List Q

1/24/2021

Attachment C3: 2015 NAMCS-1 List of all proposed questions for Traditional Office-based Physicians and CHC Providers

This table lists all proposed 2015 survey questions in the order that they would appear in the survey. In the computerized instrument, questions are not numbered, so question numbers are provided in the left column of this table, which corresponds to question numbers in the 2014 NAMCS-1 sample card found in Attachment C1. Question numbers 4a through 16b match exactly in 2014 and 2015. Starting at question 17, new questions were added for 2015 and will not match the 2014 sample card. Skip patterns in 2015 are included only if they diverge from 2014, otherwise, refer to Attachment C1 for skip patterns. Additions and modifications for 2015 are indicated in highlighted red font. Instructions for field representatives are in blue.

OMB No. 0920-0234 Exp. Date XX/XX/20XX

Notice-Public reporting burden for this collection of information is estimated to average 45 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 (0920-0234).

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).

Q#

Variable

Name

Traditional Office-based Physicians

CHC Providers

Section 1: Telephone Screener

4a

SPECVER

Your specialty is [Pre-filled Specialty],

Is that right?

1. Yes

2. No

N/A

4b

PRV_SPEC

What is your (your/Physician name's) specialty (including general practice)?

N/A

PRV_SPEC_SP

  Enter verbatim response for specialty

N/A

4c

PRVETHN

What is (your/Physician name's) ethnicity?

1. Hispanic or Latino

2. Not Hispanic or Latino

Same

4d

RACE

What is (your/Physician name's) race?  

         Enter all that apply, separate with commas

1. White

2. Black or African-American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

Same

5

PROFACT

Which of the following categories best describes (your/Physician name's) professional activity -
patient care, research, teaching, administration, or something else?

1. Patient Care

2. Research

3. Teaching

4. Administration

5. Something else – Specify PROFACT_SP

Same

6a

AMBCARE

(Do/Does) (you/physician's name) directly care for any ambulatory patients in (Your/ his/her) work?

1. Yes

2. No - does not give direct care

3. No longer in practice (i.e., retired, not licensed)

4. Temporarily not practicing (refers to duration of 3 months or more)

Same

Skip Instructions:

1: Goto FED
2: Goto VERIF9A
3: Goto THANK_OOS

4: Goto THANK_OOS

1: If CHCPROV = 1, goto ADDCHECK
2: Goto VERIF9A
3: Goto THANK_OOS

4: Goto THANK_OOS

6b

VERIF9A

We include as ambulatory patients, individuals receiving health services without admission to a hospital or other facility.  Does (your/Physician name's) work include any such individuals?

1. Yes, cares for ambulatory patients

2. No, does not give direct care

Specify reason VERIF9a_SP

Same

Skip Instructions:

1: Goto FED
2: Goto VERIF9A_SP

1: If CHCPROV =1, goto ADDCHECK
2: Goto VERIF9A_SP

6c

FED

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

1. Yes

2. No

N/A

Skip Instructions:

1: Goto PRIVPAT
2: Goto HOSPRIVPAT

N/A

6d

PRIVPAT

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

1. Yes

2. No

N/A

Skip Instructions:

1: Goto HOSPRIVPAT
2: Goto THANK_OOS

N/A

6e

HOSPRIVPAT

(do/does) (you/physician's name)  work in an office-based practice owned by a hospital?

1. Yes

2. No

N/A

Skip Instructions:

(1 or 2) AND FED = 1: Goto REMINDER
(1 or 2) AND FED = 2: Goto ADDCHECK

N/A

6f

REMINDER

  Although the physician works in a federal patient care setting, hospital emergency department, hospital outpatient department, or community health center please make sure the respondent is aware that all of the following questions are NOT concerned with these settings/patients/visits. The survey is ONLY concerned with their private patients.

N/A

7a

ADDCHECK

We have (your/Physician name's) address as
( Address)

Is that the correct address for your office?

1. Yes

2. No, update address

We have (your/Physician name's) address as
( Address)

Is that the correct address for the CHC?

1. Yes

2. No, update address

7b

NEW_PINFO

What is the correct address and phone number?

What is the correct address and phone number of your current CHC location?

8

THANK_OOS

Thank you, (Respondent's name/Physician's name), but since you are not currently practicing, our questions would not be appropriate for you.
I appreciate your time and interest.

Same

Skip Instructions:

IF AMBCARE = 3 goto WHYNO_PRACT
IF AMBCARE = 4 goto WHY_UNAVAIL

Same

8a

WHYNO_PRACT

  Why isn't the doctor practicing?

1. Retired

2. Not licensed

Deleted Temporarily not practicing

3. Other

Same

8b

WHY_OOS

Describe the provider's practice or medical activities which define him/her as

ineligible or out-of-scope.

Enter all that apply, separate with commas

1. Federally employed

2. Radiology, anesthesiology or pathology specialist

3. Administrator

4. Work in institutional setting

5. Work in hospital emergency department, hospital outpatient department, or community health center

6. Work in industrial setting

7. Ambulatory surgicenter

8. Laser vision surgery

9. Other – Specify WHY_OO_SP

Same

8c

WHY_UNAVAIL

Why is provider temporarily not practicing?

Verbatim response

Same

9

INDUCT_APPT

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

Same

Questions for Non-responding physicians (10a-10g)

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.

“Physicians” filled for Traditional physicians

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

“Providers” filled for CHC Providers

10a

NUMLOCR

Overall, at how many different office locations do you see ambulatory patients? Do not include settings such as EDs, outpatient departments, surgicenters, Federal Clinics, and community health centers.

Same

New

NUMLOCR_CHC

N/A

Overall, at how many different CHC locations do you see ambulatory patients?

10b

NOPATSENR

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

Same

10c

LTHALFR

LTHALFR_SP

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

1. Yes

2. No – Please explain LTHALFR_SP

Same

10d

ALLYEARR

ALLYEARR_SP

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

1. Yes

2. No – Please explain ALLYEARR_SP

Same

10e

NUMVISR

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

During your last normal week of practice how many patient visits did you have at all CHC locations?

10f

WKHOURSR

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.

Same

10g(1)

NUMBPAR

At the office location where you see the most ambulatory patients:

How many physicians are associated with you?

At the current CHC location:

How many physicians are associated with you?

10g(2)

SINGSPCR

At the office location where you see the most ambulatory patients:

Is this a single- or multi-specialty group practice?

At the current CHC location:

Is this a single- or multi-specialty CHC at this location?

10g(3)

OWNERSHR

At the office location where you see the most ambulatory patients:

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

At the current CHC location:

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

10g(4)

OWNSR

At the office location where you see the most ambulatory patients:

Who owns the practice?

At the current CHC location:

Who owns the CHC at this location?

Section 2: Induction Interview

INDUCT_INTRO

Before we begin, I'd like to give you some background about this study.

Medical researchers and educators are especially interested in topics like medical education, health workforce needs, and the changing nature of health care delivery.  The National Ambulatory Medical Care Survey (or NAMCS) was developed to meet the need for such information.  

The Centers for Disease Control and Prevention works closely with members of the medical profession to design the NAMCS each year.  The NAMCS supplies essential information about how ambulatory medical care is provided in the United States, and how it is utilized by patients.  

Your part in the study is very important and should not take much of your time.  It consists of your participation during a specified 7-day period.  During that time, you would supply a minimal amount of information about the patients you see.

First, I have some questions to ask about your practice.  Your answers will only be used to provide data on the characteristics of office-based practices in the U.S.  Any and all information you provide for this study will be kept confidential.

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 the CHC at this location.  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

NUMLOC

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

Same

11b

NOPATSEN

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

Same

11c

LTHALF

LTHALF_SP

(You/physician's name) typically (see/sees) patients fewer than half the weeks in each year.
Is that correct?

1. Yes

2. No Please explain LTHALF_SP

Same

11d

ALLYEAR

ALLYEAR_SP

(You/physician's name) typically (see/sees) patients all 52 weeks of the year.
Is that correct?

1. Yes

2. No Please explain ALLYEAR_SP

Same

12a

12b

SEEPAT

WHYNOPAT

This study will be concerned with the AMBULATORY patients (you/physician's name) will see in (Your/ his/her) (office/offices) during the week of Monday, (Reporting period begin date) through Sunday, (Reporting period end date).

(Are/Is) (you/physician's name) likely to see any ambulatory patients in (Your/ his/her) (office/offices) during that week?

  For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks, and so forth will be provided by staff in physician's absence, enter "Yes."

1. Yes

2. No Why is that?
    Enter verbatim response

(12b) WHYNOPAT

This study will be concerned with the AMBULATORY patients (you/physician's name) will see at this CHC location during the week of Monday, (Reporting period begin date) through Sunday, (Reporting period end date).

(Are/Is) (you/physician's name) likely to see any ambulatory patients at the current CHC location during that week?

  For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks, and so forth will be provided by staff in physician's absence, enter "Yes."

1. Yes

2. No Why is that?
    Enter verbatim response

(12b) WHYNOPAT

12c

CHECK_BACK

Since it's very important that we include any ambulatory patients that (you/physician's name) might see in (Your/ his/her) office during that week, I'll check back with your office just before (Reporting period begin date) to make sure (Your/ his/her) plans have not changed.

          Even though the physician/provider is not available during the reporting week, continue with the induction

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

13a

OFFSTRET

(At what office location(s) will you see ambulatory patients during your practice's 7-day reporting period Monday, ^BEGIN_DATE through Sunday, ^END_DA

  If this is a CHC sampled provider, DO NOT enter any other locations in the table below.  Since we sample CHC service delivery sites, we are only interested in visits to the sampled CHC site.  You SHOULD NOT follow CHC providers to other locations during the sample week.  Only include visits from the currently sampled CHC location.

N/A

13a

OFFICE_CITY

In what city is this office located?

N/A

13a

OFFICE_ST

In what state is this office?

N/A

13a

OFFICE_ZIP

What is the zip code for this office?

N/A

LOCTYPE

  Enter location/address type

1. Main Office address

2. Alternative/2nd office address

3. Home office

4. Home

5. Unknown

N/A

CUR_OFFICE

  Which office is the current office?

^OFF1

^OFF2

^OFF3

^OFF4

^OFF5

N/A

New

CUR_CHC_ADD

N/A

What does the current address below represent?

[Fill with original or updated CHC address]

1. Sampled CHC location-goto OTHLOC

2. Sampled CHC that moved-goto OTHLOC

3. Not sampled CHC location-goto CALL_RO_PHYS

New

CALL_RO_PHYS

N/A

Call your RO and inform them of the situation. Await resolution from the RO before continuing with this case.

13b

OFFICETYP

Looking at this list, choose ALL of the type(s) of settings that describe the office at (Office location).

       If in doubt about any clinic/facility/institution, PROBE -

         Is this/that clinic/facility/institution part of a hospital emergency department or an outpatient
         department?         If yes, select 2 or 4

         Is this/that clinic/facility/institution part operated by the Federal Government?        If yes, select 12

Enter up to 3, separate with commas

1. Private solo or group practice

2. Hospital emergency department

3. Freestanding clinic/urgicenter (not part of a hospital outpatient department)

4. Hospital outpatient department

5. Community Health Center (e.g. Federally Qualified Health Center (FQHC), federally funded clinics or 'look alike' clinics)

Moved to #16 out-of-scope

6. Ambulatory surgicenter

7. Mental health center

8. Institutional setting (school infirmary, nursing home, prison)

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

10. Industrial outpatient facility

11. Family planning clinic (including Planned Parenthood)

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

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

14. Laser vision surgery

15. Faculty practice plan

16. Community Health Center (e.g. Federally Qualified Health Center (FQHC), federally funded clinics or 'look alike' clinics)

Choice #5 will be automatically populated:

(5) Community Health Center (e.g., Federally Qualified Health Center (FQHC), federally funded clinics or ‘look alike’ clinics)

13b

FREESTAND_PROBE

Is this/that clinic in an institutional setting, in an industrial outpatient facility, or operated by the Federal Government?

1. Yes

2. No

N/A

13b

FAMPLAN_PROBE

Is this/that clinic operated by the Federal Government?

1. Yes

2. No

N/A

13c

OTHLOC

Are there other office locations where (you/physician's name) NORMALLY would see patients, even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting period?  Do not include settings such as EDs, outpatient departments, surgicenters, Federal clinics, and community health centers.

1. Yes Go to OTHLOCVS

2. No Skip to ESTDAYS

Are there other CHC locations where (you/physician's name) NORMALLY would see patients, even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting period? 

1. Yes Go to OTHLOC_NUM

2. No Skip to ESTDAYS

New

OTHLOC_NUM

N/A

In how many other CHC locations do you NORMALLY see patients?

______ Number of locations

13d

OTHLOCVS

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

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

14a

ESTDAYS

During the week of Monday, [Fill Date] through Sunday, [Fill Date] how many days do you expect to see any ambulatory patients at the following locations?

During the week of Monday, [Fill Date] through Sunday, [Fill Date] how many days do you expect to see any ambulatory patients at this CHC location?

14b

ESTVIS

During (Your/ his/her) last normal week of practice, approximately how many office visit encounters did (you/physician's name) have at each office location?

          If physician is in group practice, only include the visits to sampled physician.

During (Your/ his/her) last normal week of practice, approximately how many office visit encounters did (you/physician's name) have at this CHC location?

Only include the visits to the sampled CHC provider.

          If physician is in group practice, only include the visits to sampled physician.

14c

SAME

During the week of Monday, (Reporting period begin date) through Sunday (Reporting period end date), (do/does) (you/physician's name) expect to have about the same number of visits as (you/physician's name) saw during (Your/ his/her) last normal week in each office taking into account time off, holidays, and conferences?

1. Yes

2. No

During the week of Monday, (fill) through Sunday (fill), do you expect to have about the same number of visits as you saw during your last normal week at the current CHC location taking into account time off, holidays, and conferences?

1. Yes

2. No

14d

ESTVISP

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

Approximately how many ambulatory visits do you expect to have at this CHC location?

14e

ESTTOTVS

Tally of estimated number of visits

Same

15a

SOLO

Now, I'm going to ask about (your/Physician name's) practice at (Office location).

(Do/Does) (you/physician's name) have a solo practice, or (are/is) (you/physician's name) associated with other physicians in a partnership, in a group practice, or in some other way at this location?

1. Solo

2. Nonsolo

Now, I'm going to ask about the CHC at [Pre-fill location].

Do you work in a solo CHC, or are you associated with other physicians in a partnership, in a group CHC, or in some other way at this location?

1. Solo

2. Nonsolo

15b

OTHPHY

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

Same

15c

MULTI

Is this a single- or multi-specialty (group) practice at (Office location)?

1. Multi

2. Single

Is this a single- or multi-specialty CHC at [Pre-fill location]?

1. Multi

2. Single

15d

MIDLEV

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

Same

15e

OWNERSH

(Are/Is) (you/physician's name) a full- or part-owner, employee, or an independent contractor at (Office location)?

1. Full-owner

2. Part-owner

3. Employee

4. Contractor

Same

15f

OWNS

Who owns the practice at (Office location)?

1. Physician or Physician group

2. Insurance company, health plan, or HMO

3. Community Health Center

4. Medical/Academic health center

5. Other hospital

6. Other health care corporation

7. Other

Who owns the CHC at (Office location)?

1. Physician or Physician group

2. Insurance company, health plan, or HMO

3. Community Health Center

4. Medical/Academic health center

5. Other hospital

6. Other health care corporation

7. Other

15g

ONSITE_EKG

ONSITE_PHLEB

ONSITE_LAB

ONSITE_SPIRO

ONSITE_ULTRA

ONSITE_XRAY

Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office location)?

1. EKG/ECG

2. Phlebotomy

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

4. Spirometry

5. Ultrasound

6. X-ray

1. Yes

2. No

3. Don’t know

Does the CHC have the ability to perform any of the following on site at (Office location)?

1. EKG/ECG

2. Phlebotomy

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

4. Spirometry

5. Ultrasound

6. X-ray

1. Yes

2. No

3. Don’t know

15h

PATEVEN

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

1. Yes

2. No

3. Don’t know

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

1. Yes

2. No

3. Don’t know

15i

NPI

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

Same

15j

FEDTXID

What is your Federal Tax ID, also known as an Employer Identification Number (EIN), at (Office location)?

Same

16a

WKHOURS

During (your/Physician name's) last normal week of practice, how many hours of direct patient care did (you/physician's name) provide?

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

Same

16b

NHVISWK

HOMVISWK

HOSVISWK

TELCONWK

ECONWK

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

1. Nursing home visits

2. Other home visits

3. Hospital visits

4. Telephone consults

5. Internet/e-mail consults

Same

New National CLAS Standards Questions

CLASTRAIN

(The following two questions must be answered by the sampled provider.) Within the past 12 months, have you participated in any cultural competence training?

1. Yes

2. No

Same

CLASKNOW

(The following question must be answered by the sampled provider.) How familiar are you with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards)?

1. Never heard of it

2. Heard of it but do not know much about it

3. Know something about it

4. Very familiar with it

Same

New Alcohol Screening and Brief Intervention (SBI) Questions (17-22)

ALCOHOL_INTRO

The next set of questions are only administered to primary care providers and seeks to determine the extent to which alcohol screening and brief intervention (SBI) is being conducted within their practices.

Same

17

ALCSCREEN

Screening for alcohol misuse (excessive consumption and alcohol-related problems) is often conducted in clinical settings. How do you screen for alcohol misuse?

1. I don’t screen

2. T-ACE

3. TWEAK

4. CAGE

5. CRAFFT

6. AUDIT

7. Ask number of drinks per occasion

8. Ask frequency of drinking

9. Ask binge question

10. I don’t use a formal screening instrument

11. Other (specify) ALCSCREENOTH

Same

18

ASCREENOFT

How often do you screen for alcohol misuse?

1. At every health maintenance visit (annually)

2. At every health care visit

3. When I suspect a patient has a substance/alcohol-related problem

4. Almost never or never

Same

19

ASCREENADM

How are screening question(s) administered?

1. Interview

2. Patient completes a form

3. Electronic

4. Other (specify) ASCREENADMOTH

Same

20

ASCREENWHO

If patient is interviewed, who administers the screening?

1. Physician, nurse practitioner, physician assistant

2. Nurse, excluding nurse practitioner

3. Medical assistant

4. Administrative staff

5. Other (specify) ASCREENWHOTH

Same

21

ABRFINTERV

Brief interventions for risky alcohol use are short discussions with patients who drink too much or in ways that are harmful. These interventions typically include some of the following elements:

• Feedback on screening results

• Gathering further information on drinking patterns, alcohol-related harm, or symptoms of alcohol dependence

• Discussing the risks and consequences of drinking too much

• Providing advice about cutting back or stopping

Among patients who screen positive for risky alcohol use, how often are brief interventions conducted?

1. Never

2. Sometimes

3. Often

4. Always

Same

22

ARESOURCE

What resources would be helpful in implementing alcohol/substance screening and intervention in primary care settings? (Select all that apply)

1. Implementation guide for alcohol screening and intervention

2. Training on how to conduct alcohol screening

3. Training on how to conduct intervention

4. Office-based mentoring

5. Access to patient education materials

6. Scripts on what to say to patients

7. Information about reimbursement for services

8. Information about where or how to refer for additional services

9. Other (specify) ARESOURCEOTH

Same

Workforce Questions (23-34)

23

MOSTVIS_INTRO

The next section refers to characteristics of the sampled physician’s practice.

The next section refers to characteristics of the sampled CHC.

24

NUMPH

(one location listed)

The next questions are about the practice that is associated with [Pre-fill location].

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

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

The next questions are about the CHC that is associated with [Pre-fill location].

How many physicians, including you are associated with this CHC?

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

24

NUMPH

(two or more locations listed)

The next questions are about the practice that is associated with [Pre-fill location], which is the location where the physician has the most office visits.

How many physicians, including you are associated with that practice? Please include physicians at [Pre-fill location], and physicians at any other locations of that practice.

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

N/A

25

PCMH

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

1. Yes

   1. If yes, by whom CERT_WHO

      1. The Accreditation Association for Ambulatory Health (AAAH)

      2. The Joint Commission

      3. The National Committee for Quality Assurance (NCQA)

         1. [If yes:]  What level of certification? NCQAlevel

            1. Level 1

            2. Level 2

            3. Level 3

      4. Utilization Review Accreditation Commission (URAC)

      5. Other – Specify PCMH_OTH____________

      6. Unknown

2. No

3. Unknown  

Is the CHC at this location certified as a patient-centered medical home?

26

ACCESS

Is it possible within your practice to access patient medical records using an electronic health record (EHR) system 24-hours a day? 

1. Yes ACCESS_PH

   1. [If yes:] Is this access available to physicians only, or is it also available to other non-physician clinicians? 

1. Physicians (MD/DO) only.

2. All Physicians and non-physician Clinicians.

3. Unknown

2. No

3. Unknown

Is it possible within the CHC at this location to access patient medical records using an electronic health record (EHR) system 24 hours a day?

27

PMETHOD

What is the primary method by which your practice receives information about patients in your practice when they have been seen in the emergency department or hospitalized? (Mark only one box)

1. Electronic transmission (i.e., EHR or EMR)

2. Fax

3. Email

   1. [If yes:] Was this email sent over a secure network? SECNET

1. Yes

2. No

3. Unknown

4. Telephone or in-person communication with provider

5. Paper copy

6. Other PMETHOD_SP

What is the primary method by which the CHC at this location receives information about patients in this CHC when they have been seen in the emergency department or hospitalized?

28

TRANS

Is someone in your practice responsible for assisting patients to safely transition back to the community within 72 hours of being discharged from a hospital or nursing home? 

1. Yes

2. No

3. Unknown

Is someone in the CHC at this location responsible for assisting patients to safely transition back to the community within 72 hours of being discharged from a hospital or nursing home?

29

PROTO

Does your practice have written protocols for providing chronic care services that are used by all members of the care team?

1. Yes

2. No

3. Unknown

Does the CHC at this location have written protocols for providing chronic care services that are used by all members of the care team?

30

QUAL

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

1. Yes

2. No

3. Unknown

Does the CHC at this location report any quality measures or quality indicators to either payers or to organizations that monitor health care quality?

1. Yes

2. No

3. Unknown

31

DIFTIN

Do all other locations or offices associated with this practice use the same Federal Tax ID, also known as an Employer Identification Number (EIN), or do any locations or offices associated with this practice use a different Federal Tax ID or EIN?

1. All use the same Federal Tax ID or EIN

2. Some use a different Federal Tax ID or EIN

3. Unknown 

Do all other locations or offices associated with the CHC at this location use the same Federal Tax ID, also known as an Employer Identification Number (EIN), or do any locations or offices associated with the CHC at this location use a different Federal Tax ID or EIN?

1. All use the same Federal Tax ID or EIN

2. Some use a different Federal Tax ID or EIN

3. Unknown 

32

Staffing Types

(34 variables)

The next set of questions refer to the types of providers who work at [Pre-fill location].

How many of the following full-time and part-time providers are on staff at [Pre-fill location]?

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.

Same

Type of Provider	Number Full-time (≥30 hours)	Number Part-time (<30 hours)
Physicians (MD and DO)	MD_DO_FT	MD_DO_PT
Non-Physician Clinicians
Physician Assistants (PA)	PA_FT	PA_PT
Nurse Practitioners (NP)	NP_FT	NP_PT
Certified Nurse Midwives (CNM)	CNM_FT	CNM_PT
Other Nursing Care
Registered nurses (RN) (not an NP or CNM)	RN_FT	RN_PT
Licensed Practical Nurses (LPN)	LPN_FT	LPN_PT
Certified Nursing Assistants/Aides (CNA)	CNA_FT	CNA_PT
Allied Health
Medical Assistants (MA)	MA_FT	MA_PT
Radiology Technicians (RT)	RT_FT	RT_PT
Laboratory Technicians (LT)	LT_FT	LT_PT
Physical Therapists (PT)	PT_FT	PT_PT
Pharmacists (Ph)	PH_LT	PH_PT
Dieticians/Nutritionists (DN)	DN_FT	DN_PT
Other
Mental Health Providers (MH)	MH_FT	MH_PT
Health Educators/Counselors (HEC)	HEC_FT	HEC_PT
Case Managers (not an RN)/Certified Social Workers (CSW)	CSW_FT	CSW_PT
Community Health Workers (CHW)	CHW_FT	CHW_PT

33

Tasks performed (13 variables)

At [Pre-fill location], which type of provider most commonly performs the following tasks?  Enter all that apply.

The providers listed are generated from the previous staffing question. If any providers in your office are missing, please go back to the staffing question and check the appropriate box(es).

Same

Based on the staff selected in Question 32, a checkbox answer list of staffing types will be made available for each of the following questions A-M, but will only contain those selected providers as well as “Task is not performed in this office” and “Unknown”.
A.      Records body measurements (such as height and weight) and vital signs (such as BP, temperature, heart rate)	Task_Body
B.      Performs office-based testing such as EKG and hearing/vision testing (do not include laboratory testing)	Task_Test
C.      Draws blood for lab testing	Task_Blood
D.      Provides immunizations (includes both childhood and adult)	Task_Immun
E.       Conducts cancer screenings ( such as breast, cervical, and prostate screenings)	Task_Screen
F.       Provides behavioral health screenings (such as depression, alcohol and substance abuse)	Task_Behav
G.      Provides counseling services (such as diet/nutrition, weight reduction, tobacco cessation, stress management)	Task_Counsel
H.      Manages the routine care of patients with chronic conditions (such as hypertension, asthma, diabetes)	Task_Rout
I.        Writes refill prescriptions for medications	Task_Refill
J.        Enters patient information into medical/billing records	Task_Enter
K.      Performs imaging tests (such as X-rays and ultrasounds)	Task_Image
L.       Make referrals (for example, to specialty care, or to community-based services)	Task_Ref
M.     Contacts patients, who are transitioning from hospital or nursing home back to the community	Task_Contacts

34

Autonomy of PAs, NPs, and CNMs (15 variables)

The following questions concern the PAs, NPs, and CNMs practicing at [Pre-fill location].

Same

A.      Physician Assistant	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are PA(s) supervised by someone on-site? PA_SUP
Do you sign-off on the medical records of the patients the PA(s) see(s)? PA_SIGN
Do the PA’s patients have a separate log from your patients? PA_LOG
Is your approval required before the PA(s) prescribe(s) medication? PA_APPROVAL
Do/does the PA(s) bill for services using their own NPI number? PA_BILL
B.      Nurse Practitioner	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are NP(s) supervised by someone on-site? NP_SUP
Do you sign-off on the medical record of the patients the NP(s) see(s)? NP_SIGN
Do the NP’s patients have a separate log from your patients? NP_LOG
Is your approval required before the NP(s) prescribe(s) medication? NP_APPROVAL
Do/does the NP(s) bill for services using their own NPI number? NP_BILL
C.      Certified Nurse Midwife	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are CNM(s) supervised by someone on-site? CNM_SUP
Do you sign-off on the medical record of the patients the CNM(s) see(s)? CNM_SIGN
Do the CNM’s patients have a separate log from your patients? CNM_LOG
Is your approval required before the CNM(s) prescribe(s) medication? CNM_APPROVAL
Do/does the CNM(s) bill for services using their own NPI number? CNM_BILL

Electronic Health Record (EHR) Questions #35-51 (see Attachment C1 #28-38d)

35

EMR_INTRO

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

Answer ALL remaining questions for the current CHC location, which is [Pre-fill].

36

EBILLREC

Does the reporting location submit any claims electronically (electronic billing)?

1. Yes

2. No

3. Unknown

Does the CHC reporting location submit any claims electronically (electronic billing)?

37a

EMEDREC

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

1. Yes, all electronic

2. Yes, part paper and part electronic

3. No

4. Unknown

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

37b

EHRINSYR

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

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

37c

HHSMU

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

1. Yes

2. No

3. Unknown

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

37d

EHRNAM

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

1. Allscripts

2. Amazing Charts

3. athenahealth

4. Cerner

5. eClinicalWorks

6. e-MDs

7. Epic

8. GE/Centricity

9. Greenway Medical

10. McKesson/Practice Partner

11. NextGen

12. Practice Fusion

13. Sage/Vitera

14. Other-Specify EHRNAMOTH

15. Unknown

What is the name of the CHC’s current EHR/EMR system?

38

SECURCHCK

Has your practice made an assessment of the 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.

1. Yes

2. No

3. Unknown

Has the CHC made an assessment of the 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.

39

DIFFEHR

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

1. Yes

2. No

3. Unknown

Does the CHC’s EHR have the capacity to electronically send health information to another provider whose EHR system is different from the CHC’s system?

40

EMRINS

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

1. Yes

2. No

3. Maybe

4. Unknown

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

41a

MUINC

Medicare and Medicaid offer incentives to practices that demonstrate "meaningful use of health IT." At the reporting location, are there plans to apply for Stage 1 of these incentive payments?

1. Yes, we already applied

2. Yes, we intend to apply

3. Uncertain if we will apply

4. No, we will not apply

Medicare and Medicaid offer incentives to CHCs that demonstrate “meaningful use of health IT.” At the CHC reporting location, are there plans to apply for Stage 1of these incentive payments?

41b

MUSTAGE2

Are there plans to apply for Stage 2 incentive payments?

1. Yes

2. No

3. Maybe

4. Unknown

Same

42

EDEMOG EPROLST

EVITAL

ESMOKE

EPNOTES

EMEDALG

EMEDID

EREMIND

ECPOE

ESCRIP

EWARN

EFORMULA

ECTOE

EORDER

ERESULT

EGRAPH

ERADI

EIMGRES

EPTEDU

ECQM

EIDPT

EGENLIST

EIMMREG

ESUM

EMSG

EPTREC

Please indicate whether the ambulatory reporting location has each of the following computerized capabilities and how often these capabilities are used.

These 5 answer choices are for each of the following items a-u.

1. Yes, used routinely

2. Yes, but NOT used routinely

3. Yes, but turned off or not used

4. No

5. Unknown

1. Recording patient history and demographic information?

2. Recording patient problem list?

3. Recording and charting vital signs?

4. Recording patient smoking status

5. Recording clinical notes?

6. Recording patient’s medications and allergies?

7. Reconciling lists of patient medications to identify the most accurate list?

8. Providing reminders for guideline-based interventions or screening tests?

9. Ordering prescriptions?

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

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

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

10. Ordering lab tests?

1. If Yes, ask – Are orders sent electronically?

11. Viewing lab results?

1. If yes, ask – Can the EHR/EMR automatically graph a specific patient’s lab results over time?

12. Ordering radiology tests?

13. Viewing imaging results?

14. Identifying educational resources for patients’ specific conditions?

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

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

17. Generating lists of patients with particular health conditions?

18. Electronic reporting to immunization registries?

19. Providing patients with clinical summaries for each visit?

20. Exchanging secure messages with patients?

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

Please indicate whether the CHC reporting location has each of the following computerized capabilities and how often these capabilities are used.

Same

44a

REFOUT

^DoDoes (you/physician's name) refer any of (Your/ his/her) patients to providers outside of (Your/ his/her) office or group?

1. Yes

2. No

Do you refer any of your patients to providers outside of the CHC?

44b

REFOUTS

^DoDoes (you/physician's name) send the patient's clinical information to the other providers?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

44c

REFOUTSE

^DoDoes (you/physician's name) send it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

45a

REFIN

^DoDoes (you/physician's name) see any patients referred to (you/physician's name)  by providers outside of (you/physician's name)  office or group?

1. Yes

2. No

Do you see any patients referred to you by providers outside of the CHC?

45b

REFINS

^DoDoes (you/physician's name) send a consultation report with clinical information to the other providers?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

45c

REFINSE

^DoDoes (you/physician's name) send it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

46a

INPTCARE

^DoDoes (you/physician's name) take care of patients after they are discharged from an inpatient setting?

1. Yes

2. No

Same

46b

DISSUM

^DoDoes (you/physician's name) receive a discharge summary with clinical information from the hospital?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

46c

DISSUME

Do you receive it electronically (not fax)?

1. Yes, routinely

2. Yes, but not routinely

3. No

Same

46d

INCORINFO

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

1. Yes

2. No

3. Not applicable, I do not have an EHR system

Can you automatically incorporate the received information into the CHC’s EHR system without manually entering the data?

47a

ESHARE

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

Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1. Yes

2. No

Same

47b

ESHAREHOW

How do you electronically share patient health information?

       Enter all that apply, separate with commas

1. EHR/EMR

2. Web portal (separate from EHR/EMR)

3. Other electronic method (not fax) ESHAREHOWOTH

Same

47c

EHRTOEHR

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

[Pre-filled location is displayed.]

1. Yes, routinely

2. Yes, but not routinely

3. No

4. Unknown

Is the patient health information that you share electronically sent directly from the CHC’s EHR system to another EHR system?

[Pre-filled location is displayed.]

1. Yes, routinely

2. Yes, but not routinely

3. No

4. Unknown

47d

ESHAREPROV

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

1. Ambulatory providers inside your office/group

2. Ambulatory providers outside your office/group

3. Hospitals with which you are affiliated

4. Hospitals with which you are not affiliated

5. Behavioral health providers

6. Long-term care providers

7. Home health providers

Same

48

EOUTINFO

Are you/your staff able to electronically find health information (e.g. medications, outside encounters) from sources outside of the office for your patients? Please reference (fill location), which is the in-scope office with the most visits.

Enter all that apply.

1. Yes routinely

2. Yes, but not routinely

3. No

4. Unknown

Are you/your staff able to electronically find health information (e.g. medications, outside encounters) from sources outside of the CHC for your patients? Please reference (fill location), which is the current CHC location.

49

EOUTHOW

EOUTOSP

If Yes to EOUTINFO, How do you look up patient health information from sources outside of the office? Please reference (fill location), which is the in-scope office with the most visits.

Enter all that apply.

1. Through your EHR/EMR

2. Web portal (separate from EHR/EMR)

3. View only or restricted access to other providers’ EHR system

4. Other electronic method (not fax) EOUTOSP

If Yes to EOUTINFO, How do you look up patient health information from sources outside of the CHC? Please reference (fill location), which is the current CHC location.

50

EOUTYP

EOUTYPSP

What types of information do you routinely look up?

Enter all that apply.

1. Lab results

2. Imaging reports

3. patient problem lists

4. Medication lists

5. Other EOUTYPSP

Same

51

EOUTINCORP

Do you or your staff routinely incorporate the information you look up into your EHR?

1. Yes, via manual entry or scanned copy

2. Yes, automatically able to incorporate without manual entry or scanning

3. No, we do not routinely incorporate into our EHR

Same

Revenue & Contracts, Compensation, New Patients (#52 to end of induction)

52

PRMCARE PRMAID

PRPRVT

PRPATPAY

PROTH

Please remind physician/provider that the remaining questions refer to all offices that were determined to be in-scope.

I would like to ask a few questions about (your/Physician name's) practice revenue and contracts with managed care plans.

Roughly, what percent of (your/Physician name's) patient care revenue comes from –

1. Medicare?

2. Medicaid?

3. Private insurance?

4. Patient payments

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

Please remind physician/provider that the remaining questions refer to the current CHC location, which is [Pre-fill-in location].

I would like to ask a few questions about the current CHC’s revenue and contracts with managed care plans.

53

PCTRVMAN

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

Roughly, what percent of the patient care revenue received by this CHC comes from managed care contracts?

54

REVFFS

REVCAP

REVCASE

REVOTHER

Roughly, what percent of (your/Physician name's) patient care revenue comes from each of the following methods of payment?

1. Fee-for-service?

2. Capitation?

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

4. Other?

Same

55

ACEPTNEW

(Are/Is) (you/physician's name) currently accepting "new" patients into (Your/ his/her) practice(s) at [Fill-in location]?

1. Yes

2. No

3. Don’t know

(Are/Is) (you/physician's name) currently accepting "new" patients into the CHC at [Fill-in location]?

56

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those "new" patients, which of the following types of payment (do/does) (you/physician's name) accept at [Fill-in location]?

1. Capitated private insurance?

2. Non-capitated private insurance?

3. Medicare?

4. Medicaid?

5. Workers’ compensation?

6. Self-pay?

7. No charge?
   
   

The following answer choices are used for each of the above seven payment types:

1. Yes

2. No

3. Don’t know

Same

56

PHYSCOMP

Which of the following methods best describes your basic compensation?

Bold answer choices & add FR instruction to prompt them to read answers aloud.

1. Fixed salary

2. Share of practice billings or workload

3. 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)

4. Shift, hourly or other time-based payment

5. Other

Same

57

COMP

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 all that apply, separate with commas

1. Factors that reflect your own productivity

2. Results of satisfaction surveys from your own patients

3. Specific measures of quality, such as rates of preventive services for your patients

4. Results of practice profiling, that is, comparing your pattern of using medical resources with that of other physicians

5. The overall financial performance of the practice

CHCs may take various factors into account in determining the compensation (salary, bonus, pay rate, etc.) paid to the physicians/providers in the CHC.  Please indicate whether the CHC explicitly considers each of the following factors in determining your compensation. 

58a

SASDAPPT

Does (your/Physician name's) practice set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

Does the CHC set time aside for same day appointments?

Skip Instructions:

1. Goto SDAPPT

2. SKIP to APPTTIME

Same

58b

SDAPPT

Roughly, what percent of (your/Physician name's) daily visits are same day appointments?

Same

58c

APPTTIME

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

1. Within 1 week

2. 1 - 2 weeks

3. 3 - 4 weeks

4. 1 - 2 months

5. 3 or more months

6. Do not provide routine medical exams

7. Don't know

Same

59a

PRVBYEAR

N/A

What is (your/Physician name's) year of birth?

59b

PRVSEX

N/A

What is (your/Physician name's) sex?

1. Female

2. Male

59c

PRVDEGR

N/A

What is (your/Physician name's) highest medical degree?

1. MD

2. DO

3. Nurse practitioner

4. Physician assistant

5. Nurse midwife

6. Other

59d

PRVPSPEC PRVPSPEC_SP

N/A

What is (your/Physician name's) primary specialty?

Enter verbatim response for specialty

59e

PRVSSPEC PRVSSPEC_SP

N/A

What is (your/Physician name's) secondary specialty?
Enter verbatim response for specialty

59f

PRVPBC

N/A

What is (your/Physician name's) primary board certification?

59g

PRVSBC

N/A

What is (your/Physician name's) secondary board certification?

59h

PRVYRGRD

N/A

What year did (you/physician's name) graduate from medical school?

59i

PRVFMS

N/A

Did (you/physician's name) graduate from a foreign medical school?

1. Yes

2. No

PHY_UNAVAIL

Thank you for your time and cooperation ^RESPNAME_FILL.  The information you provided will improve the accuracy of the NAMCS in describing office-based patient care in the United States.

I will call you on Monday, (Reporting period begin date) to see if your plans have changed.
If you have any questions (Hand respondent your business card) please feel free to call me.

Same

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