2019 Instrument

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

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 U.S.C. 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 federal
computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security
weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed
for cyber threats by computer network experts working for, or on behalf of, the government.
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.

National Electronic Health Records Survey 2019
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 and use of electronic health records (EHRs) and electronic
exchange of health information in ambulatory care settings. Your participation is greatly appreciated. Your answers are completely
confidential. Participation in this survey is voluntary. There are no penalties for nonparticipation. If you have questions or comments
about this survey, please call xxx-xxx-xxxx.

1. We have your specialty as:
Is that correct?

□1 Yes
□2 No

4. Do you see ambulatory patients in any of the
following settings? CHECK ALL THAT APPLY.
1□ Private solo or group practice
2□ Freestanding clinic or Urgent Care
Center
3□ Community Health Center (e.g.,
Federally Qualified Health Center
[FQHC], federally funded clinics or
“look-alike” clinics)
4□ Mental health center
5□ Non-federal government clinic (e.g.,
state, county, city, maternal and child
health, etc.)
6□ Family planning clinic (including
Planned Parenthood)
7□ Health maintenance organization,
health system or other prepaid
practice (e.g., Kaiser Permanente)
8□ Faculty practice plan (an organized
group of physicians that treats
patients referred to an academic
medical center)

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
□2 No
□3 I am no longer
in practice

Go to Question 3

}

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

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?

9□ Hospital emergency or hospital
outpatient departments
10□ None of the above

___________________ Locations

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.”)
1

If you see
patients in
any of
these
settings,
go to
Question 5

}

If you
select only
9 or 10,
go to
Question 50

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

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

Zip Code

State

Telephone

7. How many physicians, including you, work at this 14. What percent of your patients are insured by
practice (including physicians at the reporting
Medicaid? _______________%
location, and physicians at any other locations of
15. Do you treat patients insured by Medicare?
the practice)?

□1
□2
□3

1 physician
2-3 physicians
4-10 physicians

□4
□5
□6

□1 Yes

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

□3 Don’t know

16. Who owns the reporting location? CHECK ONE.

□1 Physician or physician group
□2 Insurance company, health plan, or HMO
□3 Community health center
□4 Medical/academic health center
□5 Other hospital
□6 Other health care corporation
□7 Other

8. How many physicians, including you, work at the
reporting location? ___________
9. How many mid-level providers (i.e., nurse
practitioners, physician assistants, and nurse
midwives) are associated with the reporting
location?

17. Do you or your reporting location currently
participate in any of the following activities or
programs? CHECK ALL THAT APPLY.

__________ Mid-level providers

10. Is the reporting location a single- or multispecialty (group) practice?

□1 Single

□2 No

□1 Patient Centered Medical Home (PCMH)
□2 Accountable Care Organization (ACO) arrangement

□2 Multi

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

with public or private insurers
□3 Pay-for-Performance arrangement (P4P)
□4 Medicaid EHR Incentive Program (e.g., Meaningful Use
also called Promoting Interoperability Program)

□1 Yes □2 No (Skip to 13) □3 Don’t know (Skip to 13)

12. If yes, which of the following types of payment do
you accept from those new patients?
18. Do you participate or plan to participate in the
following Medicare programs? CHECK ALL THAT
Don’t
APPLY.
Yes
No
Know

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

□1
□1
□1
□1
□1
□1

□2
□2
□2
□2
□2
□2

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.

□3
□3
□3
□3
□3
□3

□1 Merit-Based Incentive Payment System
□2 Advanced Alternative Payment Model
□3 Not applicable
□4 Don’t know
19. Does the reporting location use an EHR system?
Do not include billing record systems.

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

□1 Yes

□2 No

□1 Yes □2 No (Skip to 24) □3 Don’t know (Skip to 24)

□3 Don’t know

2

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

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

21. Overall, how satisfied or dissatisfied are you with your EHR system?

□1 Very satisfied
□4 Somewhat dissatisfied

□2 Somewhat satisfied
□5 Very dissatisfied

□3 Neither satisfied nor dissatisfied
□6 Not applicable

22. Does your EHR system meet meaningful use criteria, also called promoting interoperability (certified EHR),
as defined by the Department of Health and Human Services?

□1 Yes

□2 No

□3 Don’t know

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)
□5 Don’t know (Skip to 24)

□2 Sometimes (Go to 23a)
□6 Not applicable (Skip to 24)

□3 Rarely (Go to 23a)

□4 Never (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

23b. How easy or difficult is it to locate information in template-based notes?

□1 Very easy

□2 Somewhat easy

□3 Somewhat difficult

□4 Very difficult

23c. How easy or difficult is it to locate information in free-text notes?

□1 Very easy

□2 Somewhat easy

□3 Somewhat difficult

24. Does the reporting location use a computerized system to (CHECK NO MORE
THAN ONE BOX PER ROW):
RECORDING
INFORMATION

Yes

No

Don’t
Know

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

Generate lists of patients with particular health conditions?

□1
□1
□1
□1
□1
□1
□1
□1
□1

□2
□2
□2
□2
□2
□2
□2
□2
□2

□3
□3
□3
□3
□3
□3
□3
□3
□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

Send clinical quality measures to public and private insurers (e.g., blood
pressure control, HbA1c, smoking status)?

□1

□2

□3

Order prescriptions?
Are prescriptions sent electronically to the pharmacy?
SAFETY

Are warnings of drug interactions or contraindications provided?
Order lab tests?
Order radiology tests?
Provide reminders for guideline-based interventions or screening tests?

PATIENT
ENGAGEMENT

POPULATION
MANAGEMENT
QUALITY
MEASUREMENT

□4 Very difficult

Create educational resources tailored to the patients’ specific conditions?
Exchange secure messages with patients?

3

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

Patient Engagement
25. Does your practice use telemedicine technology (e.g., audio with video, web videoconference) for patient
visits?

□1 Yes

□2 No

□3 Don’t know
Yes

No

Don’t
Know

Not
Applicable

Download their online medical record to their personal files?

□1
□1

□2
□2

□3
□3

□4
□4

Send their online medical record to a third party (e.g., another provider, personal
health record)?

□1

□2

□3

□4

Upload their health information from devices or apps (e.g., blood glucose meter,
Fitbit, questionnaires)?

□1

□2

□3

□4

26. Does your EHR system allow patients to…
View their online medical record?

Prescribing Controlled Substances
27. How frequently do you prescribe controlled substances?

□1 Often
□2 Sometimes
□5 Don’t know (Skip to 30)

□3 Rarely

□4 Never (Skip to 30)

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

□1 Often

□2 Sometimes

□3 Rarely or Never

□4 Don’t know

29. 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 Often (Go to 29a) □2 Sometimes (Go to 29a) □3 Rarely (Go to 29a) □4 Never (Skip to 30)
□5 Don’t know (Skip to 30)
29a. 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
29b. How easy or difficult is it to use your state’s PDMP to find your patient’s information?

□1 Very easy

□2 Somewhat easy □3 Somewhat difficult

□4 Very difficult

□5 Don’t know

29c. 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?

□1 Yes

□2 No

□3 Don’t know

29d. 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-opioid pharmacologic (e.g., NSAIDS or acetaminophen) or
non-pharmacologic therapy (e.g., exercise/physical therapy or CBT).

□3 Prescribed naloxone
□4 Referred additional treatment (e.g., substance abuse treatment, psychiatric or pain management)
□5 Confirmed patients’ misuse of prescriptions (e.g., engage in doctor shopping)
□6 Confirmed appropriateness of treatment
□7 Assessed pain and function of patient (e.g., PEG)
□8 Consulted with other prescribers listed in PDMP report
□9 Consulted and/or coordinate with other members of the care team
4

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

Electronic Exchange of Patient Health Information
30. Do you ONLY send and receive patient health information through paper-based methods including fax,
eFax, or mail?

□1 Yes (Skip to 37)

□2

□3

No (Go to 31)

Don’t know (Go to 31)

31. 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

Yes (Go to 32)

□2

□3

No (Skip to 33)

Don’t know (Skip to 33)

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

Yes

No

Don’t
Know

Not
Applicable

Ambulatory care providers outside your organization

□1

□2

□3

□4

Hospitals unaffiliated with your organization

□1

□2

□3

□4

Behavioral health providers

□1

□2

□3

□4

Long-term care providers

□1

□2

□3

□4

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

□1 Yes (Go to 34)

□2 No (Skip to 35)

□3 Don’t know (Skip to 35)

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

Yes

No

Don’t
Know

Not
Applicable

Ambulatory care providers outside your organization

□1

□2

□3

□4

Hospitals unaffiliated with your organization

□1

□2

□3

□4

Behavioral health providers

□1

□2

□3

□4

Long-term care providers

□1

□2

□3

□4

35. 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 35a)
□4 Not applicable (Skip to 36)

□2 No (Skip to 36)

□3 Don’t know (Skip to 36)

35a. 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)

5

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

36. For providers outside your
medical organization, do you
Both Send and
Send
Receive
Do not Send or
regularly electronically send and
Receive
Electronically Electronically
Receive
receive, send only, or receive
Electronically
Only
Only
Electronically
only the following types of patient
health information?

Clinical registry data

□1
□1

□2
□2

Emergency Department notifications

N/A

Summary of care records for transitions
of care or referrals

□1

Progress/consultation notes

Not
Applicable

N/A

□3
□3
□3

□4
□4
□4

□5
□5
□5

□2

□3

□4

□5

37. 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 37a)

□2 No (Skip to 38)

□3 Don’t know (Skip to 38)

37a. Do you electronically search for the
following patient health information
from sources outside your medical
organization?

Yes

No

Don’t Know

Not Applicable

Progress/consultation notes

□1

□2

□3

□4

Vaccination/Immunization history

□1

□2

□3

□4

Summary of care record

□1

□2

□3

□4

38. Does your EHR system integrate any type of patient health information received electronically (not eFax)
without special effort like manual entry or scanning?

□1 Yes (Go to 38a)

□2 No (Skip to 39)

□3 Don’t know (Skip to 39)

□4 Not applicable (Skip to 39)

38a. Does your EHR system integrate summary of care records received electronically (not eFax)
without special effort like manual entry or scanning?

□1 Yes

□2 No

39. Do you reconcile the following types of
clinical information electronically received
from providers outside your medical
organization? Reconciling involves comparing
a patient’s information from another provider
with your practice’s clinical information.

□3 Don’t know

□4 Not applicable

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

6

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

Availability and Use of Electronic Health Information
40. When treating patients seen by 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 Often
□2 Sometimes
□3 Rarely
□6 I do not see patients outside my medical organization

□4 Never

□5 Don’t know

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

□1 Often (Skip to 42) □2 Sometimes (Skip to 42) □3 Rarely (Go to 41a) □4 Never (Go to 41a)
□5 Don’t know (Skip to 42)
41a. If rarely or never used, please indicate the reason(s) why. CHECK ALL THAT APPLY.
1 Information not always available when needed (e.g., not timely, missing)
2 Do not trust accuracy of information
3 Difficult to integrate information in EHR
4 Information not available to view in EHR as part of clinicians’ workflow
5 Information not useful (e.g., redundant or unnecessary information)
6 Difficult to find necessary information

Benefits and Barriers to Exchange of Electronic Health Information
Information exchange refers to electronically sending, receiving, finding or integrating patient health information.
42. Please indicate your level of agreement with each of the following statements.
Electronically exchanging clinical information with
other providers outside my medical
organization_____________.

Strongly
Agree

Somewhat
Agree

Somewhat
Disagree

Strongly
Disagree

Not
Applicable

□1
□1
□1
□1
□1

□2
□2
□2
□2
□2

□3
□3
□3
□3
□3

□4
□4
□4
□4
□4

□5
□5
□5
□5
□5

“…improves my practice’s quality of care.”
“…increases my practice’s efficiency.”
“…prevents medication errors.”
“…enhances care coordination.”
“…reduces duplicate test ordering.”

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

Providers in our referral network lack the capability to electronically
exchange (e.g., no EHR system or health information exchange
connection).
We have limited or no IT staff.
Electronic exchange involves incurring additional costs.
Electronic exchange involves using multiple systems or portals.
Electronic exchange with providers using a different EHR vendor is
challenging.
The information that is electronically exchanged is not useful.
It is difficult to locate the electronic address of providers.
My practice may lose patients to other providers if we exchange
information.
7

Yes

No

Don’t
know

Not
Applicable

□1

□2

□3

□4

□1
□1
□1
□1
□1
□1
□1

□2
□2
□2
□2
□2
□2
□2

□3
□3
□3
□3
□3
□3
□3

□4
□4
□4
□4
□4
□4
□4

Att C1 - 2019 Instrument
National Electronic Health Records Survey

Form Approved
OMB No. 0920-1015
Exp. Date: 07/31/2020

Documentation and Burden Associated with Medical Record Systems
For the next questions, medical record system includes paper-based and EHR systems.
44. On average, how many hours per day do you spend outside of normal office hours documenting clinical
care in your medical record system?

□1 None

□2 Less than 1 hour

□3 1 to 2 hours

□4 More than 2 hours to 4 hours

□5 More than 4 hours

45. Do you have staff support (e.g., scribe) to assist you with documenting clinical care in your medical record
system?

□1 Yes

□2 No

46. How easy or difficult is it to document clinical care using your medical record system?

□1 Very easy

□2 Somewhat easy

□3 Somewhat difficult

□4 Very difficult

□5 Not applicable

47. Please indicate whether you agree or disagree with the following statements about using your medical
record system.
Strongly
Agree

Somewhat
Agree

Somewhat
Disagree

Strongly
Disagree

Not
Applicable

The amount of time I spend documenting clinical care
is appropriate.

□1

□2

□3

□4

□5

The amount of time I spend documenting clinical care
does not reduce the time I spend with patients.

□1

□2

□3

□4

□5

Additional documentation required solely for billing but
not clinical purposes increases the overall amount of
time I spend documenting clinical care.

□1

□2

□3

□4

□5

48. Clinical care documentation requirements for private insurers generally align with Medicare requirements.
□1 Strongly agree

□2 Somewhat agree

□3 Somewhat disagree

□4 Strongly disagree

□5 Not applicable

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

50. Who completed this survey? (CHECK ALL THAT APPLY)

□1 The physician to whom it was addressed

□2 Office staff

Thank you for your participation. Please return your survey in the
envelope provided. If you have misplaced the envelope, please send
the survey to:
RTI International
Attn: Data Capture (0215517.005.000.001)
5265 Capital Boulevard
Raleigh, NC 27690-1653

8

Boxes for Admin Use

□3 Other