Form 0920-0212 Att K - Ann Amb Hosp Inter

National Hospital Care Survey

Att K - Ann Amb Hosp Inter

Annual Ambulatory Hospital Interview

OMB: 0920-0212

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Attachment K: Annual Ambulatory Hospital Interview





National Hospital Care Survey

OMB No. 0920-0212; Exp. Date: XX/XX/XXXX:
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 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).
Notice – Public reporting burden for this collection of information is estimated to average 90 minutes per response, including 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 (0920-0212).

INTRO_SCR

Text:

? [F1] Hello, (Respondent’s name),


This is (insert name). I’m calling on behalf of the Centers for Disease Control and Prevention's National Center for Health Statistics concerning their study of hospital outpatient and emergency departments and hospital-based ambulatory surgery locations. You should have received a letter from Charles Rothwell, the director of the National Center for Health Statistics, describing the study. Did you receive the letter(s)?


If “No” or “DK”, offer to send or deliver another copy.

1.

Yes

2.

No

3.

Don’t know



INTROB


Text:

Is respondent ready to complete the interview?

1.

Continue

2.

Inconvenient Time CallBackNotes

3.

Other Outcome Exit Case



INTRO_AB


Text:

I'd like to briefly explain the study to you at this time and answer any questions about it. CDC’s National Center for Health Statistics of the Centers for Disease Control and Prevention is conducting a study of hospital-based ambulatory care. 


They have contracted with Westat to collect the data. (Facility Name) has been selected to participate in the study. The study is authorized under the Public Health Service Act and the information will be held strictly confidential. Participation is voluntary.


Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study. First, concerning licensing:

1.

Enter 1 to Continue

LICHOSP


Text:

Is this facility a licensed hospital?

1.

Yes

2.

No Thank_B1

H_ELIGIBLE


Text:

Are there 6 or more hospital beds staffed for inpatient use at this hospital, not including “newborn” bassinets?

1.

Yes

2.

No Thank_B2



OWN101


Text:

Is this hospital nonprofit, government, or proprietary?


Read answer categories out loud

1.

Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)

2.

State or local government (includes state, county, city, city-county, hospital district or authority)

3.

Proprietary (includes individually or privately owned, partnership or corporation)



OWNHCC


Text:

Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?

1.

Yes

2.

No

3.

Unknown



TEACHOSP


Text:

Is this a teaching hospital?

1.

Yes

2.

No



MERGER


Text:

Did this hospital either merge or separate from any OTHER hospital in the past 2 years?

1.

Merged or separated MERSEP

2.

No ESA24

3.

Unknown ESA24



MERSEP


Text:

Was this a merger or a separation?

1.

Merger

2.

Separation



MERGMEDR


Text:

Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?

1.

Yes

2.

No

3.

Unknown



OTHNAME


Text:

What is the name and address of this OTHER hospital?


Enter name



OTHSTRET


Text:

What is the name and address of this OTHER hospital?

Enter number and street




OTHSTRET2


Text:

What is the name and address of this OTHER hospital?

Enter second line of address or press enter if same/none




OTHCITY


Text:

What is the name and address of this OTHER hospital?

Enter city




OTHSTATE


Text:

What is the name and address of this OTHER hospital?

Enter state




OTHZIP


Text:

What is the name and address of this OTHER hospital?

Enter zip code




ESA24


Text:

Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?

1.

Yes

2.

No



ESANOT24


Text:

Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?

1.

Yes

2.

No



TRAUMA


Text:

What is the trauma level rating of this hospital?

1.

Level I

2.

Level II

3.

Level III

4.

Level IV

5.

Level V

6.

Other/unknown

7.

None



OOOPD


Text:

Does this hospital operate an organized outpatient department either at this hospital or elsewhere?

1.

Yes

2.

No AMSURG



PHYSSERV


Text:

Does this OPD include physician services?

1.

Yes

2.

No



AMBSURG


Text:

Is ambulatory surgery performed at this hospital? This includes ambulatory surgery performed in the general or main operating room.

1.

Yes

2.

No



STUDY_DESC


Text:

Thank you.  
  
Provide the administrator or other hospital representative with a brief description of the study. Cover the following points –


Now I would like to provide you with further information on the study. The National Hospital Care Survey (NHCS) is a new survey combining the National Hospital Discharge Survey and the National Hospital Ambulatory Medical Care Survey.


(1) NHCS will be the only source of national data on health care provided in hospital emergency and outpatient departments, including ambulatory surgery.

(2) NHCS includes a nationwide sample of 581 hospitals.

(3) A brief form will be completed for a sample of patient visits. As one of the hospitals that has been selected, your contribution will be of great value in the survey.




INDUCTION_APPT


Text:

I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative? 

 
If so, please create an appointment EROC in the AMS for when to conduct the interview.
Otherwise, enter 1 if the respondent wants to continue with the induction now.

1.

Start Induction

2.

Exit Instrument/Make appointment



SCREENER_THK


Text:

Thank you for your cooperation.  I am looking forward to our meeting.

1.

Enter 1 to Continue



THANK_MERGSEP


Text:

Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed.  I will call you back within a week and let you know which parts of your hospital will be in the survey.  Thank you for your cooperation. 


At this time, please exit the instrument using the F10 button and call your Field Manager to discuss this hospital’s merger or separation. They will work with the CDC to decide on their future participation. You should await the resolution before continuing with this hospital.


1.

Enter 1 to Continue



THANK_B1


Text:

Thank you, but it seems that our information is incorrect.
Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.

1.

Enter 1 to Continue



THANK_B2


Text:

Thank you, but it seems that our information is incorrect.
Since (facility name) does not have 24-hour emergency services or an outpatient department, it should not have been chosen for our study.  Thank you very much for your cooperation.

1.

Enter 1 to Continue



REVIEW


Text:

I would like to begin with a brief review of the background for this study.
Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures.


Press F1 for points to be covered.

1.

Enter 1 to Continue



SURGDAY


Text:

Now I would like to ask you a few more questions about your hospital.
How many days in a week are inpatient elective surgeries scheduled?

Enter F5 for unknown. 

BEDCZAR


Text:

?[F1] Does your hospital have a bed coordinator, sometimes referred to as a bed czar?

1.

Yes

2.

No

3.

Unknown



BEDDATA


Text:

How often are hospital bed census data available?

Read answer categories. 


1.

Instantaneously

2.

Every 4 hours

3.

Every 8 hours

4.

Every 12 hours

5.

Every 24 hours

6.

Other BEDDATA_OT

7.

Unknown



BEDDATA_OTHSP


Text:

How often are hospital bed census data available? – Other, specify.




HLIST


Text:

Does your hospital have hospitalists on staff?
A hospitalist is a physician whose primary professional focus is the general care of hospitalized patients.  He/she may oversee ED patients being admitted to the hospital.

1.

Yes

2.

No EMEDRES

3.

Unknown EMEDRES



HLISTED


Text:

Do the hospitalists on staff at your hospital admit patients from your ED?

1.

Yes

2.

No

3.

Unknown



EMEDRES


Text:

Does this hospital have an emergency medicine residency program?

1.

Yes

2.

No

3.

Unknown



MUINC


Text:

?[F1]

Medicare and Medicaid offer incentives to hospitals that demonstrate “meaningful use of health IT.” Does your hospital have 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 HOSPMEDREC

4.

No, we will not apply HOSPMEDREC



MUSTAGE2


Text:

?[F1]

Are there plans to apply for Stage 2 incentive payments?

1.

Yes

2.

No

3.

Maybe

4.

Unknown





HOSPMEDREC


Text:

Does your hospital currently use an electronic health record (EHR) or electronic medical record (EMR) system for ambulatory/outpatient records?  Do not include the inpatient record system or billing record systems.

  • Read answer categories out loud


1.

Yes, our hospital uses an EHR/EMR system for all ambulatory/outpatient records

2.

Yes, our hospital has part paper and part electronic ambulatory/outpatient records

3.

No, our hospital currently has all paper ambulatory/outpatient records

4.

Unknown



REMACC


Text:

Now I’d like to ask you some questions about your hospital’s electronic health records system. Can this system be accessed from the outside by entities not associated with the hospital?

1.

Yes

2.

Unsure (will have to check and get back to interviewer)

3.

No VSREPPER

4.

Unknown VSREPPER



REMREP


Text:

Would your hospital be willing to allow CDC’s contractor to obtain password access to your hospital’s electronic health records system and load the charting software onto desktop computers at their headquarters?


The contractor’s Data Security Plan complies with all relevant laws, regulations, and policies governing the security of data and protection of confidentiality.

1.

Yes

2.

Unsure (will have to check and get back to interviewer)

3.

No

4.

Unknown



VSREPPER


Text:

Now I would like to make arrangements to obtain the information needed for sampling. I will need to know how your emergency department is organized and obtain an estimate of the number of patient visits expected during the 12 week reporting period.  Would you prefer I get this information from you or someone else?

1.

Respondent CONTACT_DEPT

2.

Someone else CINFO



CINFO


Text:

What is the name of the person I should talk to?

  • To add additional contacts, please use the AMS


1.

Enter 1 Continue



THANK_RESP


Text:

Thank current respondent for his/her time and cooperation



CONTACT_DEPT


Text:

Enter the department you plan to interview. If necessary, briefly explain the survey to new respondents.


If a department is refusing, enter 4. You will be prompted to select which department is refusing.


Department    Status
ED      (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
OPD   (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)


1.

ED Intro_ED

2.

OPD Intro_OPD

4.

Department refusal Which_Dept



INTRO_ED


Text:

  • If necessary, introduce yourself and explain the survey


Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department.

1.

Enter 1 Continue



ESA_NAME


Text:

(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?)

  • Enter 999 for no more



ESA_TYPE


Text:

What type of ESA is (ESA name)?


1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other



ESA_EVISITS


Text:

What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?



TYPETRIAGE


Text:

What type of triage system does your ESA use?


1. Emergency Severity Index (ESI)


2. Canadian Triage and Acuity Scale (CTAS)


3. Other, specify


4. Do not conduct triage ED_EMR


5. Unknown



NUMTRLEV


Text:

How many levels are in (ESA name's) triage system?


1.Three


2. Four


3. Five


4. Other - Specify



NUMTRLEV_SP


Text:

Specify other triage levels

ED_EMR


Text:

  • Enter 1 to continue to the EMR questions OR Enter 2 to skip EMR questions and complete later.


1.

Continue to EMR questions

2.

Skip EMR questions ESA_ONSITE



EBILLRECE


Text:

Now I would like to ask you some questions about your ED.


  • If ESAs within the ED vary with respect to their use of the EHR/EMR systems, then ask these questions of the ESA with the largest number of expected visits during the reporting period.


Does your ED submit any
CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown





EMEDRECE


Text:

Does your ED use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system?  Do not include billing record systems.

  • Use Flashcard or read answer categories


1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No EMRINSE

4.

Unknown EMRINSE



EHRINSYRE


Text:

In which year did your ED install the EHR/EMR system?



Year:



HHSMUE


Text:

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

1.

Yes, all electronic

2.

No

3.

Unknown



EHRNAME13


Text:

What is the name of your current EHR/EMR system?

1.

Allscripts EMRINSE

2.

Amazing Charts EMRINSE

3.

athenahealth EMRINSE

4.

Cerner EMRINSE

5.

eClinicalWorks EMRINSE

6.

e-MDs EMRINSE

7.

Epic EMRINSE

8.

GE/Centricity EMRINSE

9.

Greenway Medical EMRINSE

10.

McKesson/Practice Partner EMRINSE

11.

NextGen EMRINSE

12.

Practice Fusion EMRINSE

13.

Sage/Vitera EMRINSE

14.

Other - Specify

15.

Unknown EMRINSE



EHRNAMOTHE



Text:

  Enter name of EHR/EMR system



SECURCHCKE

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

1.

Yes

2.

No

3.

Unknown



DIFFEHRE

Does your ED 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



EHRINSE


Text:

Does your ED have plans for installing a new EHR/EMR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown



EDEMOGE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Recording patient history and demographic information?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EVITALE

5.

Unknown EVITALE



EPROLSTE


Text:

Recording patient problem list?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EVITALE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Recording and charting vital signs?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESMOKEE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Recording patient smoking status?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EPNOTESE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Recording clinical notes?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EMEDIDE

5.

Unknown EMEDIDE



EMEDALGE


Text:

Recording patient's medications and allergies?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EMEDIDE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Reconciling lists of patient’s medications to identify the most accurate list?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECPOEE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Ordering prescriptions?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EREMINDE

5.

Unknown EREMINDE



ESCRIPE


Text:

Are prescriptions sent electronically to the pharmacy?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EWARNE


Text:

Are warnings of drug interactions or contraindications provided?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown





EFORMULAE


Text:

Are drug formulary checks performed?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EREMINDE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Providing reminders for guideline-based interventions or screening tests?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECTOEE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Ordering lab tests?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No ERESULTE

5.

Unknown



EORDERE


Text:

Are orders sent electronically?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ERESULTE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Viewing lab results?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EIMGRESE

5.

Unknown EIMGRESE



EGRAPHE


Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ERADIE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Ordering radiology tests? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIMGRESE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Viewing imaging results? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EPTEDUE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Identifying educational resources for patient’s specific conditions? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECQME


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIDPTEE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EGENLISTE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Generating lists of patients with particular health conditions?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIMMREGE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Electronic reporting to immunization registries? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESUME


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Providing patients with clinical summaries for each visit?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EMSGE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


Exchanging secure messages with patients?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown







EPTRECE


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESHAREE


Text:

The next questions are about sharing (either sending or receiving) patient health information


Does your ED share any patient health information (e.g., lab results, imaging reports, problem lists, medication lists) electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No OBSUNITS

3.

Unknown OBSUNITS



ESHAREHOWE


Text:

How does your ED electronically share patient health information?

  • Use Flashcard or read answer categories

  • Enter all that apply, separate with commas



1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method

4.

Unknown

ESHAREHOWOTHE


Text:

Specify other electronic method



EHRTOEHRE


Text:

Is the patient information your ED shares electronically sent directly from your ED’s EHR system to another EHR system?


1.

Yes

2.

No

3.

Not applicable. ED does not have EHR system.

4.

Unknown



ESHAREPROVE


Text:

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

  • Enter all that apply, separate with commas

  • Use Flashcard or read answer categories


1.

Ambulatory providers inside your hospital

2.

Ambulatory providers outside your hospital

3.

Hospitals with which your hospital is affiliated

4.

Hospitals with which your hospital is not affiliated

5.

Behavioral health providers

6.

Long-term care providers

7.

Home health providers

8.

Do not share

9.

Unknown



EDPRIM


Text:

When patients with identified primary care physicians arrive at the ED, how often does your ED electronically send notification to the patients' primary care physicians?


  • Read answer categories


1.

Always

2.

Sometimes

3.

Rarely

4.

Never

5.

Unknown



EDINFO


Text:

When patients arrive at the Emergency Department, are you able to query for patients' healthcare information electronically (e.g. medications, allergies) from outside sources?

1.

Yes

2.

No

3.

Unknown



OBSUNITS


Text:

Does your ED have an observation or clinical decision unit?

1.

Yes

2.

No BOARD

3.

Unknown BOARD



OBSSEP         


Text:

Is this observation or clinical decision unit physically separate from the ED?

1.

Yes

2.

No

3.

Unknown



OBSDECMD


Text:

What type of physicians make decisions for patients in this observation or clinical decision unit?


  • Enter all that apply, separate with commas

  • Read answer categories
       

ED physicians

Hospitalists

Other physicians

Unknown


1.

ED physicians

2.

Hospitalists

3.

Other physicians

4.

Unknown



BOARD


Text:

Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?

1.

Yes

2.

No

3.

Unknown



BOARDHOS


Text:

Does your ED allow some admitted patients to move from the ED to inpatient corridors while awaiting a bed (“boarding”) – sometimes called a “full capacity protocol?”

1.

Yes

2.

No

3.

Unknown



AMBDIV


Text:

Did your ED go on ambulance diversion in 2013?

1.

Yes

2.

No

3.

Unknown



TOTHRDIV


Text:

What is the total number of hours that your hospital's ED was on ambulance diversion in 2013?
 
Enter F5 if data not available



REGDIV


Text:

Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?

1.

Yes

2.

No

3.

Unknown



ADMDIV


Text:

Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?

1.

Yes

2.

No NUMSTATX

3.

Unknown NUMSTATX



NUMSTATX


Text:

As of last week, how many standard treatment spaces did your ED have?
Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs.
 Enter F5 if data not available



NUMOTHTX


Text:

As of last week, how many other treatment spaces did your ED have?
Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times.
 Enter F5 if data not available



EDSPACES


Text:

In the last two years, did your ED increase the number of standard treatment spaces?

1.

Yes

2.

No

3.

Unknown



PHYSSPACE


Text:

In the last two years, did your ED's physical space expand?

1.

Yes

2.

No

3.

Unknown



EXPAND


Text:

Do you have plans to expand your ED's physical space within the next two years?

1.

Yes

2.

No

3.

Unknown



BEDREG


Text:

Does your ED use - Bedside registration?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



KIOSELCHK


Text:

Does your ED use Kiosk self check-in?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



CATRIAGE


Text:

Does your ED use - Computer-assisted triage?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown

IMBED


Text:

Does your ED use - Immediate bedding (no triage when ED is not at capacity)?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



ADVTRIAG


Text:

Does your ED use - Advanced triage (triage-based care) protocols?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



PHYSPRACTRIA


Text:

Does your ED use - Physician/Practitioner at triage?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



FASTTRAK


Text:

Does your ED use - Separate fast track unit for nonurgent care?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown

EDPTOR


Text:

Does your ED use - Separate operating room dedicated to ED patients?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



DASHBORD


Text:

Does your ED use - Electronic dashboard (i.e., displays updated patient information and integrates multiple data sources)?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



RFID


Text:

Does your ED use - Radio frequency identification (RFID) tracking (i.e., shows exact location of patients, caregivers, and equipment)?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



WIRELESS


Text:

Does your ED use - Wireless communication devices by providers?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



ZONENURS


Text:

Does your ED use - Zone nursing (i.e., all of a nurse's patients are located in one area)?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



POOLNURS


Text:

Does your ED use -   Pool nurses (i.e., nurses that can be pulled to the ED to respond to surges in demand)?


  • Use Flashcard or read answer categories


1.

Yes

2.

No

3.

Unknown



ESA_NAME


Text:

*** SHOW ONLY **



ESA_TYPE


Text:

** SHOW ONLY **

1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other

ESA_EVISITS


Text:

** SHOW ONLY **



ESA_ONSITE


Text:

Is (ESA name) on-site?

1.

Yes

2.

No



ESA_STRET


Text:

What is (ESA name)'s address?



ESA_PHONE


Text:

What is (ESA name)'s telephone number?



ESA_PHTYP


Text:

Enter phone type       



ESA_CONTACT


Text:

Enter ESA contact person's name       



EDK_CHECK


Text:

Are there any Don’t Know items that you need to call back for? Press Ctrl-M to review all Don’t Knows.      

1.

Yes

2.

No

EDWALL


Text:

This is the last screen of the Emergency Department section. If you progress past this screen you will no longer be able to edit this section.     

1.

Enter 1 to Continue



INTRO_OPD


Text:

If necessary, introduce yourself and explain the survey

Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's outpatient department.

1.

Enter 1 to Continue



CLIN_NAME


Text:

** SHOW ONLY **





CLIN_EVISITS


Text:

What was the total number of OPD visits that occurred in your hospital from (Begin date-End date)? Include visits for which no insurance claims were made.



SAMPLE_QUESTION


Text:

Patient visit information about the OPD has been entered.

Enter 1 to Continue to the OPD section of the Induction interview.

Enter 2 to return to the previous screen and revise patient visit information.

1.

Continue to OPD section

2.

Returns to previous screen CLIN_EVISITS



OPD_EMR


Text:

  • Enter 1 to continue to the EMR questions OR Enter 2 to skip EMR questions and complete later.


1.

Continue to EMR questions

2.

Skip EMR questions


EBILLRECO


Text:

Now I would like to ask you some questions about your OPD.


If clinics within the OPD vary with respect to their use of the EHR/EMR systems, then ask these questions of the clinic with the largest number of expected visits during the reporting period.


Does your OPD submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EMEDRECO


Text:

Does your OPD use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system?  Do not include billing record systems.


 Read answer categories

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No EMRINSO

4.

Unknown EMRINSO



MEDRECCEN


Text:

Are medical records for your OPD clinics centrally located?


  • Read answer categories


1.

Yes, all clinics

2.

Yes, some clinics

3.

No

4.

Unknown



EHRINSYRO


Text:

In which year did your OPD install the EHR/EMR system?


Year:



HHSMUO


Text:

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

1.

Yes, all electronic

2.

No

3.

Unknown



EHRNAMO13


Text:

What is the name of your current EMR/EHR system?

1.

Allscripts EMRINSO

2.

Amazing Charts EMRINSO

3.

athenahealth EMRINSO

4.

Cerner EMRINSO

5.

eClinicalWorks EMRINSO

6.

e-MDs EMRINSO

7.

Epic EMRINSO

8.

GE/Centricity EMRINSO

9.

Greenway Medical EMRINSO

10.

McKesson/Practice Partner EMRINSO

11.

NextGen EMRINSO

12.

Practice Fusion EMRINSO

13.

Sage/Vitera EMRINSO

14.

Other – Specify

15.

Unknown EMRINSO



EHRNAMOTHO


Text:

Enter name of EHR/EMR system.


SECURCHCKO

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

1.

Yes

2.

No

3.

Unknown



DIFFEHRO

Does your OPD 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



EMRINSO


Text:

Does your OPD have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown



EDEMOGO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Recording patient history and demographic information?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EVITALO

5.

Unknown EVITALO



EPROLSTO


Text:

Recordingpatient problem list?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EVITALO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Recording and charting vital signs?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESMOKEO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often are these capabilities used: 


Recording patient smoking status?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EPNOTESO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Recording clinical notes?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EMEDIDO

5.

Unknown EMEDIDO



EMEDALGO


Text:

Recording patient's medications and allergies?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EMEDIDO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Reconciling lists of patient’s medications to identify the most accurate list?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECPOEO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Ordering prescriptions?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EREMINDO

5.

Unknown EREMINDO




ESCRIPO


Text:

Are prescriptions sent electronically to the pharmacy?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EWARNO


Text:

Are warnings of drug interactions or contraindications provided?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EFORMULAO


Text:

Are drug formulary checks performed?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown




EREMINDO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Providing reminders for guideline-based interventions or screening tests?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECTOEO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Ordering lab tests?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No ERESULTO

5.

Unknown ERESULTO



EORDERO


Text:

Are orders sent electronically?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ERESULTO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: 


Viewing lab results?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No EIMGRESO

5.

Unknown EIMGRESO



EGRAPHO


Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ERADIO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Ordering radiology tests? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIMGRESO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Viewing imaging results? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EPTEDUO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Identifying educational resources for patient’s specific conditions? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ECQMO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIDPTEO


Text:

Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EGENLISTO

Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Generating lists of patients with particular health conditions?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EIMMREGO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Electronic reporting to immunization registries? 


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESUMO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 

  

Providing patients with clinical summaries for each visit?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EMSGO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


Exchanging secure messages with patients?


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



EPTRECO


Text:

Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 


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


  • Use Flashcard or read answer categories


1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown



ESHAREO


Text:

The next questions are about sharing (either sending or receiving) patient health information.

Does your OPD share any patient health information (e.g., lab results, imaging reports, problem lists, medication lists) electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No CLIN_STRET

3.

Unknown CLIN_STRET



ESHAREHOWO


Text:

How does your OPD electronically share patient health information?


  • Use Flashcard or read answer categories

  • Enter all that apply, separate with commas




1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method

4.

Unknown



ESHAREHOWOTHO

  • Specify other electronic method


EHRTOEHRO


Text:

Is the patient health information your OPD shares electronically sent directly from your OPD’s EHR system to another EHR system?

1.

Yes

2.

No

3.

Not applicable. OPD does not have EHR system.

4.

Unknown



ESHAREPROVO


Text:

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

  • Enter all that apply, separate with commas

  • Use Flashcard or read answer categories


1.

Ambulatory providers inside your hospital

2.

Ambulatory providers outside your hospital

3.

Hospitals with which your hospital is affiliated

4.

Hospitals with which your hospital is not affiliated

5.

Behavioral health providers

6.

Long-term care providers

7.

Home health providers

8.

Do not share

9.

Unknown



REFOUTO


Text:

Does your OPD refer any patients to providers outside of your OPD?

1.

Yes

2.

No REFINO

3.

Unknown



REFOUTSO


Text:

When your OPD refers a patient to a provider outside your OPD:

Does your OPD send the patient’s clinical information to the other providers?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No REFINO

4.

Unknown REFINO



REFOUTEO


Text:

Does your OPD send it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

4.

Unknown



REFINO


Text:

Does your OPD see any patients referred to your OPD by providers outside of your OPD?

1.

Yes

2.

No INPTCAREO

3.

Unknown INPTCAREO



REFINSO


Text:

Does your OPD send a consultation report with clinical information to the other providers?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No INPTCAREO

4.

Unknown INPTCAREO



REFINSEO


Text:

Does your OPD send it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

4.

Unknown



INPTCAREO


Text:

Does your OPD take care of patients after they are discharged from an inpatient setting?

1.

Yes

2.

No CLIN_STRET

3.

Unknown CLIN_STRET



DISSUMO


Text:

When a patient is discharged from an inpatient setting:

Does your OPD receive a discharge summary with clinical information from the hospital?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No CLIN_STRET

4.

Unknown CLIN_STRET



DISSUMEO


Text:

Does your OPD receive it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

4.

Unknown



INCORINFOO


Text:

Can your OPD automatically incorporate the received information into your EHR system without manually entering the data?

1.

Yes

2.

No

3.

Not applicable. OPD does not have EHR system.

4.

Unknown



Clin_NAME


Text:

*** SHOW ONLY **



CLin_Group


Text:

** SHOW ONLY **

1.

General medicine

2.

Surgery

3.

Pediatric

4.

Obstetrics/Gynecology

5.

Substance abuse

6.

Other

Clin_EVISITS


Text:

** SHOW ONLY **



OPD_ONSITE


Text:

  • Is [name of clinic] onsite?



CLIN_STRET


Text:

  • What is (Clinic Name)'s address?



CLIN_PHONE


Text:

What is Outpatient Department’s telephone number?



CLIN_PHTYP


Text:

  • Enter phone type       



CLIN_CONTACT


Text:

  • Enter clinic director/contact person's name       



OPDDK_CHECK


Text:

  • Are there any Don’t Know items that you need to call back for? Press Ctrl-M to review all Don’t Knows

1.

Yes

2.

No



OPDWALL


Text:

  • This is the last screen of the Outpatient Department section. If you progress past this screen you will no longer be able to edit this section.

1.

Enter 1 to continue





31



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCenters for Disease Control & Prevention
File Modified0000-00-00
File Created2021-01-24

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