS-1A
DISPLAY THE FOLLOWING:

17. How many physicians, including you, are
associated with this practice? Please include
physicians at [fill address of sampled
location], and physicians at any other
locations of this practice.

1
2
3

1 physician
2–3 physicians
4–10 physicians

4

1 physician
2–3 physicians
4–10 physicians

4

5
6

11–50 physicians
51–100 physicians
More than 100 physicians

IF TWO OR MORE LOCATIONS LISTED IN
NAMCS-1A, DISPLAY THE FOLLOWING
TEXT AND QUESTION:
The next questions are about the location
where you have the most office visits.

17. How many physicians, including you, are
associated with that practice? Please include
physicians at [fill address of location with the
most office visits based on NAMCS-1A], and
physicians at any other locations of that
practice.

18. Is your practice certified as a

1
2
3

a

patient-centered medical home?

6
c
FORM NAMCS-1A (4-22-2014)

6

11–50 physicians
51–100 physicians
More than 100 physicians

Yes – By whom is your practice certified as a
patient-centered medical home? Mark (X) all that apply.
1
Accreditation Association
for Ambulatory Health (AAAH)
2
Joint Commission
National Committee for
3
Quality Assurance (NCQA)
What is the level of certification for
the National Committee for Quality
Assurance (NCQA)?
(a)
Level 1
(b)
Level 2
Level 3
(c)
4
Utilization Review Accreditation
Commission (URAC)
5

b

5

Other – Specify
Unknown

No
Unknown
Page 9

19. Give FLASHCARD H (p. 8 Flashcard and Job Aid Booklet) and ask: 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.
Number Full-time
( ≥ 30 hours)

Type of Provider

Number Part-time
(<30 hours)

Physicians (MD and DO)
Non-Physician Clinicians

Physician Assistants (PA)
Nurse Practitioners (NP)
Certified Nurse Midwives (CNM)
Other Nursing Care

Registered nurses (RN) (not an NP or CNM)
Licensed Practical Nurses (LPN)
Certified Nursing Assistants/Aides (CNA)
Allied Health

Medical Assistants (MA)
Radiology Technicians (RT)
Laboratory Technicians (LT)
Physical Therapists (PT)
Pharmacists (Ph)
Dietitians/Nutritionists (DN)
Other

Mental Health Providers (MH)
Health Educators/Counselors (HEC)
Case Managers (not RNs)/Certified Social
Workers (CSW)
Community Health Workers (CHW)
Page 10

FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued

20. At the office location where you have the most office visits, which

Mark (X) all that apply.

type of provider most commonly performs the following tasks?
Mark (X) all that apply.
Based on the staff selected in Question 19, a drop-down list will be made available Yes
for each of the following questions a–m, but will only contain those selected providers
as well as "Unknown" and "Task is not performed in this office" if needed.
Records
Body Measurements (such as height and weight) and
a.
1
vital signs (such as blood pressure, temperature, heart rate)
b. Performs office-based testing such as EKG and hearing/vision
1
testing (do not include laboratory testing)
1
c. Draws blood for lab testing

d. Provides immunizations (includes both childhood and adult)
e. Conducts cancer screenings (such as breast, cervical, and
f.
g.
h.
i.
j.
k.
l.

prostate screenings)
Provides behavioral health screenings (such as depression, alcohol
and substance abuse)
Provides counseling services (such as diet/nutrition, weight
reduction, tobacco cessation, stress management)
Manages the routine care of patients with chronic conditions
(such as hypertension, asthma, diabetes)
Writes refill prescriptions for medications
Enters patient information into medical/billing records
Performs imaging tests (such as X-rays and ultrasounds)
Makes referrals (for example, to specialty care, or to communitybased services)

No

Unknown

Task is
not
performed
in this office

2

3

4

2

3

4

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

Yes,

No

m. Contacts patients, who are transitioning from hospital or nursing
home back to the community

21a. The following questions concern the mid-level providers

Yes,

Unknown/
Not applicable

practicing at the location where you have the most office visits. always sometimes
Physician Assistant
(1) Are PA(s) supervised by someone on-site? . . . . . . . . . . . . . . . . . . 1
2

3

4

(2) Do you sign-off on the medical records of the patients
the PA(s) see(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

(3) Do the PA’s patients have a separate log from your patients?

1

2

3

4

(4) Is your approval required before the PA(s) prescribe(s)
medication? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

b. Nurse Practitioner
(1) Are NP(s) supervised by someone on-site? . . . . . . . . . . . . . . . . . .

1

2

3

4

(2) Do you sign-off on the medical record of the patients the
NP(s) see(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

(3) Do the NP’s patients have a separate log from your patients?
(4) Is your approval required before the NP(s) prescribe(s)
medication? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Do/does the NP(s) bill for services using their own
NPI number? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Certified Nurse Midwife
(1) Are CNM(s) supervised by someone on-site? . . . . . . . . . . . . . . . .
(2) Do you sign-off on the medical record of the patients the
CNM(s) see(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Do the CNM’s patients have a separate log from your
patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Is your approval required before the CNM(s) prescribe(s)
medication? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Do/does the CNM(s) bill for services using their own NPI
number? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FORM NAMCS-1A (4-22-2014)

Page 11

The remaining questions are to be answered for the practice that is associated
with the location where the physician has the most office visits. When defining
this location, include only in-scope locations previously listed.

22. Is it possible within your practice to access

a

patient medical records using an electronic
health record (EMR) system 24 hours a
day?

b
c

23. 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
2
3

4
5
6

24. 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
2
3

25. Does your practice have written protocols for

1

providing chronic care services that are used
by all members of the care team?

2

26. Does your practice report any quality
measures or quality indicators to either
payers or to organizations that monitor health
care quality?

27. 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?

3
1
2

Yes – Is this access available to
physicians only, or is it also
available to other non-physician
clinicians? Mark (X) all that apply.
1
Physicians (MD/DO) only
2
All Physicians and Non-physician Clinicians
Unknown
3
No
Unknown
Electronic transmission (i.e., EHR or EMR)
Fax
Email – If yes – Was this email sent over a
secure network?
1
Yes 2 No 3 Unknown
Telephone or in-person communication with provider
Paper copy
Other
Yes
No
Unknown
Yes
No
Unknown
Yes
No
All use the same Federal Tax ID
Some use a different Federal Tax ID
Unknown

1
2
3

Answer ALL remaining questions for the in-scope location with the most visits which
is (in-scope location).
1
Yes
28. Does the reporting location submit any
claims electronically (electronic billing)?
2
No
3
Unknown

29a. Does the reporting location use an electronic
health record (EHR) or electronic medical
record (EMR) system? Do not include billing
record systems.

1
2
3
4

}

Go to
Yes, all electronic
Yes, part paper and part electronic Question 29b
No
SKIP to Question 32 on page 13
Unknown

}

b. In which year did you install your current
EHR/EMR system?

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

d. What is the name of your current EHR/EMR
system?
Enter (X) only one box. If "Other" is checked, please
specify the name.

Year
1
2
3
1
2
3
4
5
6
7
8

Page 12

Yes
No
Unknown
Allscripts
Amazing Charts
athenahealth
Cerner
eClinicalWorks
e-MDs
Epic
GE/Centricity

14

Greenway Medical
McKesson/Practice Partner
NextGen
Practice Fusion
Sage/Vitera
Other – Specify

15

Unknown

9
10
11
12
13

FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued

30. Has your practice made an assessment of the

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

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

2
3

Yes
No
Unknown

1
2
3

Yes
No
Maybe
Unknown

1
2
3
4

33a. 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?
b. Are there plans to apply for Stage 2 incentive
payments?

Yes, we already applied – Go to 33b
Yes, we intend to apply
Uncertain if we will apply SKIP to Question 34
No, we will not apply

1

}

2
3
4

Yes
No
Maybe
Unknown

1
2
3
4

34.

Give FLASHCARD C (p.3 Flashcard and Job Aid Booklet)
and ask: Please indicate whether the ambulatory
reporting location has each of the following
computerized capabilities and how often these
capabilities are used. Enter (X) only one per row.

Yes
No
Unknown

1

potential risks and vulnerabilities of your electronic
health information within the last 12 months? This
would help identify privacy or security related
issues that may need to be corrected.

Yes,
used
routinely

Yes, but
NOT
used
routinely

Yes, but
turned
off or not
used

No

Unknown

a. Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

b. Recording patient problem list? . . . . . . . . . . .
c. Recording and charting vital signs? . . . . . . . . . . .

1

2

3

4

5

1

2

3

4

5

d. Recording patient smoking status? . . . . . . . . . . .
e. Recording clinical notes? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

1

2

3

4

5

f. Recording patient’s medications and allergies?
g. Reconciling lists of patient medications to
identify the most accurate list? . . . . . . . . . . . . . . .
h. Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . . .
i. Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

Go to
34i(1)

Go to
34i(1)

3

Skip to
34j

4

Skip to
34j

5

Skip to
34j

If Yes, ask – (1) Are prescriptions sent
electronically to the pharmacy?

1

2

3

4

5

If Yes, ask – (2) Are warnings of drug interactions
or contraindications provided?

1

2

3

4

5

If Yes, ask – (3) Are drug formulary checks
performed?

1

2

3

4

5

j. Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Go to
34j(1)
If Yes, ask – (1) Are orders sent electronically?
k. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . .

FORM NAMCS-1A (4-22-2014)

3

Skip to
34k

4

Skip to
34k

1

2

3

4

1

2

3

4

Go to
34k(1)
If Yes, ask – (1) Can the EHR/EMR automatically
graph a specific patient’s lab
results over time?

Go to
34j(1)

1

Go to
34k(1)

2

Skip to
34l

3

Skip to
34l

4

5

Skip to
34k
5
5

Skip to
34l

5

Page 13

Section II – INDUCTION INTERVIEW – Continued
Yes,
used
routinely

Yes, but
NOT
used
routinely

Yes, but
turned
off or not
used

No

Unknown

34l. Ordering radiology tests? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

m. Viewing imaging results? . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

n. Identifying educational resources for patients’
specific conditions? . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

o. Reporting clinical quality measures to federal or
state agencies (such as CMS or Medicaid)? . . . . . .

1

2

3

4

5

p. Identifying patients due for preventive or follow-up
care in order to send patients reminders? . . . . . . . .

1

2

3

4

5

q. Generating lists of patients with particular
health conditions? . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

r. Electronic reporting to immunization
registries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

s. Providing patients with clinical summaries for
each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

3

4

5

t. Exchanging secure messages with patients? . . .

1

2

3

4

5

1

2

3

4

5

u. Providing patients the ability to view online,
download, or transmit information from their
medical record? . . . . . . . . . . . . . . . . . . . . . . . . . .

35a. Do you refer any of your patients to providers
outside of your office or group?
b. Do you send the patient’s clinical information to
the other providers?

1
2
1
2
3

c. Do you send it electronically (not fax)?

1
2
3

36a. Do you see any patients referred to you by
providers outside of your office or group?
b. Do you send a consultation report with clinical
information to the other providers?

1
2
1
2
3

c. Do you send it electronically (not fax)?

1
2
3

37a. Do you take care of patients after they are
discharged from an inpatient setting?
b. Do you receive a discharge summary with
clinical information from the hospital?

1
2
1
2
3

c. Do you receive it electronically (not fax)?

1
2
3

d. Can you automatically incorporate the received
information into your EHR system without
manually entering the data?

1
2
3

Page 14

Yes – Go to Question 35b
No – SKIP to Question 36a
Yes, routinely
Yes, but not routinely
No – SKIP to Question 36a
Yes, routinely
Yes, but not routinely
No
Yes – Go to Question 36b
No – SKIP to Question 37a
Yes, routinely
Yes, but not routinely
No – SKIP to Question 37a
Yes, routinely
Yes, but not routinely
No
Yes – Go to Question 37b
No – SKIP to Question 38a
Yes, routinely
Yes, but not routinely
No – SKIP to Question 38a
Yes, routinely
Yes, but not routinely
No – SKIP to Question 38a
Yes
No
Not applicable, I do not have an EHR system
FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued
The next questions are about sharing (either sending or
receiving) patient health information.

38a. Do you share any patient health information
electronically (not fax) with other providers,
including hospitals, ambulatory providers, or labs?
b. How do you electronically share patient health
information? Enter (X) all that apply.

1
2
1
2
3

c. Is the patient health information that you share
electronically sent directly from your EHR
system to another EHR system?

1
2
3
4

d. With what types of providers do you
electronically share patient health information
(e.g., lab results, imaging reports, problem lists,
medication lists)?

1
2
3
4
5
6
7

Yes
No – SKIP to Question 39
EHR/EMR
Web portal (separate from EHR/EMR)
Other electronic method (not fax)
Yes, routinely
Yes, but not routinely
No
Unknown
Ambulatory providers inside your office/group
Ambulatory providers outside your office/group
Hospitals with which you are affiliated
Hospitals with which you are not affiliated
Behavioral health providers
Long-term care providers
Home health providers

Please remind physician/provider that the remaining questions refer to all offices
that were determined to be in-scope.
Give FLASHCARD E (p. 5 Flashcard and Job Aid Booklet)
and ask: I would like to ask a few questions about
your practice revenue and contracts with
managed care plans.

39. Roughly, what percent of your patient care
revenue comes from –

Percent of patient
care revenue

(1) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(2) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(3) Private insurance?. . . . . . . . . . . . . . . . . . . . . . . .

%

(4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . .

%

(5) Other (including charity, research, Tricare,
VA, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
Revenue sources should sum close to 100%.

40. Roughly, what percentage of the patient care
revenue received by this practice comes from
managed care contracts?

Percent of revenue from
managed care

%
41. Give FLASHCARD F (p.6 Flashcard and Job Aid Booklet)
and ask: Roughly, what percent of your patient
care revenue comes from each of the following
methods of payment?

Percent of patient care
revenue

(a) Fee-for-service? . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(b) Capitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(c) Case rates (e.g., package pricing/episode
of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%

(d) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%
Revenue sources should sum close to 100%.

FORM NAMCS-1A (4-22-2014)

Page 15

Section II – INDUCTION INTERVIEW – Continued

42a. Are you currently accepting "new" patients into your

3

Yes – Go to 42b
No
SKIP to item 43
Don’t know

(1) Capitated private insurance? . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(2) Non-capitated private insurance?

.............

1

Yes

2

No

3

Don’t know

(3) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

Yes

2

No

3

Don’t know

(4) Medicaid?

1

Yes

2

No

3

Don’t know

.....................

1

Yes

2

No

3

Don’t know

...................................

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Fixed salary
Share of practice billings or workload
Mix of salary and share of billings or other
measures of performance (e.g., your own
billings, practice’s financial performance,
quality measures, practice profiling)
Shift, hourly or other time-based payment
Other

practice(s) at (in-scope locations)?

1
2

}

b. From those "new" patients, which of the following
types of payment do you accept at (in-scope locations)?

..................................

(5) Workers’ compensation?
(6) Self-pay?

(7) No charge?

.................................

43. Which of the following methods best describes your
basic compensation?

2
3

4
5

44. Clinical practices may take various factors into
account in determining the compensation (salary,
bonus, pay rate, etc.) paid to the physicians in the
practice. Please indicate whether the practice
explicitly considers each of the following factors in
determining your compensation.
Enter (X) all that apply.

1
2
3
4

5

Factors that reflect your own productivity
Results of satisfaction surveys from
your own patients
Specific measures of quality, such as rates
of preventive services for your patients
Results of practice profiling, that is,
comparing your pattern of using medical
resources with that of other physicians
The overall financial performance of the
practice

45a. Roughly, what percent of your daily visits are
same day appointments?

%

b. Does your practice set time aside for same
day appointments?

1
2
3

c. On average, about how long does it take to get
an appointment for a routine medical exam?

1
2
3
4
5
6
7

Page 16

Yes
No
Don’t know
Within 1 week
1–2 weeks
3–4 weeks
1–2 months
3 or more months
Do not provide routine
medical exams
Don’t know

FORM NAMCS-1A (4-22-2014)

Section II – INDUCTION INTERVIEW – Continued
If provider is part of the community health center sample, item 46 is asked.

46.

Provider demographics –

a. What is your year of birth?

1 9

b. What is your sex?
1
2

Male
Female

c. What is your highest medical degree?
1
2
3
4
5
6

}

MD
Go to item 46d
DO
Nurse practitioner
Physician assistant SKIP to patient
record forms
Nurse midwife
Other

}

d. What is your primary specialty?

Name of specialty

Code

Name of specialty

Code

e. What is your secondary specialty?

f. What is your primary board certification?

Board certification

g. What is your secondary board certification?

Board certification

h. What year did you graduate from medical school?
Year

i. Did you graduate from a foreign medical school?
1
2

FORM NAMCS-1A (4-22-2014)

Yes
No
Page 17

Section III – DISPOSITION AND SUMMARY

47. CASE SUMMARY
a. Number of patient visits during reporting week .

b. Number of days during reporting week on which
patients were seen . . . . . . . . . . . . . . . . . . . . . . . . . .

c. Number of patient record forms completed . . . . .
Edit

Page 18

FORM NAMCS-1A (4-22-2014)