2017 Nehrs

Attachment E - Proposed 2017 NEHRS including proposed changes outlined in Attachment D
Form Approved OMB No. 0920-1015, Exp.Date XX/XX/2017

National Electronic Health Records Survey

NOTICE - Public reporting burden of this collection of information is estimated to average 30 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 currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR
Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1015).
Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a
practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable
form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)) and the
Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA every NCHS
employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses
ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). This
law requires the Federal government to protect its information by using computer security programs to identify cybersecurity risks against federal computer
networks.
The Cybersecurity Act of 2015 permits monitoring information systems for the purpose of protecting a network from hacking, denial of service attacks and other
security vulnerabilities.1 The software used for monitoring may scan information that is transiting, stored on, or processed by the system. If the information
triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats. The Cybersecurity Act specifies that the cyber threat indicator
or defensive measure taken to remove the threat may be shared with others only after any information not directly related to a cybersecurity threat has been
removed, including removal of personal information of a specific individual or information that identifies a specific individual. Monitoring under the Cybersecurity
Act may be done by a system owner or another entity the system owner allows to monitor its network and operate defensive measures on its behalf.
____________________________________
1
“Monitor” means “to acquire, identify, or scan, or to possess, information that is stored on, processed by, or transiting an information system”; “information
system” means “a discrete set of information resources organized for the collection, processing, maintenance, use, sharing, dissemination or disposition of
information”; “cyber threat indicator” means “information that is necessary to describe or identify security vulnerabilities of an information system, enable the
exploitation of a security vulnerability, or unauthorized remote access or use of an information system”.

National Electronic Health Records Survey 2017
The National Electronic Health Records Survey is affiliated with the National Ambulatory Medical Care Survey (NAMCS). The purpose
of the survey is to collect information about the adoption of electronic health records/electronic medical records (EHRs/EMRs) in
ambulatory care settings. Your participation is greatly appreciated. Your answers are completely confidential. Participation in this survey
is voluntary. If you have questions or comments about this survey, please call xxx-xxx-xxxx.

1. We have your specialty as:

4. Do you see ambulatory patients in any of the
following settings? CHECK ALL THAT APPLY.

Is that correct?

□1
□2

No

What is your specialty?

_______________________________________
This survey asks about ambulatory care, that is, care
for patients receiving health services without admission
to a hospital or other facility.

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

□1

Yes

Continue to Question 3

□2

No

Please stop here and return
the questionnaire in the
envelope provided. Thank
you for your time.

□3

□
2□
1

Yes

I am no longer
in practice

}

The next question asks about a normal week.
We define a normal week as a week with a normal caseload, with
no holidays, vacations, or conferences.

3. Overall, at how many office locations (excluding
hospital emergency or hospital outpatient
departments) do you see ambulatory patients in a
normal week?
__________ Locations

□

3

□
5□
4

□

6

□

7

□

8

□

9

□

10

Private solo or group practice
Freestanding clinic or Urgent Care
Center
Community Health Center (e.g.,
Federally Qualified Health Center
[FQHC], federally funded clinics or
“look-alike” clinics)
If you see
patients in
any of
these
settings,
go to
Question 5

Mental health center
Non-federal government clinic
(e.g., state, county, city, maternal
and child health, etc.)
Family planning clinic (including
Planned Parenthood)
Health maintenance organization or
other prepaid practice (e.g., Kaiser
Permanente)
Faculty practice plan (an organized
group of physicians that treats
patients referred to an academic
medical center)
Hospital emergency or hospital
outpatient departments
None of the above

}

If you
select only
9 or 10,
go to
Question 41

5. At which of the settings (1-8) in question 4 do you see the most ambulatory patients?
WRITE THE NUMBER LOCATED NEXT TO THE BOX YOU CHECKED.
__________ (For the rest of the survey, we will refer to this as the “reporting location.”)

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National Electronic Health Records Survey

OMB No.

For the remaining questions, please answer regarding the reporting location indicated in question 5
even if it is not the location where this survey was sent.
6. What are the county, state, zip code, and telephone number of the reporting location?
Country

USA

County

State

Address
Zip Code

Telephone

(

7. How many physicians, including you, work at this
practice (including physicians at the reporting location,
and physicians at any other locations of the practice)?

□1
□2
□3

1 physician
2-3 physicians
4-10 physicians

□4
□5
□6

11-50 physicians
51-100 physicians
More than 100 physicians

9. How many mid-level providers (i.e., nurse practitioners,
physician assistants, and nurse midwives) are
associated with the reporting location?
__________ Mid-level providers

10. Is the reporting location a single- or multi-specialty
(group) practice?
Single

□2

Multi

11. At the reporting location, are you currently accepting
new patients?

□1
□2
□3

No (Skip to 13)
Don’t know (Skip to 13)

12. If yes, from those new patients, which of the following
types of payment do you accept?

2. Private insurance non-capitated
3. Medicare
4. Medicaid/CHIP
5. Workers’ compensation
6. Self-pay
7. No charge

□1
□2
□3

Yes
No
Don’t know

15. Who owns the reporting location? CHECK ONE.

□1
□2
□3
□4
□5
□6
□7

Physician or physician group
Insurance company, health plan, or HMO
Community health center
Medical/academic health center
Other hospital
Other health care corporation
Other

16. Estimate the approximate number of years you have
used any electronic health record (EHR) system? Do
not include billing record systems.

Yes

1. Private insurance capitated

13. What percent of your patients are insured by
Medicaid?
_______________%

14. Do you treat patients insured by Medicare?

8. How many physicians, including you, work at the
reporting location? ___________

□1

)

Yes

No

Don’t
know

□1
□1
□1
□1
□1
□1
□1

□2
□2
□2
□2
□2
□2
□2

□3
□3
□3
□3
□3
□3
□3

□ Never used an EHR system
□ Under 1 year
□ ________year(s)
17. Does the reporting location use an EHR system? Do
not include billing record systems.

□1
□2
□3

Yes
No (Skip to 19)
Don’t know (Skip to 19)

18. Does your EHR system meet meaningful use criteria
(certified EHR) as defined by the Department of
Health and Human Services?

□1
□2
□3

Yes
No
Don’t know

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National Electronic Health Records Survey

19. Indicate whether the reporting location uses each of the computerized capabilities listed
below. CHECK NO MORE THAN ONE BOX PER ROW.
Does the reporting location use a computerized system to:

Yes

No

Don’t
know

Order radiology tests?

□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□

Provide reminders for guideline-based interventions or screening tests?

□

□

□

Reconcile lists of patient medications to identify the most accurate list?

□

□

□

Provide patients with clinical summaries for each visit?

□

□

□

Provide data to generate lists of patients with particular health
conditions?

□
□
□

□
□
□

□
□
□

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

□

□

□

Record patient history & demographic information?
Record patient problem list?
BASIC
COMPUTERIZED
CAPABILITIES

Record patients’ allergies and medications?
Record clinical notes?
View lab results?
View imaging reports?
Order prescriptions?
Are prescriptions sent electronically to the pharmacy?
Are warnings of drug interactions or contraindications provided?
Order lab tests?

SAFETY

PATIENT
ENGAGEMENT

Exchange secure messages with patients?
Identify patients due for preventive or follow-up care?

POPULATION
MANAGEMENT

OMB No.

20. Has your reporting location been recognized as a Patient Centered Medical Home (PCMH) by a state, a
commercial health plan, or a national organization?

□1
□2
□3

Yes
No
Don’t know

21. Does the reporting location participate in an Accountable Care Organization (ACO) arrangement with
Medicare or private insurers?

□1
□2
□3

Yes
No
Don’t know

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National Electronic Health Records Survey

OMB No.

22. Does the reporting location participate in a Pay-for-Performance arrangement, where you can receive
financial bonuses based on your performance?

□1
□2
□3

Yes
No
Don’t know

23. Is this medical organization affiliated with an Independent Practice Association (IPA) or Physician Hospital
Organization (PHO)?

□1
□2
□3

Yes
No
Don’t know

24. Do you ONLY send and receive patient health information through paper-based methods including fax, eFax,
or mail?

□1 Yes (Skip to 36)
□2 No
□3 Don’t know
25. Do you electronically send patient health information to other providers outside your medical organization
using an EHR (not eFax) or a Web Portal (separate from EHR)?

□1
□2
□3

Yes
No (Skip to 28)
Don’t know

26. Do you send patient health information to
any of the following providers
electronically? Electronically does not
include scanned or pdf documents from fax,
eFax, or mail.

Yes

No

Don’t know

Not Applicable

Ambulatory care providers outside your organization

□

□

□

□

Hospitals unaffiliated with your organization

□

□

□

□

Hospitals affiliated with your organization

□

□

□

□

Behavioral Health providers

□

□

□

□

Long-term care providers

□

□

□

□

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National Electronic Health Records Survey

OMB No.

27. Do you electronically receive patient health information from other providers outside your medical
organization using an EHR (not eFax) or a Web Portal (separate from EHR)?

□1
□2
□3

Yes
No (Skip to 31)
Don’t know

28. Do you receive patient health information
from the following providers
electronically? Electronically does not
include scanned or pdf documents from fax,
eFax, or mail.

Yes

No

Don’t know

Not Applicable

Ambulatory care providers outside your organization

□

□

□

□

Hospitals unaffiliated with your organization

□

□

□

□

Hospitals affiliated with your organization

□

□

□

□

Behavioral Health providers

□

□

□

□

Long-term care providers

□

□

□

□

29. How frequently do you use patient health information electronically (not eFax) received from providers or
sources outside your organization when treating a patient?

 Often  Sometimes

Rarely

Never

Don’t know

29a. If rarely or never used, please indicate the reason(s) why. Check all that apply.
1.
2.
3.
4.
5.
6.
7.

Information not always available when needed (e.g. not timely)
Do not trust accuracy of information
Difficult to integrate information in EHR
Information not available to view in EHR as part of clinicians’ workflow
Information not useful (e.g. redundant or unnecessary information)
Difficult to find necessary information
Other________________________________________________________________________

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National Electronic Health Records Survey
30. For providers outside of your medical organization,
do you electronically send and receive, send only, or
receive only the following types of patient health
information?

OMB No.

Both Send
Send
Receive
Do not Send
and Receive Electronically Electronically or Receive
Electronically
Only
Only
Electronically

Medication lists

□1

□2

□3

□4

Patient problem lists

□1

□2

□3

□4

Medication allergy lists

□1

□2

□3

□4

Imaging reports

□1

□2

□3

□4

Laboratory results

□1

□2

□3

□4

Public health registry data (e.g., immunizations, cancer)

□1

□2

□3

□4

Clinical registries

□1

□2

□3

□4

Hospital discharge summaries

N/A

N/A

□3

□4

Emergency Department notifications

N/A

N/A

□3

□4

Summary of care records for transitions of care or referrals

□1

□2

□3

□4

Patient-generated data (e.g. data from self-monitoring
devices or mobile health applications)

N/A

N/A

□3

□4

31. Do you integrate summary of care records into your EHR without special effort like manual entry or
scanning?

□1 Yes
□2 No
□3 Don’t know
□4 Not applicable
32. Do you integrate any other type of patient health information into your EHR without special effort like manual
entry or scanning?

□1
□2
□3
□4

Yes
No
Don’t know
Not applicable

33. Does your EHR have the computerized capability to allow patients to…
Electronically view their health information (e.g. test results).
Request refills for prescriptions online.
Enter health information (e.g. weight, symptoms) online.

Yes

□
1□
1□
1

No

□
2□
2□
2

Don’t Know

□
3□
3□
3

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National Electronic Health Records Survey
34. Within the last 30 days has your EHR system…

OMB No.

Yes

No

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

1

□

2

Alerted you to a potential medication error?

1

Led to a potential medication error?

1

Inadvertently led you to select the wrong medication or lab order from a list?

1

Led to less effective communication during patient visits?

1

Made it difficult for you to find clinical content needed for medical decision making?

1

Increased the time spent documenting patient care?

1

Alerted you to critical lab values?

1

Reminded you to provide preventive care (e.g., vaccine, cancer screening)?

1

Reminded you to provide care that meets clinical guidelines for patients with chronic
conditions?

1

Facilitated direct communication with a patient (e.g., email or secure messaging)?

1

Facilitated direct communication with other providers who are part of your patient
care team?

1

Uploaded patient health data from self-monitoring devises (e.g., blood glucose
readings)?

1

Enhanced overall patient care?

1

Not
Applicable

□

3

□

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

1

□

3

□
□
□
□
□
□
□
□
□
□
□
□

35. When treating patients seen by other providers outside your medical organization, how often do you or your
staff have clinical information from those outside encounters electronically available at the point of care?
Electronically available does not include scanned or PDF documents.

□1
□2
□3
□4
□5
□6

Often
Sometimes
Rarely
Never
Don’t Know
I do not see patients outside my medical organization

36. Do you prescribe controlled substances?

□1
□2
□3

Yes
No (Skip to 39)
Don’t know (Skip to 39)

37. Are prescriptions for controlled substances sent electronically to the pharmacy?

□1
□2
□3

Yes
No
Don’t know

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National Electronic Health Records Survey

OMB No.

These questions ask about electronically searching, finding, or querying patient health information from sources outside
your medical organization.
38. Do you electronically search for your patient’s health information from sources outside of your medical
organization (e.g., remote access to other facility, health information exchange organization)?

□1
□2
□3

Yes
No
Don’t know

39. Do you search for the following patient health information from sources
outside your medical organization?

Yes

No

□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□

Lab results
Patient problem lists
Imaging reports
Medication lists
Medication allergy list
Discharge summaries
Vaccination history
Advance directives
Care plans

40. What is a reliable E-mail address for the physician to whom this survey was mailed?
________________________________________________________________________

41. Who completed this survey? (Check all that apply)

□1

The physician to whom it was addressed

□2

Office staff

□3

Other

Thank you for your participation. Please return your survey in the
envelope provided. If you have misplaced the envelope, please send the
survey to:
Boxes for Admin Use

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