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pdfAttachment C1: 2015 NAMCS-1
OMB No. 0920-0234: Expiration date 12/31/2017
NOTICE - Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).
Assurance of Confidentiality - All information which would permit identification of an individual, a practice, or an establishment will be held confidential; will be
used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will not be disclosed or released to
other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the
Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
NAMCS-1A
1. Physician’s address:
FORM
(2-19-2015)
Disclaimer – The following questionnaire is based on a
computer-based questionnaire. Thus, the following questions contain
the same content of the computer-based questionnaire, though the flow
of the paper-questionnaire questions does not necessarily represent the
flow of the computer-based questionnaire due to the limitations of a
paper questionnaire.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
PY
U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE
NATIONAL CENTER FOR HEALTH STATISTICS
O
CENTERS FOR DISEASE CONTROL AND PREVENTION
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3. Introduction
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Telephone
FAX
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FAX
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Office
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Office Telephone
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2. Physician’s telephone and FAX numbers (Area code and number)
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NATIONAL AMBULATORY
MEDICAL CARE SURVEY
2015 PANEL
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The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the National
Ambulatory Medical Care Survey (NAMCS). This annual study, which has been in the field since 1973, collects information about
the large portion of ambulatory care provided by physicians and midlevel providers throughout the United States. Research using
NAMCS helps to inform physicians, health care researchers, and policy makers about the changing characteristics of ambulatory
health care in this country. The information that we will request includes data about patient visits (e.g., demographics, diagnoses,
services, and treatments); physician practice characteristics (e.g., practice type), and use of electronic medical records.
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be
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Many organizations and leaders in the health care community, including those providing the enclosed letter of endorsement, have
expressed their support and join me in urging your participation in this meaningful study. You will be asked to complete a short
electronic questionnaire on a sample of about 30 patient encounters during a randomly assigned, 1-week reporting period.
Additionally, there is a short interview (approximately 35 minutes) with you about the nature of your practice. We intend to conduct
additional health care research by linking National Provider Identifiers (NPI) and Federal Tax Identification Numbers collected in
this study to health care-related data such as Medicare records. Participation is voluntary, and you or your staff may refuse to
answer any question or stop participating at any time without penalty or loss of benefits.
to
The following are some key points about the survey:
IN
• Data collection for NAMCS is authorized by Section 306 of the Public Health Service Act (Title 42, U.S. Code, 242k).
N
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• All information collected will be held in the strictest confidence according to Section 308(d) of the Public Health Service Act (Title
42, U.S. Code, 242m(d) and the Confidential Information Protection and Statistical Efficiency Act (Title 5 of PL 107-347). This
information will be used for statistical purposes only. No patient names, social security numbers, or addresses are collected.
• NAMCS conforms to the Privacy Rule as mandated by HIPAA because disclosure of patient data is permitted for public
health purposes, and the NCHS Research Ethics Review Board has approved NAMCS.
• U.S. Census Bureau employees, who administer the study, have taken an oath to abide by Title 13, U.S. Code, Section 9, which
requires them to keep all information about your practice and patients confidential.
A Census Bureau employee, acting as our agent, will call you to schedule an appointment regarding the details of your
participation. If you have any questions, please call a NAMCS representative at 1–800–392–2862. You can also find additional
information on the survey by visiting the NAMCS participant website at: http://www.cdc.gov/nchs/ahcd/namcs_participant.htm.
You may have questions about your rights as a participant in this research study. If so, please call the Research Ethics Review
Board at 1–800–223–8118. Please leave a brief message with your name and phone number and say that you are calling about
Protocol #2010-02. Your call will be returned as soon as possible.
We greatly appreciate your cooperation.
Sincerely,
Charles J. Rothwell, MS, MBA
Director
Section I – TELEPHONE SCREENER – Continued
4. Specialty
a. Your specialty is _______________________________ ,
1
is that right?
2
Yes – SKIP to item 4c
No
Edit
b. What is your specialty (including general
practice)?
(Name of specialty)
Edit
Code
Which of the following categories best
describes your professional activity –
patient care, research, teaching,
administration, or something else?
1
2
3
4
as
ed
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us
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b. PROBE: We include as ambulatory patients,
c. Do you work as an employee or a contractor
IN
3
4
1
2
1
2
ol
Yes – SKIP to item 6c
No – does not give direct care [6b PROBE]
No longer in practice (i.e., retired, not
SKIP to
licensed)
item 8 on
Temporarily not practicing (refers to
page 3
duration of 3 months or more)
}
Yes, cares for ambulatory patients
No, does not give direct care –Specify reason,
then read item 8 on page 3
Yes
No – SKIP to item 6e
N
ot
in a federally operated patient care setting
(e. g., VA, military, prison), hospital
emergency department, hospital outpatient
department, or community health center?
to
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2
be
to
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individuals receiving health services
without admission to a hospital or other
facility. Does your work include any such
individuals?
d. In addition to working in a federally
operated patient care setting, hospital
emergency department, hospital outpatient
department, or community health center,
do you also see any ambulatory patients in
another setting (e. g., office-based
practice)?
e. Do you work in an office-based practice
owned by a hospital?
f. 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.
Page 2
1
a
6a. Do you directly care for any ambulatory
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patients in your work?
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N
5.
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4
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3
White
Black or African-American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Patient care
Research
Teaching
Administration
Something else – Specify
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lle
1
Enter (X) all that apply.
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d. What is your race?
Hispanic or Latino
Not Hispanic or Latino
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2
A
1
PY
Refer to the NAMCS-252, pages 9 – 11 for codes.
c. What is your ethnicity?
1
2
Yes
No – SKIP to item 8 on page 3
2
Yes – If item 6c = 1 SKIP to item 6f; If item 6c = 2, SKIP to item 7a
No
1
Continue
1
FORM NAMCS-1A (2-19-2015)
Section I – TELEPHONE SCREENER – Continued
7a. We have your address as (Read address shown
Yes – SKIP to item 9
No, incorrect address – Ask item 7b
1
in item 1). Is that the correct address for your
office?
2
b. What is the correct address and phone
Number and street
number?
PY
City
to
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ZIP Code
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State
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Telephone (Area code and number)
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A
be appropriate for you. I appreciate your time and interest.
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8. Thank you, Dr. . . ., but since you are not currently practicing, our questions would not
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SKIP to
item 9
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9. I would like to arrange an appointment with you within the next week or so to discuss
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Time
a.m.
p.m.
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Thank you, Dr. . . .
Year
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Physician refused to participate –Go to item 10a.
Day
a
Month
Weekday
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the study. It will take about 30 minutes. What would be a good time for you, before
Friday,________________(last Friday before the assigned reporting week)?
be
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Section II – REFUSAL QUESTIONS
to
IN
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.
ot
10a. Overall, at how many different office
N
locations do you see ambulatory patients?
Do not include settings such as EDs,
outpatient departments, surgicenters,
Federal clinics, and community health
centers.
Number of
office locations
b. (Ask if CHC) Overall, at how many different
CHC locations do you see ambulatory
patients?
Number of
CHC locations
Number of weeks
If > 26 weeks, ask item 10d
If = 0, SKIP to item 10e
If 1 to 26 weeks,
SKIP to item 10f
c. In a typical year, about how many weeks do
you NOT see any ambulatory patients (e.g.,
conferences, vacations, etc.)?
d. You typically see patients fewer than half
the weeks in each year. Is that correct?
FORM NAMCS-1A (2-19-2015)
1
2
Yes
No – Please explain
}
SKIP to
item 10f
Page 3
Section II – REFUSAL QUESTIONS – Continued
10e. You typically see patients all 52 weeks of
Yes
No – Please explain
1
the year. Is that correct?
2
f. During your last normal week of practice,
how many patient visits did you have at all
office locations?
Number of
patient visits
g. During your last normal week of practice,
ambulatory patients:
(1) How many physicians are associated with
you?
ot
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as
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1
2
3
4
1
2
3
4
5
6
7
Page 4
If number of other physicians
is 0, SKIP to item 10h(3).
Multi
Single
a
A
to
IN
REFER TO FLASHCARD A.
2
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(3) Are you a full- or part-owner, employee, or
an independent contractor?
(4) Who owns the practice?
1
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N
A
Number of physicians
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(2) Is this a single- or multi-specialty group
practice?
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h. At the office location where you see the most
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Number of
weekly hours
to
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.
Full-owner – Exit
Part-owner
Employee SKIP to item 10h(4)
Contractor
}
Physician or physician group
Insurance company, health plan, or HMO
Community Health Center
Medical/Academic health center
Other hospital
Other health care corporation
Other – Specify
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW
Before we begin, I’d like to give you some background about this study.
Medical researchers and educators are especially interested in topics like medical education,
health workforce needs, and the changing nature of health care delivery. The National Ambulatory
Medical Care Survey (or NAMCS) was developed to meet the need for such information.
The Centers for Disease Control and Prevention works closely with members of the medical
profession to design the NAMCS each year. The NAMCS supplies essential information about how
ambulatory medical care is provided in the United States, and how it is utilized by patients.
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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.
11a. Overall, at how many different office locations do
a
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Yes – SKIP to item 12a
No – Please explain
us
1
2
}
SKIP to
item 12a
Yes
No – Please explain
to
FO
2
be
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d. You typically see patients all 52 weeks of the year.
Is that correct?
1
If > 26 weeks, ask item 11c
If = 0, SKIP to item 11d
If 1 to 26 weeks,
SKIP to item 12a
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the weeks in each year. Is that correct?
Number of weeks
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c. You typically see patients fewer than half
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Number of locations
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you see ambulatory patients? Do not include
settings such as EDs, outpatient departments,
surgicenters, Federal clinics, and community health
centers.
b. In a typical year, about how many weeks do you
NOT see any ambulatory patients (e.g., conferences,
vacations, etc)?
n
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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.
IN
12a. This study will be concerned with the AMBULATORY
N
ot
patients you will see in your office(s) during the week
of Monday,
_______________ through Sunday,_______________.
Are you likely to see any ambulatory patients in your
office(s) during that week?
For allergists, family practitioners, etc. – if routine care such as
allergy shots, blood pressure checks, and so forth will be
provided by staff in physician’s absence, mark "Yes."
1
2
Yes –If CHC SKIP to item 13a;
If Non – CHC Skip to item 13b
No – SKIP to item 12b
b. Why is that? Record verbatim.
c. Since it’s very important that we include any ambulatory patients that you might see in your
office during that week, I’ll check back with your office just before (Starting date) to make sure your
plans have not changed.
FORM NAMCS-1A (2-19-2015)
Page 5
Section III – INDUCTION INTERVIEW – Continued
13a. (Ask if CHC) What does the current address below represent? (office location fill)
1
Sampled CHC location
2
Sampled CHC that moved
Not sampled CHC location - Exit and call RO
3
b. (Ask if Non-CHC) Are there any other office locations at which you will see
ambulatory patients during that 7-day reporting period?
(1) What is the street address?
(2) In what city is this office located?
2
Alternative/2nd office address
Home office
3
4
Home
5
Unknown
n
Main office address
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(5) Enter location/address type
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(4) What is the zip code for this office?
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(3) In what state is this office?
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co
If in doubt about any clinic/facility/institution, PROBE –
ct
(office location). Mark up to 3.
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c. Which office is the current office?
Enter office number
d. Looking at FLASHCARD B below, choose ALL of the type(s) of settings that describe the office at
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(1) Is this/that clinic/facility/institution part of a hospital emergency department or an
outpatient department? If yes, select 2 or 4.
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(2) Is this/that clinic/facility/institution operated by the Federal Government? If yes, select 12.
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(1) Private solo or group practice
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as
A
FLASHCARD B
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(7) Mental health center
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(5) [Intentionally left blank]
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(3) Freestanding clinic/urgicenter (not part of
a hospital outpatient department)
to
IN
(9) Non-federal Government clinic (e.g., state,
county, city, maternal and child health,
etc.)
N
ot
(11) Family planning clinic (including Planned
Parenthood)
(13) Health maintenance organization or other
prepaid practice (e.g., Kaiser Permanente)
(15) Faculty practice plan
(2) Hospital emergency department
(4) Hospital outpatient department
(6) Ambulatory surgicenter
(8) Institutional setting (school infirmary,
nursing home, prison)
(10) Industrial outpatient facility
(12) Federal Government operated clinic
(e.g., VA, military, etc.)
(14) Laser vision surgery
(16) Community Health Center (e.g., Federally
Qualified Health Center (FQHC), federally
funded clinics or ‘look alike’ clinics)
13e. Are there other office locations where you NORMALLY would see patients, even though you
will not see any during your 7-day reporting period? Do not include settings such as EDs,
outpatient departments, surgicenters, and Federal clinics, and community health centers.
1
Yes – SKIP to item 13g
2
No – SKIP to item 14a
f. (Ask if CHC) In how many other CHC locations do you NORMALLY see patients?
Number of CHC locations
g. Of these locations where you will not be seeing patients during your 7-day reporting
period, how many total office visits did you have during your last week of practice at
these locations?
Number of visits
Page 6
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
Ask item 14a ONCE to obtain total for ALL in-scope locations.
14a. During the week of Monday, ____________ through Sunday, ___________ how many days do
you expect to see any ambulatory patients at all in-scope locations? (Read locations)
Estimated Number
of Days
Enter street name or town of in-scope location(s).
NOTE: Keep the location numbers the same as the office numbers in item 13a.
PY
Office location No.
#5
_____
_____ _____
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A
N
#4
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Yes . . .
No . . . .
1
1
1
1
1
2
2
2
2
2
as
a
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A
#3
ol
_____ _____
da
O
c. During the week of Monday, ____________ through
Sunday ____________, do you expect to have about
the same number of visits as you saw during
your last normal week in each office taking into
account time off, holidays, and conferences?
n
Number
of visits
If physician is in group practice, only
include the visits to sampled physician.
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approximately how many office visit encounters
did you have at each office location?
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b. During your last normal week of practice,
#2
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#1
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NOTE: Enter (X) response. If answer is "Yes", instrument
copies the number in 14b to 14d for that office location. If
answer is "No" then item 14d is ASKED for that office
location.
d. Approximately how many ambulatory visits do
be
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you expect to have at this office location?
Number
of visits
_____
_____ _____ _____ _____
to
IN
e. Tally of estimated number of visits
Number of visits
N
ot
NOTE: To obtain the total number of estimated visits,
instrument adds the estimate for each office location in
14d.
Now, I’m going to ask about your practice at
(in-scope location).
15a. Do you have a solo practice, or are you
_____
Office Location
#1
#2
Solo . . . . . .
1
1
associated with other physicians in a
partnership, in a group practice, or in some
other way at this location?
#3
1
#4
#5
1
1
2
2
If Solo, SKIP to item 15d.
Nonsolo . . .
2
2
2
_____
_____
Multi . . . . . .
1
1
1
1
1
Single . . . . .
2
2
2
2
2
b. How many physicians are associated with you
at (this/that in-scope location)?
How many
c. Is this a single- or multi-specialty (group)
practice at (this/that in-scope location)?
FORM NAMCS-1A (2-19-2015)
_____ _____ _____
Page 7
Section III – INDUCTION INTERVIEW – Continued
#1
#2
_____
_____
Office Location
15d. How many mid-level providers (i.e., nurse
practitioners, physician assistants, and
nurse midwives) are associated with you at
(this/that in-scope location)?
How many
e. Are you a full- or part-owner, employee, or an Full-owner . . . . . . .
independent contractor at (this/that in-scope
location)? If "Owner" is marked then automatically
mark "Physician or physician group" in item 15f.
Part-owner . . . . . .
Employee . . . . . . .
Contractor . . . . . . .
f. Who owns the practice at (this/that in-scope
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
6
ed
us
to
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ct
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7
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
h. Do you see patients in the office during the
evening or on weekends at (office location)?
to
5
C
FO
6. X-Ray
N
IN
5. Ultrasound
be
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M
3. Lab testing (not including urine dipstick,
urine pregnancy, fingerstick blood
glucose, or rapid swab testing for
infectious diseases)
4. Spirometry
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2. Phlebotomy
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O
N
1. EKG/ECG
A
perform any of the following on site at
(this/that in-scope location)?
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g. Does your practice have the ability to
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location)?
#5
#4
_____ _____ _____
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Physician/
Physician group . . . .
Insurance company,
health plan, or
HMO . . . . . . . . . .
Community Health
Center . . . . . . . . .
Medical/Academic
health center . . . . .
Other hospital . . . .
Other health care corp
Other . . . . . . . . . .
Give FLASHCARD A (p.1 Flashcard and
Job Aid Booklet) and ask:
#3
1
2
3
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
Yes
No
DK
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
Yes
No
DK
i. What is your National Provider Identifier
(NPI) at (office location)?
j. What is your Federal Tax ID, also known as
Employer Identification Number (EIN), at
(office location)?
Page 8
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
16a. During your last normal week of practice,
how many hours of direct patient care did
you provide?
Number of
weekly hours
NOTE – Direct patient care includes: Seeing patients,
reviewing tests, preparing for and performing
surgery/procedures, providing other related patient
care services.
b. During your last normal week of practice,
Number of encounters
per week
as
Yes
No
1
2
3
4
ol
Never heard of it
Heard of it but do not know much about it
Know something about it
Very familiar with it
ed
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A
Standards for Culturally and Linguistically
Appropriate Services in Health and Health
Care (the National CLAS Standards)?
2
a
18. How familiar are you with the National
1
da
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cultural competence. Within the past 12
months, have you participated in any
cultural competence training?
O
17. The following two questions are about
to
O
N
(The following two questions must be answered by the
sample provider.)
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..............
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(5) Internet/e-mail consults
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..................
A
(4) Telephone consults
C
.......................
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(3) Hospital visits
....................
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(2) Other home visits
..................
n
(1) Nursing home visits
PY
about how many encounters of the
following type did you make with patients:
us
R
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.
be
FO
19. Screening for alcohol misuse (excessive
to
ot
N
IN
consumption and alcohol-related problems)
is often conducted in clinical settings. How
do you screen for alcohol misuse? (Enter all
that apply.)
1
2
3
4
5
6
7
8
20. How often do you screen for alcohol
misuse?
1
2
3
4
FORM NAMCS-1A (2-19-2015)
I don’t screen – SKIP to item 24 9
T-ACE
TWEAK
CAGE
CRAFFT
AUDIT
Ask number of drinks per
occasion (For example,
"On a typical drinking day,
how many drinks do you
10
have?")
Ask frequency of drinking
11
(For example, "On average,
how many days a week do
you have an alcoholic
drink?")
Ask binge question
(For example, for
women: "How many
times in the past
year have you had 4
or more drinks in a
day?" For men: "how
many times in the
past year have you
had 5 or more drinks
in a day?")
I don’t use a formal
screening instrument
Other – Specify
At every health maintenance visit (annually)
At every health care visit
When I suspect a patient has a
substance/alcohol-related problem
Almost never or never
Page 9
Section III – INDUCTION INTERVIEW – Continued
1
administered?
2
3
4
22. If patient is interviewed, who administers
1
the screening?
2
3
4
}
Physician, nurse practitioner, physician assistant
Nurse excluding nurse practitioner
Medical assistant
Administrative staff
Other – Specify
ol
to
io
ct
co
ta
da
as
a
TI
N
ot
to
be
implementing alcohol/substance screening
and intervention in primary care settings?
Mark (X) all that apply.
FO
4
Never
Sometimes
Often
Always
ed
A
us
M
R
24. What resources would be helpful in
IN
3
lle
A
N
1
2
O
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?
L
23. Brief interventions for risky alcohol use are
n
C
O
5
Interview (in person/face-to-face) – SKIP to item 22
Patient completes a form
SKIP to item 23
Electronic (self-administered)
Other – Specify
PY
21. How are screening question(s)
1
2
3
4
5
6
7
8
9
Implementation guide for alcohol screening and
intervention
Training on how to conduct alcohol screening
Training on how to conduct intervention
Office-based mentoring
Access to patient education materials
Scripts of what to say to patients
Information about reimbursement for services
Information about where or how to refer for additional
services
Other – Specify
The next set of questions pertain to characteristics of the sampled physician’s practice.
IF ONE LOCATION LISTED IN NAMCS-1A
DISPLAY THE FOLLOWING:
The next questions are about the practice
that is associated with (fill address of
sampled location).
1
2
3
25. How many physicians, including you, are
1 physician
2–3 physicians
4–10 physicians
4
5
6
11–50 physicians
51–100 physicians
More than 100 physicians
associated with this practice? Please
include physicians at [fill address of
sampled location], and physicians at any
other locations of this practice.
Page 10
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
The next set of questions pertain to characteristics of the sampled physician’s practice.
IF TWO OR MORE LOCATIONS LISTED IN
NAMCS-1A, DISPLAY THE FOLLOWING:
2
3
b. By whom is your practice certified as a
1
patient-centered medical home? Mark (X)
all that apply.
as
M
29. Is this access available to physicians only,
ed
or is it also available to other non-physician
clinicians? Mark (X) all that apply.
us
30. What is the primary method by which your
R
a
2
A
1
patient medical records using an electronic
health record (EHR) system 24 hours a day?
3
1
2
3
1
2
3
4
5
6
ol
PY
O
Yes
No
Unknown
Physicians (MD-DO) only
All Physicians and non-physician Clinicians
Unknown
Electronic transmission (i.e., EHR or EMR)
Fax
Email – SKIP to item 31
Telephone or in-person communication with provider
Paper copy
Other – Specify
N
ot
to
be
practice receives information about
patients in your practice when they have
been seen in the emergency department or
hospitalized?
FO
Accrediation Association for Ambulatory Health (AAAH)
Joint Commission
National Committee for Quality Assurance (NCQA)
Utilization Review Accrediation Commission (URAC)
Other
Unknown
da
O
TI
5
6
28. Is it possible within your practice to access
IN
}
ta
3
4
31. Was this email sent over a secure network?
1
2
3
32. 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?
33. Does your practice have written protocols for
providing chronic care services that are used
by all members of the care team?
34. Does your practice report any quality
measures or quality indicators to either
payers or to organizations that monitor
health care quality?
35. Do all other locations or offices associated
with this practice use the same Federal Tax
ID, also known as Employer Identification
Number (EIN), or do any locations or offices
associated with this practice use a different
Federal Tax ID or EIN?
FORM NAMCS-1A (2-19-2015)
Yes
No
SKIP to item 28
Unknown
N
2
to
1
patient-centered medical home?
n
27a. Is your practice certified as a
io
6
C
5
ct
4
lle
3
L
2
1 physician
2–3 physicians
4–10 physicians
11–50 physicians
51–100 physicians
More than 100 physicians
co
1
A
The next questions are about the practice
that is associated with (fill office location
with most visits).
26. How many physicians, including you, are
associated with that practice? Please include
physicians at [fill address of location with the
most office visits based on NAMCS-1A], and
physicians at any other locations of that
practice.
1
2
3
1
2
3
1
2
3
1
2
3
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
All use the same Federal Tax ID or EIN
Some use a different Federal Tax ID or EIN
Unknown
Page 11
Section III – INDUCTION INTERVIEW – Continued
36. The next set of questions refers to the types of providers who work at (fill office location with most visits). Give
FLASHCARD H (p. 8 Flashcard and Job Aid Booklet) and ask: How many of the following full-time and
part-time providers are on staff at (fill office location with most visits)? Full-time is 30 or more hours
per week. Part-time is less than 30 hours per week. Please provide the total number of full-time and part-time
providers. Please include the sampled provider in the total count of staff below.
Number Full-time
( ≥ 30 hours)
Type of Provider
Number Part-time
(<30 hours)
Non-Physician Clinicians
to
O
n
Physician Assistants (PA)
ol
PY
Physicians (include MDs and DOs)
io
C
Nurse Practitioners (NP)
d
co
us
Allied Health
be
R
F
o O
Medical Assistants (MA)
M
A
e
Certified Nursing Assistants/Aides (CNA)
s
a
T
a I
Licensed Practical Nurses (LPN)
da
O
Registered nurses (RN) (not an NP or CNM)
ta
N
Other Nursing Care
le
A
L
l
ct
Certified Nurse Midwives (CNM)
tt
o
Radiology Technicians (RT)
N
IN
Laboratory Technicians (LT)
Physical Therapists (PT)
Pharmacists (PH)
Dieticians/Nutritionists (DN)
Other
Mental Health Providers (MH)
Health Educators/Counselors (HEC)
Case Managers (not RNs)/Certified Social
Workers (CSW)
Community Health Workers (CHW)
Page 12
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
The following group of questions asks about specific tasks performed by the
providers at (fill office location with most visits).
37.
At (fill office location with most visits), which type of provider most commonly performs the
following tasks? Mark (X) all that apply.
Based on the staff selected in Question 36, a drop-down list will be made available for each of the following
questions a–m, but will only contain those selected providers as well as "Unknown" and "Task is not performed in
this office" if needed.
a. Records Body Measurements (such as height and weight) and vital signs (such as blood
pressure, temperature, heart rate)
PY
b. Performs office-based testing such as EKG and hearing/vision testing (do not include
laboratory testing)
c. Draws blood for lab testing
ol
n
io
L
stress management)
to
C
O
d. Provides immunizations (includes both childhood and adult)
e. Conducts cancer screenings (such as breast, cervical, and prostate screenings)
f. Provides behavioral health screenings (such as depression, alcohol and substance abuse)
g. Provides counseling services (such as diet/nutrition, weight reduction, tobacco cessation,
lle
N
asthma, diabetes)
ct
A
h. Manages the routine care of patients with chronic conditions (such as hypertension,
co
ta
da
TI
O
i. Writes refill prescriptions for medications
j. Enters patient information into medical/billing records
k. Performs imaging tests (such as X-rays and ultrasounds)
a
A
l. Makes referrals (for example, to specialty care, or to community-based services)
m. Contacts patients, who are transitioning from hospital or nursing home back to the community
as
ed
us
be
to
ot
IN
FO
R
M
The following questions concern the PAs, NPs, and CNMs practicing at (fill office
location with most visits).
38. Are PA(s)/NP(s)/CNM(s) supervised by someone
1
Yes, always
on-site?
2
Yes, sometimes
3
No
4
Unknown/Not applicable
39. Do you sign-off on the medical records of the
1
Yes, always
patients the PA(s)/NP(s)/CNM(s) see(s)?
2
Yes, sometimes
3
No
4
Unknown/Not applicable
N
40. Do the PA’s/NP’s/CNM’s patients have a
separate log from your patients?
1
2
3
4
41. Is your approval required before the
PA(s)/NP(s)/CNM(s) prescribe(s) medication?
1
2
3
4
42. Do/Does the PA(s)/NP(s)/CNM(s) bill for services
using their own NPI number?
1
2
3
4
Yes, always
Yes, sometimes
No
Unknown/Not applicable
Yes, always
Yes, sometimes
No
Unknown/Not applicable
Yes, always
Yes, sometimes
No
Unknown/Not applicable
The following questions pertain to the electronic medical records at (fill office
location with most visits).
43. Does the reporting location submit any claims
electronically (electronic billing)?
1
2
3
FORM NAMCS-1A (2-19-2015)
Yes
No
Unknown
Page 13
Section III – INDUCTION INTERVIEW – Continued
The following questions pertain to the electronic medical records at (fill office
location with most visits).
1
Yes, all electronic
44a. Does the reporting location use an electronic
Go to
health record (EHR) or electronic medical
Yes, part paper and part electronic item 44b
2
record (EMR) system? Do not include billing
3
No
record systems. Read answer categories.
4
Unknown SKIP to item 47
}
}
b. In which year did you install your current
EHR/EMR system?
Year
3
2
3
Enter (X) only one box. If "Other" is checked, please
specify the name.
Allscripts
Amazing Charts
athenahealth
Cerner
eClinicalWorks
e-MDs
Epic
GE/Centricity
C
4
5
46. Does your EHR have the capability to electronically
a
as
A
send health information to another provider whose
EHR system is different from your system?
47. At the reporting location, are there plans for
M
1
ta
2
3
da
TI
O
45. 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.
14
15
Unknown
11
12
13
ct
co
N
A
8
lle
7
10
io
L
6
Greenway Medical
McKesson/Practice Partner
NextGen
Practice Fusion
Sage/Vitera
Other – Specify
9
O
1
system?
to
d. What is the name of your current EHR/EMR
ol
2
PY
Yes
No
Unknown
1
use criteria as defined by the Department of
Health and Human Services?
n
c. Does your current system meet meaningful
Yes
No
Unknown
Yes
No
Unknown
1
2
3
Yes
No
3
Maybe
4
Unknown
Answer ALL remaining questions for the in-scope location with the most visits which
is (in-scope location).
ed
to
48a. Medicare and Medicaid offer incentives to practices
N
ot
that demonstrate "meaningful use of health IT." At
the reporting location, are there plans to apply for
Stage 1 of these incentive payments?
IN
1
2
us
be
FO
R
installing a new EHR/EMR system within the next
18 months?
b. Are there plans to apply for Stage 2 incentive
payments?
Yes, we already applied – Go to item 48b
Yes, we intend to apply
Uncertain if we will apply SKIP to item 49
No, we will not apply
1
}
2
3
4
Yes
No
Maybe
Unknown
1
2
3
4
49. Give FLASHCARD C (p.3 Flashcard and Job Aid Booklet)
and ask: Please indicate whether the ambulatory
reporting location has each of the following
computerized capabilities and how often these
capabilities are used. Enter (X) only one per row.
a. Recording patient history and demographic
information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
c.
d.
e.
f.
Page 14
Yes,
used
routinely
Yes, but
NOT
used
routinely
Yes, but
turned
off or not
used
No
Unknown
1
2
3
4
5
Recording patient problem list? . . . . . . . . . .
Recording and charting vital signs? . . . . . . . . . . .
1
2
3
4
5
1
2
3
4
5
Recording patient smoking status? . . . . . . . . . . .
1
2
3
4
5
Recording clinical notes? . . . . . . . . . . . . . . . . . . . .
1
2
3
4
5
Recording patient’s medications and allergies?
1
2
3
4
5
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
Answer ALL remaining questions for the in-scope location with the most visits which
is (in-scope location).
Yes, but
Yes, but
Yes,
turned
NOT
Unknown
used
No
off or not
used
routinely routinely
used
49g. Reconciling lists of patient medications to
2
3
4
5
1
2
3
4
5
1
2
L
1
O
a
A
If Yes, ask – (1) Can the EHR/EMR automatically
graph a specific patient’s lab
results over time?
as
ed
M
l. Ordering radiology tests? . . . . . . . . . . . . . . . . . . . . .
m. Viewing imaging results? . . . . . . . . . . . . . . . . . . . . .
n. Identifying educational resources for patients’
R
1
1
Go to
49k(1)
ta
da
TI
k. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . .
us
specific conditions? . . . . . . . . . . . . . . . . . . . . . . . . .
2
ct
2
Go to
49j(1)
lle
If Yes, ask – (1) Are orders sent electronically?
Go to
49j(1)
co
N
A
1
2
2
2
Go to
49k(1)
4
Skip to
49j
5
Skip to
49j
4
5
3
4
5
3
4
5
3
4
to
1
3
ol
2
C
1
If Yes, ask – (2) Are warnings of drug interactions
or contraindications provided?
If Yes, ask – (3) Are drug formulary checks
performed?
j. Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . .
Skip to
49j
n
If Yes, ask – (1) Are prescriptions sent
electronically to the pharmacy?
3
Go to
49i(1)
O
Go to
49i(1)
PY
1
io
identify the most accurate list? . . . . . . . . . . . . . . .
h. Providing reminders for guideline-based
interventions or screening tests? . . . . . . . . . . . . . .
i. Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . . .
Skip to
49k
3
3
Skip to
49l
Skip to
49k
4
4
Skip to
49l
5
Skip to
49k
5
5
Skip to
49l
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
FO
o. Reporting clinical quality measures to federal
be
or state agencies (such as CMS or Medicaid)? . .
p. Identifying patients due for preventive or
to
ot
IN
follow-up care in order to send patients
reminders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q. Generating lists of patients with particular
health conditions? . . . . . . . . . . . . . . . . . . . . . . . . . . .
N
r. Electronic reporting to immunization
registries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
s. Providing patients with clinical summaries for
each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
t. Exchanging secure messages with patients? . . .
u. Providing patients the ability to view online,
download, or transmit information from their
medical record? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50a. Do you refer any of your patients to providers
outside of your office or group?
b. Do you send the patient’s clinical information to
the other providers?
1
2
1
2
3
c. Do you send it electronically (not fax)?
1
2
3
FORM NAMCS-1A (2-19-2015)
Yes
No – SKIP to item 51a
Yes, routinely
Yes, but not routinely
No – SKIP to Question 51a
Yes, routinely
Yes, but not routinely
No
Page 15
Section III – INDUCTION INTERVIEW – Continued
3
c. Do you send it electronically (not fax)?
1
2
3
52a. Do you take care of patients after they are
1
discharged from an inpatient setting?
2
b. Do you receive a discharge summary with
1
clinical information from the hospital?
2
3
c. Do you receive it electronically (not fax)?
1
2
3
d. Can you automatically incorporate the received
1
information into your EHR system without
manually entering the data?
2
Yes, routinely
Yes, but not routinely
No
Yes
No – SKIP to item 53a
Yes, routinely
Yes, but not routinely
No – SKIP to item 53a
Yes, routinely
Yes, but not routinely
No – SKIP to item 53a
Yes
No
Not applicable, I do not have an EHR system
L
3
Yes, routinely
Yes, but not routinely
No – SKIP to item 52a
ol
2
PY
1
information to the other providers?
to
b. Do you send a consultation report with clinical
Yes
No – SKIP to item 52a
n
2
O
1
providers outside of your office or group?
C
51a. Do you see any patients referred to you by
Read answer categories.
a
as
ed
M
A
c. Is the patient health information that you share
electronically sent directly from your EHR
system to another EHR system?
R
d. With what types of providers do you
us
to
ot
IN
Enter (X) all that apply.
be
FO
electronically share patient health information
(e.g., lab results, imaging reports, problem lists,
medication lists)?
e. Are you/your staff able to electronically find
N
health information (e.g., medications, outside
encounters) from sources outside of the office
for your patients? Please reference (office location
fill), which is the in-scope office with the most visits.
f. How do you look up patient health information
from sources outside of the office?
Please reference (office location fill), which is the in-scope
with the most visits. Mark (X) all that apply.
2
1
da
TI
b. How do you electronically share patient health
information? Enter (X) all that apply.
1
ta
O
N
electronically (not fax) with other providers,
including hospitals, ambulatory providers, or labs?
2
3
1
2
3
4
1
2
3
4
5
6
7
1
2
3
4
1
2
3
4
Page 16
io
ct
Yes
No – SKIP to item 53e
co
53a. Do you share any patient health information
lle
A
The next questions are about sharing (either sending or
receiving) patient health information.
EHR/EMR
Web portal (separate from EHR/EMR)
Other electronic method (not fax)
Yes, routinely
Yes, but not routinely
No
Unknown
Ambulatory providers inside your office/group
Ambulatory providers outside your office/group
Hospitals with which you are affiliated
Hospitals with which you are not affiliated
Behavioral health providers
Long-term care providers
Home health providers
Yes, routinely
Yes, but not routinely
No
SKIP to item 54
Unknown
}
Through your EHR/EMR
Web portal (separate from EHR/EMR)
View only or restricted access to other
providers’ EHR system
Other electronic method (not fax) – Specify
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
1
look up? Mark (X) all that apply.
2
3
4
5
h. Do you or your staff routinely incorporate the
1
information you look up into your EHR?
2
3
Lab
Imaging reports
Patient problem lists
Medication lists
Other – Specify
Yes, via manual entry or scanned copy
Yes, automatically able to incorporate without
manual entry or scanning
No, we do not routinely incorporate into our EHR
PY
53g. What types of information do you routinely
O
(1) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ta
da
TI
(2) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
A
(3) Private insurance?. . . . . . . . . . . . . . . . . . . . . . . .
as
M
(4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . .
ed
us
be
FO
R
(5) Other (including charity, research, Tricare,
VA, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55. Roughly, what percentage of the patient care
ol
to
ct
%
%
%
%
%
Revenue sources should
sum close to 100%.
ot
to
Percent of revenue from
managed care
%
N
IN
revenue received by this practice comes from
managed care contracts?
Percent of patient
care revenue
co
N
A
revenue comes from –
lle
54. Roughly, what percent of your patient care
io
L
C
Give FLASHCARD E (p. 5 Flashcard and Job Aid Booklet)
and ask: I would like to ask a few questions about
your practice revenue and contracts with
managed care plans.
n
O
Please remind physician/provider that the remaining questions refer to all offices
that were determined to be in-scope.
56. Give FLASHCARD F (p. 6 Flashcard and Job Aid Booklet)
and ask: Roughly, what percent of your patient
care revenue comes from each of the following
methods of payment?
Percent of patient
care revenue
(a) Fee-for-service? . . . . . . . . . . . . . . . . . . . . . . . . . .
%
(b) Capitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%
(c) Case rates (e.g., package pricing/episode
of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%
(d) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%
Revenue sources should
sum close to 100%.
FORM NAMCS-1A (2-19-2015)
Page 17
Section III – INDUCTION INTERVIEW – Continued
The next set of questions is about new patients, payments, compensation and appointments.
57a. Are you currently accepting "new" patients into
Yes
No
SKIP to item 58
Don’t know
1
your practice(s) at (read in-scope locations listed)?
}
2
3
b. From those "new" patients, which of the following
1
3
2
2
3
3
Don’t know
Don’t know
Don’t know
Don’t know
3
co
N
ta
a
as
1
2
3
us
ed
5
4
5
ot
to
FO
N
IN
be
R
M
account in determining the compensation (salary,
bonus, pay rate, etc.) paid to the physicians in the
practice. Please indicate whether the practice
explicitly considers each of the following factors in
determining your compensation.
Enter (X) all that apply.
Read answer categories.
4
da
O
TI
A
59. Clinical practices may take various factors into
3
Don’t know
Don’t know
Don’t know
Fixed salary
Share of practice billings or workload
Mix of salary and share of billings or
other measures of performance (e.g.,
your own billings, practice’s financial
performance, quality measures,
practice profiling)
Shift, hourly or other time-based
payment
Other
A
3
Read answer categories.
No
No
No
No
3
io
2
2
L
1
basic compensation?
3
ct
58. Which of the following methods best describes your
2
2
C
1
Yes
Yes
Yes
Yes
No
No
No
ol
1
2
PY
1
2
to
1
Yes
Yes
Yes
n
1
O
1
lle
types of payment do you accept at (read in-scope
locations listed)?
(1) Capitated private insurance? . . . . . . . . . . . . . . . . . .
(2) Non-capitated private insurance? . . . . . . . . . . . . .
(3) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Workers’ compensation? . . . . . . . . . . . . . . . . . . . . .
(6) Self-pay? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(7) No charge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60a. Does (fill physician name’s) practice set time
1
aside for same day appointments?
2
3
Factors that reflect your own
productivity
Results of satisfaction surveys from
your own patients
Specific measures of quality, such as
rates of preventive services for your
patients
Results of practice profiling, that is,
comparing your pattern of using
medical resources with that of other
physicians
The overall financial performance of
the practice
Yes
No
Don’t know
b. Roughly, what percent of your daily visits are
same day appointments?
%
c. On average, about how long does it take to get
1
an appointment for a routine medical exam?
2
3
4
5
6
7
Page 18
Within 1 week
1–2 weeks
3–4 weeks
1–2 months
3 or more months
Do not provide routine
medical exams
Don’t know
FORM NAMCS-1A (2-19-2015)
Section III – INDUCTION INTERVIEW – Continued
If provider is part of the community health center sample, item 61 is asked.
61.
Provider demographics –
a. What is your year of birth?
1 9
b. What is your sex?
PY
Female
Male
c. What is your highest medical degree?
5
ta
lle
Code
Name of specialty
Code
ed
as
a
Name of specialty
us
R
M
A
e. What is your secondary specialty?
da
TI
O
N
d. What is your primary specialty?
}
co
A
L
6
ct
4
io
C
3
MD
DO
Nurse practitioner
Physician assistant SKIP to patient
record forms
Nurse midwife
Other
ol
2
O
1
to
2
n
1
be
to
ot
Board certification
N
IN
FO
f. What is your primary board certification?
g. What is your secondary board certification?
Board certification
h. What year did you graduate from medical school?
Year
i. Did you graduate from a foreign medical school?
1
2
FORM NAMCS-1A (2-19-2015)
Yes
No
Page 19
Section IV – DISPOSITION AND SUMMARY
62. CASE SUMMARY
a. Number of patient visits during reporting
week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Page 20
to
ot
to
be
us
ed
as
a
da
ta
co
lle
ct
io
n
Edit
N
IN
FO
R
M
A
TI
O
N
A
L
C
O
c. Number of patient record forms completed . . . . .
ol
PY
b. Number of days during reporting week on which
patients were seen . . . . . . . . . . . . . . . . . . . . . . . . . .
FORM NAMCS-1A (2-19-2015)
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2015-08-06 |
| File Created | 2015-02-20 |