Form 0920-0234 Att C4- 2016 NAMCS-201

Attachment C4: 2016 NAMCS-201 CHC Service Delivery Site Induction Interview, List of all questions

This table lists all proposed 2016 survey questions in the order that they would appear in the survey. Additions and modifications for 2016 are indicated in red font.

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

Notice-Public reporting burden for this collection of information is estimated to average 30 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).

Variable name

Question text and answer categories

START

One button is selected to start the interview:

1. Continue

2. Noninterview (Unable to locate, refusal, etc.)

3. Issue preventing CHC facility interview

4. Quit

CHCTYPE

How would you classify this center?
Enter all that apply - separate with commas

1. Federally-funded Community Health Center (330)

• Community Health Center (CHC)

• Migrant Health Center (MHC)

• Health Care for the Homeless (HCH)

• Public Housing Primary Care (PHPC) grant program

2. Federally Qualified Health Center, but not federally funded (330 look-alike)

3. Urban Indian (437) Health Center

4. None of the above

ADDCHECK

We have your address and telephone number as
(Name and Address) (Phone number)
Is this correct?

1. Yes

2. No, update address and phone

CHC_NAME

What is the correct address?
        Enter 1 to update the CHC name, address, and phone

PR330

PRTITLEV

PROTHFED

PRSTLOC

PRPRIVAT

PRCARE

PRCAID

PRFEES

PROTHER

TOTALGRANT

What percent of your CHC's revenue comes from the following sources?

1. 330 Grant

2. Title V grant or contract

3. Other Federal Grant

4. State/Local Grant

5. Individual, corporation or foundation grants or donations

6. Medicare

7. Medicaid/CHIP

8. Patient payments

9. Other (including private insurance, Tricare, VA, etc.)?

AVG_WEEKS

On average, in a normal year, how many weeks does the CHC at this location see patients?"

________Number of weeks

WEEK_FOLLUP

"You indicated that this CHC LOCATION does not usually see patients in a typical year, is this correct?"

1. Yes

2. No

INTRO_SAMP

I would like to discuss a plan for conducting the National Ambulatory Medical Care Survey (NAMCS) to a sample of your providers.  This clinic (site) has been assigned to a 1-week reporting period that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date).

I will need to sample 3 providers from your Center.  In order to do this, I will need the name, specialty, and estimated visit volume, corresponding to the sample week, for all physicians and mid-level providers ONLY AT THE CURRENTLY SAMPLED IN-SCOPE LOCATION.

 Please include all providers who see patients at this sampled clinic (site) even if they do NOT plan on seeing patients during the sample week. .

Please exclude anesthesiologists, dentists, hygienists, optometrists, pathologists, psychologists, podiatrists, and radiologists.  Include physicians (both MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (NMWs).

  List all providers only from the currently sampled in-scope location, even if they do not expect to see patients during the sampled week.  Enter a zero for the expected visit volume for those providers with no expected visits.   

    If the CHC that has been sampled is a health department, please verify that they will not be distributing the 330 grant money to other administratively unconnected community health centers.  If the health department  does distribute the money to other CHCs, these need to be sampled, so please contact your supervisor for further instructions. 

PROV_FNAME

What is the provider's first name?
(Include providers from only the sampled CHC location.)

PROV_MNAME

What is the provider's middle name?

PROV_LNAME

What is the provider's last name?

PROV_TYPE

Is (Provider's name) a Medical Doctor (MD) or Doctor of Osteopathy (DO), Nurse Practitioner (NP), Physician Assistant (PA), or Nurse Midwife (NMW)?

1. Medical Doctor (MD)

2. Doctor of Osteopathy (DO)

3. Nurse Practitioner (NP)

4. Physician Assistant (PA)

5. Nurse Midwife (NMW)

Skip Instructions:

1,2: Goto PROV_SPEC
Else goto PROVIDED

PROV_SPEC

What is (Provider's name)'s specialty?
  Enter 'XXX' if the specialty is not listed

PROV_SPEC2

  Is the provider an anesthesiologist, dentist, hygienist, optometrist, pathologist, psychologist, podiatrist, or radiologist?

1. Yes

2. No

PROV_SPEC_SP

  Enter verbatim response for specialty

PROVIDED

?  [F1]
What is the expected visit volume during the sample week for (Provider's name)?
         Enter 0 if provider does not expect to see patients during the reference period.

PREVSAMP

  Compare this provider ((Providers name)) to the listed providers that have been sampled from this community health center in the past.  
        Previously sampled providers
        (Previously sampled providers)

1. Yes, previously sampled

2. No, not previously sampled

VER_PREVSAMP

  Were the previously sampled providers selected correctly?
           Current name                     Previous name
         (Current provider names)     (Previously sampled provider names)

1. Yes

2. No

NOPATIENTS

You have told me that NONE of these providers expect to see patients during the sample week that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date).  Is this correct?

1. Yes, there are no providers seeing patients during reference week

2. No, incorrect - there are providers seeing patients

Skip Instructions:

1: Exit block and goto BlkBACK.THANK_OOS
2: Go back to TblProv1.PROV_FNAME for the last row.

PROV_STRT

What is (Provider's name)'s address?
           Enter number and street.

PROV_STRT2

What is (Provider's name)'s address?
           Enter line two of address.

PROV_CITY

What is (Provider's name)'s address?
          Enter city.

PROV_STATE

What is (Provider's name)'s address?
          Enter state.

PROV_ZIPCODE

What is (Provider's name)'s address?
         Enter zipcode.

PROV_LOCTYPE

    Enter location/address type

1. Main Office address

2. Alternative/2nd office address

3. Home office

4. Home

5. Unknown

PROV_PHONE

What is (Provider's name)'s telephone number?

PROV_PHTYP

What type of telephone number is this?

1. Main

2. Home

3. Work

4. Mobile

5. Pager, Beeper, Answering Service

6. Public pay phone

7. Toll Free

8. Other

9. Fax

10. Unknown

GREET_NAME

  Enter Greet Name
   (Greet name will be used on the letter that is sent to the provider.)
    Provider Name:  (Provider's name)

MOSTVIS_INTRO

The next section refers to characteristics of the sampled CHC at this location.

NUMPH

(one location listed)

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

How many physicians 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

NUMPH

(two or more locations listed)

N/A

PCMH

Is the CHC at this location 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  

ACCESS

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?

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

PMETHOD

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? (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

TRANS

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?

1. Yes

2. No

3. Unknown

PROTO

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

1. Yes

2. No

3. Unknown

QUAL

Does 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

DIFTIN

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 

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.

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
Clinical Nurse Specialist (CNS)	CNS_FT	CNS_PT
Nurse Anesthetists (NA)	NA_FT	NA_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

Autonomy of PAs, NPs, CNMs, CNSs, & NAs (15 variables)

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

A.      Physician Assistant	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the PA’s patients logged separately from other providers at this CHC? PA_LOG
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 the NP’s patients logged separately from other providers at this CHC? NP_LOG
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 the CNM’s patients logged separately from other providers at this CHC?CNM_LOG
Do/does the CNM(s) bill for services using their own NPI number? CNM_BILL
D. Clinical Nurse Specialist	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CNS’s patients logged separately from other providers at this CHC?CNS_LOG
Do/Does the CNS(s) bill for services using their own NPI number? CNS_BILL
E. Nurse Anesthetists	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the NA’s patients logged separately from other providers at this CHC?NA_LOG
Do/Does the NA(s) bill for services using their own NPI number? NA_BILL

EMR_INTRO

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

EBILLREC

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

1. Yes

2. No

3. Unknown

EMEDREC

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

1. Yes, all electronic

2. Yes, part paper and part electronic

3. No

4. Unknown

EHRINSYR

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

HHSMU

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

1. Yes

2. No

3. Unknown

EHRNAM

What is the name of the CHC’s 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

EMRINS

At the CHC 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

EDEMOG EPROLST

EPNOTES

EMEDALG

EMEDID

EREMIND

ECPOE

ESCRIP

EWARN

ECONTRSUB

ECONTRSUBS

ECTOE

ERESULT

ERADI

EIMGRES

EIDPT

EGENLIST

EDATAREP

ESUM

EMSG

EPTREC

Please indicate whether the CHC 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-q.

1. Yes

2. No

3. Unknown

1. Recording patient history and demographic information?

2. Recording patient problem list?

3. Recording clinical notes?

4. Recording patient’s medications and allergies?

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

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

7. 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?

8. Do you prescribe controlled substances?

1. If Yes, ask Are prescriptions for controlled substances sent electronically to the pharmacy?

9. Ordering lab tests?

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

10. Viewing lab results?

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

11. Ordering radiology tests?

12. Viewing imaging results?

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

14. Providing data to generate lists of patients with particular health conditions?

15. Providing data to create reports on clinical care measures for patients with specific chronic conditions (e.g. HbA1c for diabetics)?

16. Providing patients with clinical summaries for each visit?

17. Exchanging secure messages with patients?

REFOUT

◊Please remind the CHC administrator that when responding to any of the remaining questions with the word “you”/”your” in the text, they should refer to the currently sampled CHC location.

Do you refer any patients to providers outside of the CHC? Electronic does not include fan, eFax, or mail.

1. Yes

2. No

REFOUTHOW

How do you send patient health information to them?

1. Electronically

2. Via paper-based methods

3. Do not send patient health information to the provider

REFIN

Do you see patients from providers outside of the CHC? Electronic does not include fan, eFax, or mail.

1. Yes

2. No

REFINHOW

How do you receive patient health information from them? Check all that apply.

1. Electronically

2. Via paper-based methods

3. Do not send patient health information to the provider

ESHARE

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

Do you share any patient health information electronically?

Electronically does not include scanned or pdf documents, fax, eFax, or mail.

1. Yes

2. No

ESHARES

Do you electronically send patient health information to another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

ESHARER

Do you electronically receive patient health information from another provider whose EHR system is different from your own?
    

1. Yes

2. No

3. Don’t know

EDISCHSR

Do you electronically send or receive hospital discharge summaries to or from providers outside of your medical organization? Check all that apply.
    

1. Send electronically

2. Receive electronically

3. Do not send or receive

EEDSR

Do you electronically send or receive summary of care records for transitions of car or referrals to or from providers outside of your medical organization? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

ESUMCSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of your medical organization? Check all that apply.    

1. Send electronically

2. Receive electronically

3. Do not send or receive

PTONLINE

Can patients seen at the reporting location do the following online activities? Check all that apply.
    

1. View their medical record online

2. Download and transmit health information in the electronic medical record to their personal files

3. Request corrections to their electronic medical record

4. Enter their health information online (e.g. weight, symptoms)?

5. Upload their data from self-monitoring devices (e.g. blood glucose readings)?

Revenue & Contracts, Compensation, New Patients

PRMCARE PRMAID

PRPRVT

PRPATPAY

PROTH

Please remind the CHC administrator 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.

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

1. Medicare?

2. Medicaid?

3. Private insurance?

4. Patient payments

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

PCTRVMAN

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

REVFFS

REVCAP

REVCASE

REVOTHER

Roughly, what percent of your 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?

ACEPTNEW

Are you currently accepting "new" patients into the CHC at [Fill-in location]?

1. Yes

2. No

3. Don’t know

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those "new" patients, which of the following types of payment do you 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

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

COMP

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. 
  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

SASDAPPT

Does the CHC set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

Skip Instructions:

1. Goto SDAPPT

SKIP to APPTTIME

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

Don't know

CALLBACKNOTES

I'd like to schedule a DATE to (conduct/complete) the interview.
What DATE AND TIME would be best to visit again?
           Today is:  ^IntDate                        

Skip Instructions:

RF: Goto CBREF
All others, goto THANKCB

CBREF

   Exit this case now.
    Call the case up again and make it a non-interview before transmitting.

THANKCB

Thank you.
I will call/come back at the time suggested
      Revisit   (Appointment information)

THANKYOU

This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.

THANK_OOS

Thank you (Respondent name), your center is not within the scope of this study.
We appreciate your time and interest.

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