Form 0920-0212 Att K - Ann Amb Hosp Inter

National Hospital Care Survey

Att K - Ann Amb Hosp Inter

Annual Ambulatory Hospital Interview

OMB: 0920-0212

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0212 can be found here:

Document [docx]

Download: docx | pdf

Attachment K: Annual Ambulatory Hospital Interview

National Hospital Care Survey

OMB No. 0920-0212; Exp. Date: XX/XX/XXXX: 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 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). Notice – Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0212).
INTRO_SCR
Text:	? [F1] Hello, (Respondent’s name), This is (insert name). I’m calling on behalf of the Centers for Disease Control and Prevention's National Center for Health Statistics concerning their study of hospital outpatient and emergency departments and hospital-based ambulatory surgery locations. You should have received a letter from Charles Rothwell, the director of the National Center for Health Statistics, describing the study. Did you receive the letter(s)? If “No” or “DK”, offer to send or deliver another copy.
1.	Yes
2.	No
3.	Don’t know

INTROB
Text:	Is respondent ready to complete the interview?
1.	Continue
2.	Inconvenient Time  CallBackNotes
3.	Other Outcome  Exit Case

INTRO_AB
Text:	I'd like to briefly explain the study to you at this time and answer any questions about it. CDC’s National Center for Health Statistics of the Centers for Disease Control and Prevention is conducting a study of hospital-based ambulatory care. They have contracted with Westat to collect the data. (Facility Name) has been selected to participate in the study. The study is authorized under the Public Health Service Act and the information will be held strictly confidential. Participation is voluntary. Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study. First, concerning licensing:
1.	Enter 1 to Continue
LICHOSP
Text:	Is this facility a licensed hospital?
1.	Yes
2.	No  Thank_B1
H_ELIGIBLE
Text:	Are there 6 or more hospital beds staffed for inpatient use at this hospital, not including “newborn” bassinets?
1.	Yes
2.	No  Thank_B2

OWN101
Text:	Is this hospital nonprofit, government, or proprietary? Read answer categories out loud
1.	Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)
2.	State or local government (includes state, county, city, city-county, hospital district or authority)
3.	Proprietary (includes individually or privately owned, partnership or corporation)

OWNHCC
Text:	Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?
1.	Yes
2.	No
3.	Unknown

TEACHOSP
Text:	Is this a teaching hospital?
1.	Yes
2.	No

MERGER
Text:	Did this hospital either merge or separate from any OTHER hospital in the past 2 years?
1.	Merged or separated  MERSEP
2.	No  ESA24
3.	Unknown  ESA24

MERSEP
Text:	Was this a merger or a separation?
1.	Merger
2.	Separation

MERGMEDR
Text:	Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?
1.	Yes
2.	No
3.	Unknown

OTHNAME
Text:	What is the name and address of this OTHER hospital? Enter name

OTHSTRET
Text:	What is the name and address of this OTHER hospital? ♦ Enter number and street

OTHSTRET2
Text:	What is the name and address of this OTHER hospital? ♦ Enter second line of address or press enter if same/none

OTHCITY
Text:	What is the name and address of this OTHER hospital? ♦ Enter city

OTHSTATE
Text:	What is the name and address of this OTHER hospital? ♦ Enter state

OTHZIP
Text:	What is the name and address of this OTHER hospital? ♦ Enter zip code

ESA24
Text:	Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?
1.	Yes
2.	No

ESANOT24
Text:	Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?
1.	Yes
2.	No

TRAUMA
Text:	What is the trauma level rating of this hospital?
1.	Level I
2.	Level II
3.	Level III
4.	Level IV
5.	Level V
6.	Other/unknown
7.	None

OOOPD
Text:	Does this hospital operate an organized outpatient department either at this hospital or elsewhere?
1.	Yes
2.	No  AMSURG

PHYSSERV
Text:	Does this OPD include physician services?
1.	Yes
2.	No

AMBSURG
Text:	Is ambulatory surgery performed at this hospital? This includes ambulatory surgery performed in the general or main operating room.
1.	Yes
2.	No

STUDY_DESC
Text:	Thank you. Provide the administrator or other hospital representative with a brief description of the study. Cover the following points – Now I would like to provide you with further information on the study. The National Hospital Care Survey (NHCS) is a new survey combining the National Hospital Discharge Survey and the National Hospital Ambulatory Medical Care Survey. (1) NHCS will be the only source of national data on health care provided in hospital emergency and outpatient departments, including ambulatory surgery. (2) NHCS includes a nationwide sample of 581 hospitals. (3) A brief form will be completed for a sample of patient visits. As one of the hospitals that has been selected, your contribution will be of great value in the survey.

INDUCTION_APPT
Text:	I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative? If so, please create an appointment EROC in the AMS for when to conduct the interview. Otherwise, enter 1 if the respondent wants to continue with the induction now.
1.	Start Induction
2.	Exit Instrument/Make appointment

SCREENER_THK
Text:	Thank you for your cooperation. I am looking forward to our meeting.
1.	Enter 1 to Continue

THANK_MERGSEP
Text:	Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed. I will call you back within a week and let you know which parts of your hospital will be in the survey. Thank you for your cooperation. At this time, please exit the instrument using the F10 button and call your Field Manager to discuss this hospital’s merger or separation. They will work with the CDC to decide on their future participation. You should await the resolution before continuing with this hospital.
1.	Enter 1 to Continue

THANK_B1
Text:	Thank you, but it seems that our information is incorrect. Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.
1.	Enter 1 to Continue

THANK_B2
Text:	Thank you, but it seems that our information is incorrect. Since (facility name) does not have 24-hour emergency services or an outpatient department, it should not have been chosen for our study. Thank you very much for your cooperation.
1.	Enter 1 to Continue

REVIEW
Text:	I would like to begin with a brief review of the background for this study. Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures. Press F1 for points to be covered.
1.	Enter 1 to Continue

SURGDAY
Text:	Now I would like to ask you a few more questions about your hospital. How many days in a week are inpatient elective surgeries scheduled? Enter F5 for unknown.
BEDCZAR
Text:	?[F1] Does your hospital have a bed coordinator, sometimes referred to as a bed czar?
1.	Yes
2.	No
3.	Unknown

BEDDATA
Text:	How often are hospital bed census data available? Read answer categories.
1.	Instantaneously
2.	Every 4 hours
3.	Every 8 hours
4.	Every 12 hours
5.	Every 24 hours
6.	Other  BEDDATA_OT
7.	Unknown

BEDDATA_OTHSP
Text:	How often are hospital bed census data available? – Other, specify.

HLIST
Text:	Does your hospital have hospitalists on staff? A hospitalist is a physician whose primary professional focus is the general care of hospitalized patients. He/she may oversee ED patients being admitted to the hospital.
1.	Yes
2.	No  EMEDRES
3.	Unknown  EMEDRES

HLISTED
Text:	Do the hospitalists on staff at your hospital admit patients from your ED?
1.	Yes
2.	No
3.	Unknown

EMEDRES
Text:	Does this hospital have an emergency medicine residency program?
1.	Yes
2.	No
3.	Unknown

MUINC
Text:	?[F1] Medicare and Medicaid offer incentives to hospitals that demonstrate “meaningful use of health IT.” Does your hospital have plans to apply for Stage 1 of these incentive payments?
1.	Yes, we already applied
2.	Yes, we intend to apply
3.	Uncertain if we will apply  HOSPMEDREC
4.	No, we will not apply  HOSPMEDREC

MUSTAGE2
Text:	?[F1] Are there plans to apply for Stage 2 incentive payments?
1.	Yes
2.	No
3.	Maybe
4.	Unknown

HOSPMEDREC
Text:	Does your hospital currently use an electronic health record (EHR) or electronic medical record (EMR) system for ambulatory/outpatient records? Do not include the inpatient record system or billing record systems. Read answer categories out loud
1.	Yes, our hospital uses an EHR/EMR system for all ambulatory/outpatient records
2.	Yes, our hospital has part paper and part electronic ambulatory/outpatient records
3.	No, our hospital currently has all paper ambulatory/outpatient records 
4.	Unknown

REMACC
Text:	Now I’d like to ask you some questions about your hospital’s electronic health records system. Can this system be accessed from the outside by entities not associated with the hospital?
1.	Yes
2.	Unsure (will have to check and get back to interviewer)
3.	No  VSREPPER
4.	Unknown  VSREPPER

REMREP
Text:	Would your hospital be willing to allow CDC’s contractor to obtain password access to your hospital’s electronic health records system and load the charting software onto desktop computers at their headquarters? The contractor’s Data Security Plan complies with all relevant laws, regulations, and policies governing the security of data and protection of confidentiality.
1.	Yes
2.	Unsure (will have to check and get back to interviewer)
3.	No
4.	Unknown

VSREPPER
Text:	Now I would like to make arrangements to obtain the information needed for sampling. I will need to know how your emergency department is organized and obtain an estimate of the number of patient visits expected during the 12 week reporting period. Would you prefer I get this information from you or someone else?
1.	Respondent  CONTACT_DEPT
2.	Someone else  CINFO

CINFO
Text:	What is the name of the person I should talk to? To add additional contacts, please use the AMS
1.	Enter 1 Continue

THANK_RESP
Text:	Thank current respondent for his/her time and cooperation

CONTACT_DEPT
Text:	Enter the department you plan to interview. If necessary, briefly explain the survey to new respondents. If a department is refusing, enter 4. You will be prompted to select which department is refusing. Department Status ED (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) OPD (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
1.	ED  Intro_ED
2.	OPD  Intro_OPD
4.	Department refusal  Which_Dept

INTRO_ED
Text:	If necessary, introduce yourself and explain the survey Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department.
1.	Enter 1 Continue

ESA_NAME
Text:	(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?) Enter 999 for no more

ESA_TYPE
Text:	What type of ESA is (ESA name)?
1.	General
2.	Adult
3.	Pediatric
4.	Urgent care/Fast track
5.	Psychiatric
6.	Other

ESA_EVISITS
Text:	What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?

TYPETRIAGE
Text:	What type of triage system does your ESA use?
	1. Emergency Severity Index (ESI)
	2. Canadian Triage and Acuity Scale (CTAS)
	3. Other, specify
	4. Do not conduct triage  ED_EMR
	5. Unknown

NUMTRLEV
Text:	How many levels are in (ESA name's) triage system?
	1.Three
	2. Four
	3. Five
	4. Other - Specify

NUMTRLEV_SP
Text:	Specify other triage levels
ED_EMR
Text:	Enter 1 to continue to the EMR questions OR Enter 2 to skip EMR questions and complete later.
1.	Continue to EMR questions
2.	Skip EMR questions  ESA_ONSITE

EBILLRECE
Text:	Now I would like to ask you some questions about your ED. If ESAs within the ED vary with respect to their use of the EHR/EMR systems, then ask these questions of the ESA with the largest number of expected visits during the reporting period. Does your ED submit any CLAIMS electronically (electronic billing)?
1.	Yes
2.	No
3.	Unknown


EMEDRECE
Text:	Does your ED use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system? Do not include billing record systems. Use Flashcard or read answer categories
1.	Yes, all electronic
2.	Yes, part paper and part electronic
3.	No  EMRINSE
4.	Unknown  EMRINSE

EHRINSYRE
Text:	In which year did your ED install the EHR/EMR system?
	Year:

HHSMUE
Text:	Does your ED’s current system meet meaningful use criteria as defined by the Department of Health and Human Services?
1.	Yes, all electronic
2.	No
3.	Unknown

EHRNAME13
Text:	What is the name of your current EHR/EMR system?
1.	Allscripts  EMRINSE
2.	Amazing Charts  EMRINSE
3.	athenahealth  EMRINSE
4.	Cerner  EMRINSE
5.	eClinicalWorks  EMRINSE
6.	e-MDs  EMRINSE
7.	Epic  EMRINSE
8.	GE/Centricity  EMRINSE
9.	Greenway Medical  EMRINSE
10.	McKesson/Practice Partner  EMRINSE
11.	NextGen  EMRINSE
12.	Practice Fusion  EMRINSE
13.	Sage/Vitera  EMRINSE
14.	Other - Specify
15.	Unknown  EMRINSE

EHRNAMOTHE
Text:	Enter name of EHR/EMR system

SECURCHCKE	Has your ED made an assessment of the potential risks and vulnerabilities of your electronic health information within the last 12 months? This assessment would help identify privacy- or security-related issues that may need to be corrected.
1.	Yes
2.	No
3.	Unknown

DIFFEHRE	Does your ED have the capability to electronically send health information to another provider whose EHR system is different from your system?
1.	Yes
2.	No
3.	Unknown

EHRINSE
Text:	Does your ED have plans for installing a new EHR/EMR system within the next 18 months?
1.	Yes
2.	No
3.	Maybe
4.	Unknown

EDEMOGE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Recording patient history and demographic information? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EVITALE
5.	Unknown  EVITALE

EPROLSTE
Text:	Recording patient problem list? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EVITALE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Recording and charting vital signs? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESMOKEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Recording patient smoking status? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EPNOTESE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Recording clinical notes? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EMEDIDE
5.	Unknown  EMEDIDE

EMEDALGE
Text:	Recording patient's medications and allergies? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EMEDIDE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Reconciling lists of patient’s medications to identify the most accurate list? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECPOEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Ordering prescriptions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EREMINDE
5.	Unknown  EREMINDE

ESCRIPE
Text:	Are prescriptions sent electronically to the pharmacy? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EWARNE
Text:	Are warnings of drug interactions or contraindications provided? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown


EFORMULAE
Text:	Are drug formulary checks performed? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EREMINDE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Providing reminders for guideline-based interventions or screening tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECTOEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Ordering lab tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  ERESULTE
5.	Unknown

EORDERE
Text:	Are orders sent electronically? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ERESULTE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Viewing lab results? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EIMGRESE
5.	Unknown  EIMGRESE

EGRAPHE
Text:	Can the EHR/EMR automatically graph a specific patient's lab results over time? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ERADIE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Ordering radiology tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIMGRESE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Viewing imaging results? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EPTEDUE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Identifying educational resources for patient’s specific conditions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECQME
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIDPTEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Identifying patients due for preventive or follow-up care in order to send patients reminders? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EGENLISTE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Generating lists of patients with particular health conditions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIMMREGE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Electronic reporting to immunization registries? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESUME
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Providing patients with clinical summaries for each visit? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EMSGE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Exchanging secure messages with patients? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown


EPTRECE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Providing patients the ability to view online, download or transmit information from their medical record? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESHAREE
Text:	The next questions are about sharing (either sending or receiving) patient health information Does your ED share any patient health information (e.g., lab results, imaging reports, problem lists, medication lists) electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?
1.	Yes
2.	No  OBSUNITS
3.	Unknown  OBSUNITS

ESHAREHOWE
Text:	How does your ED electronically share patient health information? Use Flashcard or read answer categories Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method
4.	Unknown
ESHAREHOWOTHE
Text:	Specify other electronic method

EHRTOEHRE
Text:	Is the patient information your ED shares electronically sent directly from your ED’s EHR system to another EHR system?
1.	Yes
2.	No
3.	Not applicable. ED does not have EHR system.
4.	Unknown

ESHAREPROVE
Text:	With what types of providers does your ED electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)? Enter all that apply, separate with commas Use Flashcard or read answer categories
1.	Ambulatory providers inside your hospital
2.	Ambulatory providers outside your hospital
3.	Hospitals with which your hospital is affiliated
4.	Hospitals with which your hospital is not affiliated
5.	Behavioral health providers
6.	Long-term care providers
7.	Home health providers
8.	Do not share
9.	Unknown

EDPRIM
Text:	When patients with identified primary care physicians arrive at the ED, how often does your ED electronically send notification to the patients' primary care physicians? Read answer categories
1.	Always
2.	Sometimes
3.	Rarely
4.	Never
5.	Unknown

EDINFO
Text:	When patients arrive at the Emergency Department, are you able to query for patients' healthcare information electronically (e.g. medications, allergies) from outside sources?
1.	Yes
2.	No
3.	Unknown

OBSUNITS
Text:	Does your ED have an observation or clinical decision unit?
1.	Yes
2.	No  BOARD
3.	Unknown  BOARD

OBSSEP
Text:	Is this observation or clinical decision unit physically separate from the ED?
1.	Yes
2.	No
3.	Unknown

OBSDECMD
Text:	What type of physicians make decisions for patients in this observation or clinical decision unit? Enter all that apply, separate with commas Read answer categories ED physicians Hospitalists Other physicians Unknown
1.	ED physicians
2.	Hospitalists
3.	Other physicians
4.	Unknown

BOARD
Text:	Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?
1.	Yes
2.	No
3.	Unknown

BOARDHOS
Text:	Does your ED allow some admitted patients to move from the ED to inpatient corridors while awaiting a bed (“boarding”) – sometimes called a “full capacity protocol?”
1.	Yes
2.	No
3.	Unknown

AMBDIV
Text:	Did your ED go on ambulance diversion in 2013?
1.	Yes
2.	No
3.	Unknown

TOTHRDIV
Text:	What is the total number of hours that your hospital's ED was on ambulance diversion in 2013? Enter F5 if data not available

REGDIV
Text:	Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?
1.	Yes
2.	No
3.	Unknown

ADMDIV
Text:	Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?
1.	Yes
2.	No  NUMSTATX
3.	Unknown  NUMSTATX

NUMSTATX
Text:	As of last week, how many standard treatment spaces did your ED have? Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs. Enter F5 if data not available

NUMOTHTX
Text:	As of last week, how many other treatment spaces did your ED have? Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times. Enter F5 if data not available

EDSPACES
Text:	In the last two years, did your ED increase the number of standard treatment spaces?
1.	Yes
2.	No
3.	Unknown

PHYSSPACE
Text:	In the last two years, did your ED's physical space expand?
1.	Yes
2.	No
3.	Unknown

EXPAND
Text:	Do you have plans to expand your ED's physical space within the next two years?
1.	Yes
2.	No
3.	Unknown

BEDREG
Text:	Does your ED use - Bedside registration? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

KIOSELCHK
Text:	Does your ED use - Kiosk self check-in? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

CATRIAGE
Text:	Does your ED use - Computer-assisted triage? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown
IMBED
Text:	Does your ED use - Immediate bedding (no triage when ED is not at capacity)? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

ADVTRIAG
Text:	Does your ED use - Advanced triage (triage-based care) protocols? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

PHYSPRACTRIA
Text:	Does your ED use - Physician/Practitioner at triage? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

FASTTRAK
Text:	Does your ED use - Separate fast track unit for nonurgent care? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown
EDPTOR
Text:	Does your ED use - Separate operating room dedicated to ED patients? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

DASHBORD
Text:	Does your ED use - Electronic dashboard (i.e., displays updated patient information and integrates multiple data sources)? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

RFID
Text:	Does your ED use - Radio frequency identification (RFID) tracking (i.e., shows exact location of patients, caregivers, and equipment)? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

WIRELESS
Text:	Does your ED use - Wireless communication devices by providers? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

ZONENURS
Text:	Does your ED use - Zone nursing (i.e., all of a nurse's patients are located in one area)? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

POOLNURS
Text:	Does your ED use - Pool nurses (i.e., nurses that can be pulled to the ED to respond to surges in demand)? Use Flashcard or read answer categories
1.	Yes
2.	No
3.	Unknown

ESA_NAME
Text:	* SHOW ONLY

ESA_TYPE
Text:	SHOW ONLY
1.	General
2.	Adult
3.	Pediatric
4.	Urgent care/Fast track
5.	Psychiatric
6.	Other
ESA_EVISITS
Text:	SHOW ONLY

ESA_ONSITE
Text:	Is (ESA name) on-site?
1.	Yes
2.	No

ESA_STRET
Text:	What is (ESA name)'s address?

ESA_PHONE
Text:	What is (ESA name)'s telephone number?

ESA_PHTYP
Text:	Enter phone type

ESA_CONTACT
Text:	Enter ESA contact person's name

EDK_CHECK
Text:	Are there any Don’t Know items that you need to call back for? Press Ctrl-M to review all Don’t Knows.
1.	Yes
2.	No
EDWALL
Text:	This is the last screen of the Emergency Department section. If you progress past this screen you will no longer be able to edit this section.
1.	Enter 1 to Continue

INTRO_OPD
Text:	If necessary, introduce yourself and explain the survey Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's outpatient department.
1.	Enter 1 to Continue

CLIN_NAME
Text:	SHOW ONLY


CLIN_EVISITS
Text:	What was the total number of OPD visits that occurred in your hospital from (Begin date-End date)? Include visits for which no insurance claims were made.

SAMPLE_QUESTION
Text:	Patient visit information about the OPD has been entered. Enter 1 to Continue to the OPD section of the Induction interview. Enter 2 to return to the previous screen and revise patient visit information.
1.	Continue to OPD section
2.	Returns to previous screen  CLIN_EVISITS

OPD_EMR
Text:	Enter 1 to continue to the EMR questions OR Enter 2 to skip EMR questions and complete later.
1.	Continue to EMR questions
2.	Skip EMR questions
EBILLRECO
Text:	Now I would like to ask you some questions about your OPD. If clinics within the OPD vary with respect to their use of the EHR/EMR systems, then ask these questions of the clinic with the largest number of expected visits during the reporting period. Does your OPD submit any CLAIMS electronically (electronic billing)?
1.	Yes
2.	No
3.	Unknown
EMEDRECO
Text:	Does your OPD use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system? Do not include billing record systems. Read answer categories
1.	Yes, all electronic
2.	Yes, part paper and part electronic
3.	No  EMRINSO
4.	Unknown  EMRINSO

MEDRECCEN
Text:	Are medical records for your OPD clinics centrally located? Read answer categories
1.	Yes, all clinics
2.	Yes, some clinics
3.	No
4.	Unknown

EHRINSYRO
Text:	In which year did your OPD install the EHR/EMR system?
	Year:

HHSMUO
Text:	Does your OPD’s current system meet meaningful use criteria as defined by the Department of Health and Human Services?
1.	Yes, all electronic
2.	No
3.	Unknown

EHRNAMO13
Text:	What is the name of your current EMR/EHR system?
1.	Allscripts  EMRINSO
2.	Amazing Charts  EMRINSO
3.	athenahealth  EMRINSO
4.	Cerner  EMRINSO
5.	eClinicalWorks  EMRINSO
6.	e-MDs  EMRINSO
7.	Epic  EMRINSO
8.	GE/Centricity  EMRINSO
9.	Greenway Medical  EMRINSO
10.	McKesson/Practice Partner  EMRINSO
11.	NextGen  EMRINSO
12.	Practice Fusion  EMRINSO
13.	Sage/Vitera  EMRINSO
14.	Other – Specify
15.	Unknown  EMRINSO

EHRNAMOTHO
Text:	Enter name of EHR/EMR system.
SECURCHCKO	Has your OPD made an assessment of the potential risks and vulnerabilities of its electronic health information within the last 12 months? This would help identify privacy- or security-related issues that may need to be corrected.
1.	Yes
2.	No
3.	Unknown

DIFFEHRO	Does your OPD have the capability to electronically send health information to another provider whose EHR system is different from your system?
1.	Yes
2.	No
3.	Unknown

EMRINSO
Text:	Does your OPD have plans for installing a new EMR/EHR system within the next 18 months?
1.	Yes
2.	No
3.	Maybe
4.	Unknown

EDEMOGO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Recording patient history and demographic information? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EVITALO
5.	Unknown  EVITALO

EPROLSTO
Text:	Recordingpatient problem list? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EVITALO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Recording and charting vital signs? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESMOKEO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often are these capabilities used: Recording patient smoking status? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EPNOTESO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Recording clinical notes? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EMEDIDO
5.	Unknown  EMEDIDO

EMEDALGO
Text:	Recording patient's medications and allergies? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EMEDIDO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Reconciling lists of patient’s medications to identify the most accurate list? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECPOEO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Ordering prescriptions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EREMINDO
5.	Unknown  EREMINDO

ESCRIPO
Text:	Are prescriptions sent electronically to the pharmacy? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EWARNO
Text:	Are warnings of drug interactions or contraindications provided? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EFORMULAO
Text:	Are drug formulary checks performed? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EREMINDO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Providing reminders for guideline-based interventions or screening tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECTOEO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Ordering lab tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  ERESULTO
5.	Unknown  ERESULTO

EORDERO
Text:	Are orders sent electronically? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ERESULTO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used: Viewing lab results? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No  EIMGRESO
5.	Unknown  EIMGRESO

EGRAPHO
Text:	Can the EHR/EMR automatically graph a specific patient's lab results over time? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ERADIO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Ordering radiology tests? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIMGRESO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Viewing imaging results? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EPTEDUO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Identifying educational resources for patient’s specific conditions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ECQMO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIDPTEO
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Identifying patients due for preventive or follow-up care in order to send patients reminders? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EGENLISTO	.
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Generating lists of patients with particular health conditions? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EIMMREGO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Electronic reporting to immunization registries? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESUMO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Providing patients with clinical summaries for each visit? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EMSGO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Exchanging secure messages with patients? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

EPTRECO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Providing patients the ability to view online, download or transmit information from their medical record? Use Flashcard or read answer categories
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown

ESHAREO
Text:	The next questions are about sharing (either sending or receiving) patient health information. Does your OPD share any patient health information (e.g., lab results, imaging reports, problem lists, medication lists) electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?
1.	Yes
2.	No  CLIN_STRET
3.	Unknown  CLIN_STRET

ESHAREHOWO
Text:	How does your OPD electronically share patient health information? Use Flashcard or read answer categories Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method
4.	Unknown

ESHAREHOWOTHO	Specify other electronic method
EHRTOEHRO
Text:	Is the patient health information your OPD shares electronically sent directly from your OPD’s EHR system to another EHR system?
1.	Yes
2.	No
3.	Not applicable. OPD does not have EHR system.
4.	Unknown

ESHAREPROVO
Text:	With what types of providers does your OPD electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)? Enter all that apply, separate with commas Use Flashcard or read answer categories
1.	Ambulatory providers inside your hospital
2.	Ambulatory providers outside your hospital
3.	Hospitals with which your hospital is affiliated
4.	Hospitals with which your hospital is not affiliated
5.	Behavioral health providers
6.	Long-term care providers
7.	Home health providers
8.	Do not share
9.	Unknown

REFOUTO
Text:	Does your OPD refer any patients to providers outside of your OPD?
1.	Yes
2.	No  REFINO
3.	Unknown

REFOUTSO
Text:	When your OPD refers a patient to a provider outside your OPD: Does your OPD send the patient’s clinical information to the other providers?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No  REFINO
4.	Unknown  REFINO

REFOUTEO
Text:	Does your OPD send it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown

REFINO
Text:	Does your OPD see any patients referred to your OPD by providers outside of your OPD?
1.	Yes
2.	No  INPTCAREO
3.	Unknown  INPTCAREO

REFINSO
Text:	Does your OPD send a consultation report with clinical information to the other providers?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No  INPTCAREO
4.	Unknown  INPTCAREO

REFINSEO
Text:	Does your OPD send it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown

INPTCAREO
Text:	Does your OPD take care of patients after they are discharged from an inpatient setting?
1.	Yes
2.	No  CLIN_STRET
3.	Unknown  CLIN_STRET

DISSUMO
Text:	When a patient is discharged from an inpatient setting: Does your OPD receive a discharge summary with clinical information from the hospital?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No  CLIN_STRET
4.	Unknown  CLIN_STRET

DISSUMEO
Text:	Does your OPD receive it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown

INCORINFOO
Text:	Can your OPD automatically incorporate the received information into your EHR system without manually entering the data?
1.	Yes
2.	No
3.	Not applicable. OPD does not have EHR system.
4.	Unknown

Clin_NAME
Text:	* SHOW ONLY

CLin_Group
Text:	SHOW ONLY
1.	General medicine
2.	Surgery
3.	Pediatric
4.	Obstetrics/Gynecology
5.	Substance abuse
6.	Other
Clin_EVISITS
Text:	SHOW ONLY

OPD_ONSITE
Text:	Is [name of clinic] onsite?

CLIN_STRET
Text:	What is (Clinic Name)'s address?

CLIN_PHONE
Text:	What is Outpatient Department’s telephone number?

CLIN_PHTYP
Text:	Enter phone type

CLIN_CONTACT
Text:	Enter clinic director/contact person's name

OPDDK_CHECK
Text:	Are there any Don’t Know items that you need to call back for? Press Ctrl-M to review all Don’t Knows
1.	Yes
2.	No

OPDWALL
Text:	This is the last screen of the Outpatient Department section. If you progress past this screen you will no longer be able to edit this section.
1.	Enter 1 to continue

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Centers for Disease Control & Prevention
File Modified	0000-00-00
File Created	2021-01-15