Att A_ Changes to NEHRS 2017 Questionnaire

Att A – Changes to 2017 NEHRS

Questions deleted

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

□ Never used an EHR system □ Under 1 year □ ________year(s)

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	□	□

Current confidentiality language in the 2017 NEHRS is in black; revised language in the proposed 2018 NEHRS is in red

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”.

The Federal Cybersecurity Enhancement Act of 2015 allows software programs to scan information that is sent, stored on, or processed by government networks in order to protect the networks from hacking, denial of service attacks, and other security threats. If any information is suspicious, it may be reviewed for specific threats by computer network experts working for the government (or contractors or agents who have governmental authority to do so). Only information directly related to government network security is monitored. The Act further specifies that such information may only be used for the purpose of protecting information and information systems from cybersecurity risks.

Current versions of the questions are in black; revised questions are in red

Current Version

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 Yes □2 No □3 Don’t know

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

□1 Yes □2 No □3 Don’t know

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

□1 Yes □2 No □3 Don’t know

11. Do you participate in the Medicaid EHR Incentive Program (e.g. Meaningful Use Program)?

□1 Yes □2 No □3 Don’t know □4 Not applicable

Revised Version

Revised Q17 amends questions above (Q20, 21 and 22 in the 2017 NEHRS and Q11 in the 2017 NEHRS Supplement survey) to assess physicians’ participation in payment models/programs offered by the Center for Medicare & Medicaid’s (CMS). These measures were refined and streamlined in the question below to reduce burdens on respondents.

17. Do you or your reporting location currently participate in any one of the following activities or programs? Check all that apply.

□1 Patient Centered Medical Home (PCMH)

□2 Accountable Care Organization (ACO) arrangement with public or private insurers

□3 Pay-for-Performance arrangement (P4P)

□4 Medicaid EHR Incentive Program (e.g., Meaningful Use Program)

Current Version

12. Do you participate or plan to participate in the Merit-Based Incentive Payment System? Merit-Based Incentive Payment System, a new program for Medicare-participating physicians, will adjust payment based on performance and consolidate three programs: the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare EHR Incentive Program (“Meaningful Use”).

□1 Yes □2 No □3 Don’t know □4 Not applicable

13. Do you participate or plan to participate in the Alternative Payment Model? Alternative Payment Models are new approaches to paying for medical care through Medicare that incentivize quality and value, including CMS Innovation Center model, Medicare Shared Savings Program, Health Care Quality Demonstration Program or Demonstration required by federal law.

□1 Yes □2 No □3 Don’t know □4 Not applicable

Revised Version

Revised Q18 amends questions above (Q12 and 13 in the 2017 NEHRS Supplement survey) to assess physicians’ participation in programs offered by the Center for Medicare & Medicaid’s (CMS). These measures were refined and streamlined in the question below to reduce burdens on respondents.

18. Do you participate or plan to participate in the following Medicare programs? Check all that apply. Merit-Based Incentive Payment System will adjust payment based on performance. Advanced Alternative Payment Models are new approaches to paying for medical care that incentivize quality and value.

□1 Merit-Based Incentive Payment System

□2 Advanced Alternative Payment Model

□3 Not applicable

Current Version

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
BASIC COMPUTERIZED CAPABILITIES	Record patient history & demographic information?	□	□	□
	Record patient problem list?	□	□	□
	Record patients’ allergies and medications?	□	□	□
	Record clinical notes?	□	□	□
	View lab results?	□	□	□
	View imaging reports?	□	□	□
SAFETY	Order prescriptions?	□	□	□
	Are prescriptions sent electronically to the pharmacy?	□	□	□
	Are warnings of drug interactions or contraindications provided?	□	□	□
	Order lab tests?	□	□	□
	Order radiology tests?	□	□	□
	Provide reminders for guideline-based interventions or screening tests?	□	□	□
	Reconcile lists of patient medications to identify the most accurate list?	□	□	□
PATIENT ENGAGEMENT	Provide patients with clinical summaries for each visit?	□	□	□
	Exchange secure messages with patients?	□	□	□
POPULATION MANAGEMENT	Identify patients due for preventive or follow-up care?	□	□	□
	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)?	□	□	□

Revised Version

Revised Q22 amends questions above (Q19 in the 2017 NEHRS) to assess physicians’ use of computerized system that are relevant to the evolving program goals of ONC, the sponsor of NEHRS. These measures were refined and streamlined in the question below. Additionally, there are fewer number of items listed to reduce burdens on the respondents to reduce burdens on respondents.

22. Does the reporting location use a computerized system to (CHECK NO MORE THAN ONE BOX PER ROW):		Yes	No	Don’t know
DOCUMENTATION	Record social determinants of health (e.g., employment, education)?	□1	□2	□3
	Record behavioral determinants of health (e.g., tobacco use, physical activity, alcohol use)?	□1	□2	□3
SAFETY	Order prescriptions?	□1	□2	□3
	Are prescriptions sent electronically to the pharmacy?	□1	□2	□3
	Are warnings of drug interactions or contraindications provided?	□1	□2	□3
	Order lab tests?	□1	□2	□3
	Order radiology tests?	□1	□2	□3
	Provide reminders for guideline-based interventions or screening tests?	□1	□2	□3
PATIENT ENGAGEMENT	Create educational resources tailored to the patients’ specific conditions?	□1	□2	□3
	Exchange secure messages with patients?	□1	□2	□3
POPULATION MANAGEMENT	Generate lists of patients with particular health conditions?	□1	□2	□3
	Create reports on clinical care measures for patients with specific chronic conditions (e.g., HbA1c for diabetics)?	□1	□2	□3
	Create shared care plans that are available across the clinical care team?	□1	□2	□3
QUALITY MEASUREMENT	Send clinical quality measures to public and private insurers (e.g., blood pressure control, HbA1C, smoking status)?	□1	□2	□3

Current Version

36. Do you prescribe controlled substances?

□1 Yes □2 No (Skip to 39) □3 Don’t know (Skip to 39)

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

□1 Yes □2 No □3 Don’t know

Revised Versions

Revised Q26, 27 and 28 amend questions above (Q36 and 37 in the 2017 NEHRS questionnaire) to assess physicians’ prescribing behavior relating to controlled substances, which reflect the current priorities of ONC. These measures were refined and streamlined in the following questions.

26. How frequently do you prescribe controlled substances?

□1 Often □2 Sometimes □3 Rarely □4 Never (Skip to 29) □4 Don’t know (Skip to 29)

27. How frequently are prescriptions for controlled substances sent electronically to the pharmacy?

□1 Always or Often □2 Sometimes □3 Rarely or Never □4 Don’t know

New Questions to obtain information on prescribing controlled substances and care of PDMP, given the current public health concerns regarding prescribing patterns.

28. How frequently do you or designated  staff check your state’s prescription drug monitoring program

(PDMP) prior to prescribing a controlled substance to a patient for the first time?

□1 Always or Often (Go to 28a) □2 Sometimes (Go to 28a) □3 Rarely or Never (Skip to 29)

□4 Don’t know (Skip to 29)

28a. How do you or your designated staff check your state’s PDMP?

□1 Use EHR system □2 Use system outside of EHR (e.g. PDMP portal or secure website)

□3 Don’t know

28b. How easy or difficult is it to use your state’s PDMP to find your patient’s information?

□1 Very difficult □2 Somewhat difficult □3 Somewhat easy □4 Very Easy □5 Don’t know

28c. When checking your state’s PDMP, do you or designated staff typically request to view

PDMP data from other states prior to prescribing a controlled substance for the first time?

28d. Have you done any of the following as a result of using the PDMP? Check all that apply.

□1 Reduced or eliminated controlled substance prescriptions for a patient

□2 Changed controlled substance prescriptions to non-controlled substance prescriptions for a patient

□3 Refer additional treatment (e.g. substance abuse treatment, psychiatric or pain management)

□4 Confirm patients’ misuse of prescriptions (e.g., engage in doctor shopping)

□5 Confirm appropriateness of treatment

□6 Consult with other prescribers listed in PDMP report

Current Version

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 Yes □2 No □3 Don’t know

Revised Version

Revised Q36 amends question above (Q38 in the 2017 NEHRS questionnaire) to assess measures on electronic exchange of patient health information as an evolving program goal of ONC. These measures were refined and streamlined in the question below.

36. When seeing a new patient or a patient who has previously seen another provider, do you electronically search or query for your patient’s health information from sources outside of your medical organization? This could include via remote or view only access to other facilities’ EHR or health information exchange organization.

□1 Yes (Go to 36a) □2 No (Skip to 37) □3 Don’t know (Skip to 37)

Current Versions

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 Yes □2 No □3 Don’t know □4 Not applicable

Revised Version

Revised Q37 and 37a amend questions above (Q31 and 32 in the 2017 NEHRS questionnaire) to assess measures on electronic exchange of patient health information as an evolving program goal of ONC. These measures were refined and streamlined in the following questions.

37. Does your EHR integrate any type of patient health information received electronically (not e-fax) without special effort like manual entry or scanning?

□1 Yes (Go to 37a) □2 No (Skip to 38) □3 Don’t know (Skip to 38) □4 Not applicable (Skip to 38)

37a. Does your EHR integrate summary of care records received electronically (not e-fax) without special effort like manual entry or scanning?

□1 Yes □2 No □3 Don’t know □4 Not applicable

Current Version

16. Please indicate whether these issues are barriers to electronic information exchange with providers outside your medical organization. Note: Information exchange refers to electronically sending, receiving, finding or integrating patient health information.

	Yes	No	Don’t know	Not applicable
Providers outside my medical organization cannot electronically exchange data with me.	□1	□2	□3	□4
My practice would have to pay additional costs to electronically exchange data with providers outside my medical organization.	□1	□2	□3	□4
It is cumbersome to use my EHR to electronically exchange data with providers outside my medical organization.	□1	□2	□3	□4
I have to use multiple systems or portals to electronically exchange data with providers outside my medical organization.	□1	□2	□3	□4
It is challenging to electronically exchange data with other providers who use a different EHR vendor.	□1	□2	□3	□4
It is difficult to locate the address of the provider to electronically send patient health information.	□1	□2	□3	□4
My practice is concerned about the privacy and security of health information that is electronically exchanged.	□1	□2	□3	□4
The information that is electronically exchanged is not useful.	□1	□2	□3	□4

Revised Version

Revised Q42 amends question above (Q16 in the 2017 NEHRS Supplement) to assess attitudinal measures regarding barriers to electronic information exchange with providers outside physician’s medical organization. These attitudinal measures were refined and streamlined in the question below to reduce burdens on the respondents.

42. Please indicate whether these issues are barriers to electronic information exchange with providers outside your medical organization.

Note: Information exchange refers to electronically sending, receiving, finding or integrating patient health information.

	Yes	No	Don’t know	Not applicable
Providers in our referral network lack the capability to electronically exchange (e.g. no EHR or HIE connection).	□1	□2	□3	□4
We have limited or no IT staff.	□1	□2	□3	□4
Electronic exchange involves incurring additional costs.	□1	□2	□3	□4
Electronic exchange involves using multiple systems or portals.	□1	□2	□3	□4
Electronic exchange with providers using a different EHR vendor is challenging.	□1	□2	□3	□4
The information that is electronically exchanged is not useful.	□1	□2	□3	□4
It is difficult to locate the electronic address of providers.	□1	□2	□3	□4
My practice may lose patients to other providers if we exchange information.	□1	□2	□3	□4

Current Version

Within the last 30 days has your EHR system…	Yes	No	Not Applicable
Alerted you to a potential medication error?	1□	2□	3□
Led to a potential medication error?	1□	2□	3□
Inadvertently led you to select the wrong medication or lab order from a list?	1□	2□	3□
Led to less effective communication during patient visits?	1□	2□	3□
Made it difficult for you to find clinical content needed for medical decision making?	1□	2□	3□
Increased the time spent documenting patient care?	1□	2□	3□
Alerted you to critical lab values?	1□	2□	3□
Reminded you to provide preventive care (e.g., vaccine, cancer screening)?	1□	2□	3□
Reminded you to provide care that meets clinical guidelines for patients with chronic conditions?	1□	2□	3□
Facilitated direct communication with a patient (e.g., email or secure messaging)?	1□	2□	3□
Facilitated direct communication with other providers who are part of your patient care team?	1□	2□	3□
Uploaded patient health data from self-monitoring devises (e.g., blood glucose readings)?	1□	1□	1□
Enhanced overall patient care?	1□	2□	3□

Revised Versions

Q45, 46, 47 and 48 amend question above (Q34 in the 2017 NEHRS) to assess attitudinal measures regarding documentation and burden associated with EHRs. These attitudinal measures were refined and streamlined in the following questions to reduce burdens on the respondents.

45. Please rate the level of staff support you have to assist you with the following tasks.

	Adequate support	Inadequate support	No support provided	Not applicable
Documenting in your medical record system.	□1	□2	□3	□4
Responding to electronic messages received from patients and clinicians.	□1	□2	□3	□4

46. To what extent does your medical record system allows you to document efficiently?

□1 A great extent □2 Somewhat □3 Very little or not at all □4 Not applicable

47. To what extent does your medical record system allow you to efficiently respond to electronic messages received from patients or clinicians?

□1 A great extent □2 Somewhat □3 Very little or not at all □4 Not applicable

48. Please indicate the extent to which you agree with the following statements.

	Strongly Agree	Somewhat agree	Somewhat disagree	Strongly disagree	Not applicable
I spend too much time responding to alerts.	□1	□2	□3	□4	□5
I can easily locate information in template-based notes.	□1	□2	□3	□4	□5
I can easily locate information in free-text notes.	□1	□2	□3	□4	□5
Documentation takes time away from patient care.	□1	□2	□3	□4	□5
My EHR disrupts the way I interact with my patients.	□1	□2	□3	□4	□5

New Questions

Q20 was approved for prior NEHRS questionnaires (2010-2015) although it was deleted from the 2017 NEHRS. This question is added to the proposed 2018 NEHRS because ONC will continue to use this information as their primary source of reference.

20. What is the name of your primary EHR system? CHECK ONLY ONE BOX. IF OTHER IS CHECKED, PLEASE SPECIFY THE NAME.

□1 Allscripts □2 Amazing charts. □3 athenahealth □4 Cerner □5 eClinical Works

□6 e-MDs □7 Epic □8 GE/Centricity □9 Modernizing Medicine □10 NextGen

□11 Practice Fusion □12 Sage/Vitera/ Greenway □13 Other, specify: ___________________ □14 Unknown

Q23 and 23a are added to the proposed 2018 NEHRS to assess measures on the uses of computerized system by physicians that are relevant to measuring progress towards the program goals of ONC.

23. How frequently do you use template-based notes in your EHR system? Template-based notes are generated through forms or pre-filled text in an EHR rather than free text alone.

□1 Often (Go to 23a) □2 Sometimes (Go to 23a) □3 Rarely or Never (Skip to 24)

□4 Don’t know (Skip to 24) □5 Not Applicable (Skip to 24)

23a. To what extent do you customize your templates?

□1 A great extent □2 Somewhat □3 Very little or not at all □4 Don’t know

Questions 34 and 34a are added to the proposed 2018 NEHRS to assess measures on electronic exchange of patient health information, which reflect the current priorities of ONC.

34. Does your reporting location electronically send or receive patient health information with public

health agencies? Public health agencies can include the CDC, state or local public health authorities.

□1 Yes (Go to 34a) □2 No (Skip to 35) □3 Don’t Know (Skip to 35)

□4 Not applicable (Skip to 35)

34a. What types of information do you electronically send or receive? Check all that apply.

□1 Syndromic surveillance data

□2 Case reporting of reportable conditions

□3 Immunization data

□4 Public health registry data (e.g., cancer)

Q38 is added to the proposed 2018 NEHRS to assess measures on electronic exchange of patient health information, which reflects the current priorities of ONC.

38. Do you reconcile the following types of clinical information electronically received from providers outside of your medical organization? Reconciling involves comparing a patient’s information from another provider with your practice’s clinical information.	Yes	No	Don’t know	Not Applicable
Medication lists	□1	□2	□3	□4
Medication allergy lists	□1	□2	□3	□4
Problem lists	□1	□2	□3	□4

Questions 43 and 44 are added to the proposed 2018 NEHRS to assess documentation and burden associated with EHRs, which will help provide insights on how physicians’ care has been affected since implementing EHR systems; these measures are a priority for ONC.

43. On average, how many hours per day do you spend outside of normal office hours documenting in your medical record system?

□1 None □2 Less than 1 hour □3 1 to 2 hours □4 Greater than 2 hours to 4 hours

□5 More than 4 hours

44. On average, how many hours per day do you spend outside of normal office hours responding to electronic messages received from patients and clinicians?

□1 None □2 Less than 1 hour □3 1 to 2 hours □4 Greater than 2 hours to 4 hours

□5 More than 4 hours □6 Not Applicable

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