2019 NAMCS-1 Questions for Traditional Physicians

Form Approved

OMB No. 0920-0234

Exp. Date xx/xx/20xx

Attachment C1: 2019 NAMCS-1 List of All Proposed Questions for Traditional Office-based Physicians

This table lists all proposed 2019 survey questions in the order that they would appear in the survey. Several blocks of questions have been deleted and are indicated in red.

Notice-CDC estimates the average public reporting burden for this collection of information as 30minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 NE, MSD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0234).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.

Variable

Name

Traditional Office-based Physicians

Section 1: Telephone Screener

SPECVER

Your specialty is [Pre-filled Specialty],

Is that right?

1. Yes

2. No

PRV_SPEC

What is your (your/Physician name's) specialty (including general practice)?

PRV_SPEC_SP

  Enter verbatim response for specialty

PROFACT

Which of the following categories best describes (your/Physician name's) professional activity -
patient care, research, teaching, administration, or something else?

1. Patient Care

2. Research

3. Teaching

4. Administration

5. Something else – Specify PROFACT_SP

AMBCARE

(Do/Does) (you/physician's name) directly care for any ambulatory patients in (Your/ his/her) work?

1. Yes

2. No - does not give direct care

3. No longer in practice (i.e., retired, not licensed)

4. Temporarily not practicing (refers to duration of 3 months or more)

Skip Instructions:

1: Goto FED
2: Goto VERIF9A
3: Goto THANK_OOS

4: Goto THANK_OOS

VERIF9A

We include as ambulatory patients, individuals receiving health services without admission to a hospital or other facility.  Does (your/Physician name's) work include any such individuals?

1. Yes, cares for ambulatory patients

2. No, does not give direct care

Specify reason VERIF9a_SP

Skip Instructions:

1: Goto FED
2: Goto VERIF9A_SP

FED

(Do/Does) (you/physician's name) work as an employee or a contractor in a federally operated patient care setting (e.g., VA, military, prison), hospital emergency department, hospital outpatient department, or community health center?

1. Yes

2. No

Skip Instructions:

1: Goto PRIVPAT
2: Goto HOSPRIVPAT

PRIVPAT

In addition to working in a federally operated patient care setting, hospital emergency department, hospital outpatient department, or community health center, (do/does) (you/physician's name) also see any ambulatory patients in another setting (e.g., office based practice or community health center)?

1. Yes

2. No

Skip Instructions:

1: Goto HOSPRIVPAT
2: Goto THANK_OOS

HOSPRIVPAT

(Do/does) (you/physician's name)  work in an office-based practice owned by a hospital?

1. Yes

2. No

Skip Instructions:

(1 or 2) AND FED = 1: Goto REMINDER
(1 or 2) AND FED = 2: Goto ADDCHECK

REMINDER

  Although the physician works in a federal patient care setting, hospital emergency department, hospital outpatient department, or community health center please make sure the respondent is aware that all of the following questions are NOT concerned with these settings/patients/visits. The survey is ONLY concerned with their private patients.

ADDCHECK

We have (your/Physician name's) address as
(Address)

Is that the correct address for your office?

1. Yes

2. No, update address

NEW_PINFO

What is the correct address and phone number?

THANK_OOS

Thank you, (Respondent's name/Physician's name), but since you are not currently practicing, our questions would not be appropriate for you.
I appreciate your time and interest.

Skip Instructions:

IF AMBCARE = 3 goto WHYNO_PRACT
IF AMBCARE = 4 goto WHY_UNAVAIL

WHYNO_PRACT

  Why isn't the doctor practicing?

1. Retired

2. Not licensed

3. Other

WHY_OOS

Describe the provider's practice or medical activities which define him/her asineligible or out-of-scope.

Enter all that apply, separate with commas

1. Federally employed

2. Radiology, anesthesiology or pathology specialist

3. Administrator

4. Work in institutional setting

5. Work in hospital emergency department, hospital outpatient department, or community health center

6. Work in industrial setting

7. Ambulatory surgicenter

8. Laser vision surgery

9. Other – Specify WHY_OO_SP

WHY_UNAVAIL

Why is provider temporarily not practicing?

Verbatim response

INDUCT_APPT

I would like to arrange an appointment with you within the next week or so to discuss the study.
It will take about 45 minutes.  What would be a good time for you, before Friday, (last Friday before the assigned reference week)?

Questions for Non-responding physicians

I appreciate that you choose not to participate in the study, but I would like to ask a few short questions about your practice so we can make sure responding physicians do not differ from nonresponding physicians.

“Physicians” filled for Traditional physicians

NUMLOC

At how many different office locations do you see ambulatory patients? Do not include settings such as emergency departments, outpatient departments, surgicenters, federal clinics, and community health centers.

NOPATSEN

In a typical year, about how many weeks do you not see ambulatory patients (for example, conferences, vacations, etc.)?

LTHALFR

LTHALFR_SP

You typically see patients fewer than half the weeks in each year. Is that correct?

1. Yes

2. No – Please explain LTHALFR_SP

ALLYEARR

ALLYEARR_SP

You typically see patients all 52 weeks of each year. Is that correct?

1. Yes

2. No – Please explain ALLYEARR_SP

NUMVISR

During your last normal week of practice, how many patient visits did you have at all office locations?

WKHOURSR

During your last normal week of practice, how many hours of direct patient care did you provide?

NOTE – Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services. Do not include hours from EDs, outpatient departments, surgicenters, or Federal clinics.

NUMBPAR

At the office location where you see the most ambulatory patients:

How many physicians are associated with you?

SINGSPCR

At the office location where you see the most ambulatory patients:

Is this a single- or multi-specialty group practice?

OWNERSHR

At the office location where you see the most ambulatory patients:

Are you a full- or part-owner, employee, or an independent contractor?

OWNSR

At the office location where you see the most ambulatory patients:

Who owns the practice?

Section 2: Induction Interview

INDUCT_INTRO

Before we begin, I'd like to give you some background about this study.

Medical researchers and educators are especially interested in topics like medical education, health workforce needs, and the changing nature of health care delivery.  The National Ambulatory Medical Care Survey (or NAMCS) was developed to meet the need for such information.  

The CDC’s National Center for Health Statistics works closely with members of the medical profession to design the NAMCS each year.  The NAMCS supplies essential information about how ambulatory medical care is provided in the United States, and how it is utilized by patients.  

Your part in the study is very important and should not take much of your time.  It consists of your participation during a specified 7-day period.  During that time, you would supply a minimal amount of information about the patients you see.

First, I have some questions to ask about your practice.  Your answers will only be used to provide data on the characteristics of office-based practices in the U.S.  Any and all information you provide for this study will be kept confidential. Participation is voluntary, and you or your staff may refuse to answer any question or stop participating at any time without penalty or loss of benefits.

NUMLOC

At how many different office locations do you see ambulatory patients?  Do not include settings such as emergency departments, outpatient departments, surgicenters, federal clinics, and community health centers.

NOPATSEN

In a typical year, about how many weeks (do/does) (you/physician's name) not see any ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALF

LTHALF_SP

(You/physician's name) typically (see/sees) patients fewer than half the weeks in each year.
Is that correct?

1. Yes

2. No Please explain LTHALF_SP

ALLYEAR

ALLYEAR_SP

(You/physician's name) typically (see/sees) patients all 52 weeks of the year.
Is that correct?

1. Yes

2. No Please explain ALLYEAR_SP

SEEPAT

WHYNOPAT

This study will be concerned with the ambulatory patients (you/physician's name) will see in (Your/ his/her) (office/offices) during the week of Monday, (Reporting period begin date) through Sunday, (Reporting period end date).

(Are/Is) (you/physician's name) likely to see any ambulatory patients in (Your/ his/her) (office/offices) during that week?

  For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks, and so forth will be provided by staff in physician's absence, enter "Yes."

1. Yes

2. No Why is that?
    Enter verbatim response

(12b) WHYNOPAT

CHECK_BACK

Since it's very important that we include any ambulatory patients that (you/physician's name) might see in (Your/ his/her) office during that week, I'll check back with your office just before (Reporting period begin date) to make sure (Your/ his/her) plans have not changed.

          Even though the physician/provider is not available during the reporting week, continue with the induction

OFFSTRET

Are there any other office locations at which you will see ambulatory patients during that 7-day reporting period?

  If this is a CHC sampled provider, DO NOT enter any other locations in the table below.  Since we sample CHC service delivery sites, we are only interested in visits to the sampled CHC site.  You SHOULD NOT follow CHC providers to other locations during the sample week.  Only include visits from the currently sampled CHC location.

OFFICE_CITY

In what city is this office located?

OFFICE_ST

In what state is this office?

OFFICE_ZIP

What is the zip code for this office?

LOCTYPE

  Enter location/address type

1. Main Office address

2. Alternative/2nd office address

3. Home office

4. Home

5. Unknown

CUR_OFFICE

Is (street address) the current office?

^OFF1

^OFF2

^OFF3

^OFF4

^OFF5

OFFICETYP

Looking at this list, choose all of the type(s) of settings that describe the office at (Office location).

       If in doubt about any clinic/facility/institution, PROBE -

         Is this/that clinic/facility/institution part of a hospital emergency department or an outpatient
         department?         If yes, select 2 or 4

         Is this/that clinic/facility/institution operated by the Federal Government?        If yes, select 12

Enter up to 3, separate with commas

1. Private solo or group practice

2. Hospital emergency department

3. Freestanding clinic/surgicenter (not part of a hospital outpatient department)

4. Hospital outpatient department

5. Intentionally left blank

6. Ambulatory surgicenter

7. Mental health center

8. Institutional setting (school infirmary, nursing home, prison)

9. Non-federal Government clinic (e.g., state, county, city, maternal and child health, etc.)

10. Industrial outpatient facility

11. Family planning clinic (including Planned Parenthood)

12. Federal government operated clinic (e.g., VA, military, etc.)

13. Health maintenance organization or other prepaid practice (e.g., Kaiser Permanente)

14. Laser vision surgery

15. Faculty practice plan

16. Community Health Center (e.g. Federally Qualified Health Center (FQHC), federally funded clinics or 'look alike' clinics)

FREESTAND_PROBE

Is this/that clinic in an institutional setting, in an industrial outpatient facility, or operated by the Federal Government?

1. Yes

2. No

FAMPLAN_PROBE

Is this/that clinic operated by the Federal Government?

1. Yes

2. No

OTHLOC

Are there other office locations where (you/physician's name) normally would see patients, even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting period?  Do not include settings such as emergency departments, outpatient departments, surgicenters, federal clinics, and community health centers.

1. Yes Go to OTHLOCVS

2. No Skip to ESTDAYS

OTHLOC_NUM

1. Office #1

2. Office #2

3. Office #3

4. Office #4

5. Office #5

6. Office #6

7. Office #7

8. Office #8

9. Office #9

10. Office #10

OTHLOCVS

Of these locations where (you/physician's name) will not be seeing patients during (Your/ his/her) 7-day reporting period, how many total office visits did (you/physician's name) have during (Your/ his/her) last week of practice at these locations?

ESTDAYS

During the week of Monday, [Fill Date] through Sunday, [Fill Date] how many days do you expect to see any ambulatory patients at all in-scope locations?

ESTVIS

During (Your/ his/her) last normal week of practice, approximately how many office visit encounters did (you/physician's name) have at each office location?

          If physician is in group practice, only include the visits to sampled physician.

SAME

During the week of Monday, (Reporting period begin date) through Sunday (Reporting period end date), (do/does) (you/physician's name) expect to have about the same number of visits as (you/physician's name) saw during (Your/ his/her) last normal week in each office taking into account time off, holidays, and conferences?

1. Yes

2. No

ESTVISP

Approximately how many ambulatory visits (do/does) (you/physician's name) expect to have at this office location?

ESTTOTVS

Tally of estimated number of visits

SOLO

Now, I'm going to ask about (your/Physician name's) practice at (Office location).

(Do/Does) (you/physician's name) have a solo practice, or (are/is) (you/physician's name) associated with other physicians in a partnership, in a group practice, or in some other way at this location?

1. Solo

2. Nonsolo

OTHPHY

How many physicians are associated with (you/physician's name) at (Office location)? Do not include interns, residents, or fellows.

MULTI

Is this a multi- or single-specialty (group) practice at (Office location)?

1. Multi

2. Single

MIDLEV

How many advanced practice providers (nurse practitioners, physician assistants, and certified nurse midwives) are associated with (you/physician's name) at (Office location)?

OWNERSH

(Are/Is) (you/physician's name) a full- or part-owner, employee, or an independent contractor at (Office location)?

1. Full-owner

2. Part-owner

3. Employee

4. Contractor

OWNS

Who owns the practice at (Office location)?

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

ONSITE_EKG

ONSITE_PHLEB

ONSITE_LAB

ONSITE_SPIRO

ONSITE_ULTRA

ONSITE_XRAY

Does (your/Physician name's) practice have the ability to perform any of the following on site at (Office location)?

1. EKG/ECG

2. Phlebotomy

3. Laboratory testing (not including urine dipstick, urine pregnancy, fingerstick blood glucose, or rapid swab testing for infectious diseases)

4. Spirometry

5. Ultrasound

6. X-ray

1. Yes

2. No

3. Don’t know

PATEVEN

(Do/Does) (you/physician's name) see patients in the office during the evening or on weekends at (Office location)?

1. Yes

2. No

3. Don’t know

NPI

What is (your/Physician name's) National Provider Identifier (NPI) at (Office location)?

FEDTXID

What is your Federal Tax ID, also known as an Employer Identification Number (EIN), at (Office location)?

WKHOURS

During (your/Physician name's) last normal week of practice, how many hours of direct patient care did (you/physician's name) provide?

Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services.

NHVISWK

HOMVISWK

HOSVISWK

TELCONWK

ECONWK

During (Your/ his/her) last normal week of practice, about how many encounters of the following type did (you/physician's name) make with patients:

1. Nursing home visits

2. Other home visits

3. Hospital visits

4. Telephone consults

5. Internet/e-mail consults

STD-PrEP Questions

STD_INTRO

The following question set asks about policies, services, and experiences related to the prevention and treatment of sexually transmitted infections (STIs) and HIV prevention.

1. Enter 1 to Continue-SKIP to STIADOLPOL

STIADOLPOL

STIADOLPOL_ASK

◊ The next 5 questions refer to Dr. X’s (fill last name or greet name) office at (fill address of sampled location/office location with most visits).

Does the office have a written policy that asks parents, relatives or guardians of an adolescent patient to leave the room during any part of the visit?

1. Yes-go to STIADOLPOL_ASK

2. No-go to STIEVAL

3. I don’t know/Dr. X (fill last name or greet name) doesn’t know—go to STIEVAL

When does the office policy require that I/Dr. X (fill last name or greet name) ask relatives or guardians of adolescent patients to leave the room during part of the visit?

1. Always

2. Depending on the circumstance

3. Don’t know

STIEVAL

Do you/Does Dr. X (fill last name or greet name) evaluate patients for sexually transmitted infections or treat patients with sexually transmitted infections in your/his office at (fill in address of sampled location/office location with most visits)?

1. Yes-SKIP to STINJABX

2. No-SKIP to STIRSKEVAL

STINJABX

Which of the following injectable antibiotics are provided onsite at (fill in address of sampled location/office location with most visits) for same-day treatment for patients diagnosed with gonorrhea or syphilis? (Mark all that apply)

1. Benzathine penicillin G (bicillin) 2.4 million units IM

2. Ceftriaxone 250 mg IM

3. Other injectable cephalosporin

4. None of the above

STIPOSTST

For patients with vaginal discharge or urethritis, which of the following point-of-service tests does your/Dr. X’s (fill last name or greet name) office at (fill in address of sampled location/office location with most visits) provide onsite? (check all that apply)

1. Dipstick urinalysis

2. KOH (whiff) test

3. pH test

4. Rapid bacterial vaginosis test

5. Rapid Trichomonas test

6. Stained microscopy using either gram stain, methylene blue stain, or gentian violet stain

7. Standard (unstained) microscopy of urine sediment

8. Wet mount microscopy (wet prep)

9. None of the above

STIRSKEVAL

The next question asks about STI and HIV-related risk assessment and services that you/Dr. X (fill last name or greet name) provide(s).

Do you/Does Dr. X (fill last name or greet name) document any of the following about your/their patients on at least an annual basis? [Mark all that apply]

1. Any substance abuse or injection drug use

2. Condom use

3. HIV status of their sex partners

4. Number of sex partners they have

5. Patients’ sexual orientation or the sex of their sex partners

6. Types of sex that they have (vaginal, anal, oral)

7. None of the above

PRP_INTRO

The next questions must be answered by Dr. X (fill last name or greet name). They ask specifically about Dr. X’s (fill last name or greet name) experience with HIV-prevention using PrEP (pre-exposure prophylaxis).

1. Enter 1 to Continue-SKIP to PRPHRD

PRPHRD

The following question must be answered by the sampled physician.)

Have you heard of PrEP (pre-exposure prophylaxis) to prevent HIV infection?

1. Yes-SKIP to PRPEFF

2. No-SKIP to CLASTRAIN [end section]

(The following question must be answered by the sampled physician.)

Please indicate whether you agree or disagree with the following statements about PrEP. They include various attitudes and beliefs that some providers might have about PrEP.

	1. Disagree	2. Agree	3. Don’t know
PrEP is effective for HIV prevention. [PRPEFF]
PrEP use will result in an increase in risky sexual behavior and sexually transmitted infections. [PRPRSB]
PrEP will lead to drug resistance if a patient gets infected while taking PrEP. [PRPDR]
Most patients will have difficulty affording PrEP regardless of their insurance status. [PRPAFF]
Most patients will have difficulty adhering to daily dosing of PrEP. [PRPADH]

	1. Yes		2. No
One or more of my patients have asked for PrEP. [PRPASK]
One or more of my patients have declined PrEP [PRPDEC]

PRPRX

◊ (The following question must be answered by the sampled physician.)

Have you prescribed PrEP?

1. Yes-CLASTRAIN [end section]

2. No-Go to PRPWHY

PRPWHY

◊ (The following question must be answered by the sampled physician.)

Why have you not prescribed PrEP? (Mark all that apply):

1. I do not have any patients at high risk of acquiring HIV infection.

2. Prescribing PrEP is outside my scope of practice.

3. I do not have enough information about PrEP to prescribe it.

4. I am uncomfortable prescribing antiretroviral medications.

5. I refer my patients to another provider or clinic for PrEP.

6. My patients have not asked for PrEP.

7. I have offered PrEP to one or more of my patients but they have declined.

8. PrEP is not effective for HIV prevention.

9. PrEP use will cause an increase in risky sexual behavior and sexually-transmitted infections in my patients.

10. PrEP will lead to drug resistance if my patients get infected while taking PrEP.

11. My patients will have difficulty affording PrEP, regardless of their insurance status.

12. My patients will have difficulty adhering to daily dosing of PrEP.

13. Other (Prompt text field for response)

New National CLAS Standards Questions

CLASTRAIN

(The following two questions must be answered by the sampled provider.) The following two questions are about cultural competence. _Within the past 12 months, have you participated in any cultural competence training?

1. Yes

2. No

CLASKNOW

(The following question must be answered by the sampled provider.) How familiar are you with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards)?

1. Never heard of it

2. Heard of it but do not know much about it

3. Know something about it

4. Very familiar with it

Alcohol Screening and Brief Intervention (SBI) Questions

ALCOHOL_INTRO

The next set of questions are only administered to primary care providers and seeks to determine the extent to which alcohol screening and brief intervention (SBI) is being conducted within their practices.

ALCSCREEN

Screening for alcohol misuse (excessive consumption and alcohol-related problems) is often conducted in clinical settings. How do you screen for alcohol misuse?

1. I don’t screen

2. T-ACE

3. TWEAK

4. CAGE

5. CRAFFT

6. AUDIT

7. Ask number of drinks per occasion (For example, “On a typical day, how many drinks do you have?”

8. Ask frequency of drinking (For example, “On average, how many days a week do you have an alcoholic drink?”)

9. Ask binge question (For example, for women, “How many times in the past year have you had 4 or more drinks in a day?” For men: “How many times in the past year have you had 5 or more drinks in a day?”)

10. I don’t use a formal screening instrument

11. Other (specify) ALCSCREENOTH

ASCREENOFT

How often do you screen for alcohol misuse?

1. At every health maintenance visit (annually)

2. At every health care visit

3. When I suspect a patient has a substance/alcohol-related problem

4. Almost never or never

ASCREENADM

How are screening question(s) administered?

1. Interview (in person/face-to-face)

2. Patient completes a form

3. Electronic (self-administered)

4. Other (specify) ASCREENADMOTH

ASCREENWHO

If patient is interviewed, who administers the screening?

1. Physician, nurse practitioner, physician assistant

2. Nurse, excluding nurse practitioner

3. Medical assistant

4. Administrative staff

5. Other (specify) ASCREENWHOTH

ABRFINTERV

Brief interventions for risky alcohol use are short discussions with patients who drink too much or in ways that are harmful. These interventions typically include some of the following elements:

• Feedback on screening results

• Gathering further information on drinking patterns, alcohol-related harm, or symptoms of alcohol dependence

• Discussing the risks and consequences of drinking too much

• Providing advice about cutting back or stopping

Among patients who screen positive for risky alcohol use, how often are brief interventions conducted?

1. Never

2. Sometimes

3. Often

4. Always

ARESOURCE

What resources would be helpful in implementing alcohol/substance screening and intervention in primary care settings? (Select all that apply)

1. Implementation guide for alcohol screening and intervention

2. Training on how to conduct alcohol screening

3. Training on how to conduct intervention

4. Office-based mentoring

5. Access to patient education materials

6. Scripts on what to say to patients

7. Information about reimbursement for services

8. Information about where or how to refer for additional services

9. Other (specify) ARESOURCEOTH

Workforce Questions

MOSTVIS_INTRO

The next section refers to characteristics of the sampled physician’s practice.

NUMPH

(one location listed)

The next questions are about the practice that is associated with [Pre-fill location].

How many physicians, including you, are associated with this practice? Please include physicians at [Pre-fill location], and physicians at any other locations of this practice. Do not include interns, residents, or fellows.

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

NUMPH

(two or more locations listed)

The next questions are about the practice that is associated with [Pre-fill location], which is the location where the physician has the most office visits.

How many physicians, including you are associated with that practice? Please include physicians at [Pre-fill location], and physicians at any other locations of that practice.

1. 1 Physician

2. 2-3 physicians

3. 4-10 physicians

4. 11-50 physicians

5. 51-100 physicians

6. More than 100 physicians

PCMH

Is your practice certified as a patient-centered medical home?

1. Yes

   1. By whom is this practice certified as a patient-centered medical home? CERT_WHO

1. Accreditation Association for Ambulatory Health (AAAH)

2. Joint Commission

3. National Committee for Quality Assurance (NCQA)

1. [If yes:]  What is the level level of certification for the National Committee for Quality Assurance (NCQA)? NCQAlevel

   1. Level 1

   2. Level 2

   3. Level 3

4. Utilization Review Accreditation Commission (URAC)

5. Other – Specify PCMH_OTH____________

6. Unknown

2. No

3. Unknown  

QUAL

Does this practice report any quality measures or quality indicators to either payers or to organizations that monitor health care quality?

1. Yes

2. No

3. Unknown

Staffing Types

(34 variables)

The next set of questions refer to the types of providers who work at [Pre-fill location].

How many of the following full-time and part-time providers are on staff at [Pre-fill location]?

Full-time is 30 or more hours per week. Part-time is less than 30 hours per week.

Please provide the total number of full-time and part-time providers.

Please include the sampled provider in the total count of staff below.

Full-time physicians (include MDs and Dos)? Do not include interns, residents, or fellows

Include all out-of-scope physicians other than interns, residents, and fellows in the count

Type of Provider	Number Full-time (≥30 hours)	Number Part-time (<30 hours)
Physicians (MD and DO)	MD_DO_FT	MD_DO_PT
Non-Physician Clinicians
Physician Assistants (PA)	PA_FT	PA_PT
Nurse Practitioners (NP)	NP_FT	NP_PT
Certified Nurse Midwives (CNM)	CNM_FT	CNM_PT
Clinical Nurse Specialists	CNS_FT	CNS_PT
Nurse Anesthetists	NA_FT	NA_PT
Other Nursing Care
Registered nurses (RN) (not an NP or CNM)	RN_FT	RN_PT
Licensed Practical Nurses (LPN)	LPN_FT	LPN_PT
Certified Nursing Assistants/Aides (CNA)	CNA_FT	CNA_PT
Allied Health
Medical Assistants (MA)	MA_FT	MA_PT
Radiology Technicians (RT)	RT_FT	RT_PT
Laboratory Technicians (LT)	LT_FT	LT_PT
Physical Therapists (PT)	PT_FT	PT_PT
Pharmacists (Ph)	PH_LT	PH_PT
Dieticians/Nutritionists (DN)	DN_FT	DN_PT
Other
Mental Health Providers (MH)	MH_FT	MH_PT
Health Educators/Counselors (HEC)	HEC_FT	HEC_PT
Case Managers Certified Social Workers (CSW)	CSW_FT	CSW_PT
Community Health Workers (CHW)	CHW_FT	CHW_PT

Autonomy of PAs, NPs, and CNMs (15 variables)

The following questions concern the PAs, NPs, CNMs, CNSs and CRNAs practicing at [Pre-fill location].

A.      Physician Assistant	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the PA’s patients logged separately from your patients? PA_LOG
Do/does the PA(s) bill for services using their own NPI number? PA_BILL
B.      Nurse Practitioner	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the NP’s patients logged separately from your patients? NP_LOG
Do/does the NP(s) bill for services using their own NPI number? NP_BILL
C.      Certified Nurse Midwife	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CNM’s patients logged separately from your patients? CNM_LOG
Do/does the CNM(s) bill for services using their own NPI number? CNM_BILL
D. Clinical Nurse Specialist	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CNS's patients logged separately from your patients? CNS_LOG
Do/Does the CNS(s) bill for services using their own NPI number? CNS_BILL
E. Certified Registered Nurse Anesthetists	Yes, always	Yes, sometimes	No	Unknown/Not Applicable
Are the CRNA’s patients logged separately from your patients? NA_LOG
Do/Does the CRNA(s) bill for services using their own NPI number? NA_BILL

Electronic Health Record (EHR) Questions

EMR_INTRO

Answer ALL remaining questions for the eligible location with the most visits which is (Office location with most visits)

EBILLREC

Does the reporting location submit any claims electronically (electronic billing)?

1. Yes

2. No

3. Unknown

EMEDREC

Does the reporting location use an electronic health record (EHR) system?  Do not include billing record systems.

1. Yes, all electronic

2. Yes, part paper and part electronic

3. No

4. Unknown

EHRINSYR

In which year did you install your current EHR system?

HHSMU

Does your current system meet meaningful use criteria as defined by the Department of Health and Human Services?

1. Yes

2. No

3. Unknown

EHRNAM

What is the name of your current EHR system?

1. Allscripts

2. Amazing Charts

3. athenahealth

4. Cerner

5. eClinicalWorks

6. e-MDs

7. Epic

8. GE/Centricity

9. Modernizing Medicine

10. NextGen

11. Practice Fusion

12. Sage/Vitera/Greenway

13. Other-Specify EHRNAMOTH

14. Unknown

EMRINS

At the reporting location, are there plans for installing a new EHR system within the next 18 months

1. Yes

2. No

3. Maybe

4. Unknown

EDEMOG EPROLST

EPNOTES

EMEDALG

EMEDID

EREMIND

ECPOE

ESCRIPT

EWARN

ECONTRSUB

ECONTRSUBS

ECTOE

ERESULT

ERADI

EIMGRES

EIDPT

EGENLIST

EDATAREP

ESUM

EMSG

Please indicate whether the ambulatory reporting location has each of the following computerized capabilities.

These 5 answer choices are for each of the following items a-q.

1. Yes

2. No

3. Unknown

1. Recording patient history and demographic information?

2. Recording patient problem list?

3. Recording clinical notes?

4. Recording patient’s medications and allergies?

5. Reconciling lists of patient medications to identify the most accurate list?

6. Providing reminders for guideline-based interventions or screening tests?

7. Ordering prescriptions?

1. If Yes, ask – Are prescriptions sent electronically to the pharmacy?

2. If Yes, ask – Are warnings of drug interactions or contraindications provided?

8. Do you prescribe controlled substances?

1. If Yes, ask-Are prescriptions for controlled substances sent electronically to the pharmacy?

REFOUT

DoDoes (you/physician's name) refer (Your/ his/her) patients to providers outside of (Your/ his/her) office or group?

1. Yes

No

REFOUTHOW

How do you send patient health information to them?

1. Electronically (EHR, webportal, or online registries)

2. Via paper-based methods (Fax, eFax, or mail)

3. We do not send patient health information to the provider

REFIN

DoDoes (you/physician's name) see any patients from (you/physician's name) providers outside of (you/physician's name)  office or group?

1. Yes

2. No

REFINHOW

How do you receive patient health information from them? Electronically does not include scanned or PDF documents, fax, or eFax. Check all that apply.

1. Electronically (EHR, webportal, or online registries)

2. Via paper-based methods (Fax, eFax, or mail)

3. We do not receive patient health information from the provider

ESHARE

The next questions are about sharing (either sending or receiving) patient health information.

Do you send or receive patient health information electronically? Electronically does not include scanned or PDF documents from fax, eFax, or mail.

1. Yes

2. No

3. Don't know

ESHARES

Do you electronically send patient health information to another provider whose EHR system is different from your own?

1. Yes

2. No

3. Don't know

ESHARER

Do you electronically receive patient health information to another provider whose EHR system is different from your own?

1. Yes

2. No

3. Don't know

EDISCHSR

Do you electronically send or receive hospital discharge summaries to or from providers outside of your medical organization? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

EEDSR

Do you electronically send or receive Emergency Department notifications to or from providers outside of your medical organization? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

ESUMCSR

Do you electronically send or receive summary of care records for transitions of care or referrals to or from providers outside of your medical organization? Check all that apply.

1. Send electronically

2. Receive electronically

3. Do not send or receive

PTONLINE

Can patients seen at the reporting location do the following online activities? Check all that apply.

1. View their medical record online

2. Download and transmit health information in the electronic medical record to their personal files

3. Request corrections to their electronic medical record

4. Enter their health information online (e.g. weight, symptoms)?

5. Upload their data from self-monitoring devices (e.g. blood glucose readings)?

Revenue & Contracts, Compensation, New Patients

PRMCARE PRMAID

PRPRVT

PRPATPAY

PROTH

Please remind physician/provider that the remaining questions refer to all offices that were determined to be in-scope.

I would like to ask a few questions about (your/Physician name's) practice revenue and contracts with managed care plans.

Roughly, what percent of (your/Physician name's) patient care revenue comes from –

1. Medicare?

2. Medicaid/CHIP?

3. Private insurance?

4. Patient payments

5. Other (including charity, research, Tricare, VA, etc.)?

PCTRVMAN

Roughly, what percentage of the patient care revenue received by this practice comes from managed care contracts?

1. Managed Care?

REVFFS

REVCAP

REVCASE

REVOTHER

Roughly, what percent of (your/Physician name's) patient care revenue comes from each of the following methods of payment?

1. Fee-for-service?

2. Cap?

3. Case rates

4. Other?

ACEPTNEW

(Are/Is) (you/physician's name) currently accepting "new" patients into (Your/ his/her) practice(s) at [Fill-in location]?

1. Yes

2. No

3. Don’t know

CAPITATE

NOCAP

NMEDICARE

NMEDICAID

NWORKCMP

NSELFPAY

NNOCHARGE

From those new patients, which of the following types of payment (do/does) (you/physician's name) accept at [Fill-in location]?

1. Accept New?

2. Capitated?

3. Non-capitated?

4. Medicare?

5. Medicaid?

6. Work comp?

7. Self-pay?

8. No charge?
   
   

The following answer choices are used for each of the above seven payment types:

1. Yes

2. No

3. Don’t know

PHYSCOMP

Which of the following methods best describes your basic compensation?

Bold answer choices & add FR instruction to prompt them to read answers aloud.

1. Fixed salary

2. Share of practice billings or workload

3. Mix of salary and share of billings or other measures of performance (e.g., your own billings, practice's financial performance, quality measures, practice profiling)

4. Shift, hourly or other time-based payment

5. Other

COMP

Clinical practices may take various factors into account in determining the compensation (salary, bonus, pay rate, etc.) paid to the physicians in the practice.  Please indicate whether the practice explicitly considers each of the following factors in determining your compensation. 
  Enter all that apply, separate with commas

1. Factors that reflect your own productivity

2. Results of satisfaction surveys from your own patients

3. Specific measures of quality, such as rates of preventive services for your patients

4. Results of practice profiling, that is, comparing the physician’s pattern of using medical resources with that of other physicians

5. The overall financial performance of the practice

SASDAPPT

Does (your/Physician name's) practice set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

Skip Instructions:

1. Goto SDAPPT

2. SKIP to APPTTIME

SDAPPT

Roughly, what percent of (your/Physician name's) daily visits are same day appointments?

APPTTIME

On average, about how long does it take to get an appointment for a routine medical exam?

1. Within 1 week

2. 1 - 2 weeks

3. 3 - 4 weeks

4. 1 - 2 months

5. 3 or more months

6. Do not provide routine medical exams

7. Don't know

PRVETHN

Are you of Hispanic, Latino/a, or Spanish origin? Enter all that apply, separate with commas

1. No, not of Hispanic, Latino/a, or Spanish origin

2. Yes, Mexican, Mexican American, Chicano/a

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, Another Hispanic, Latino/a or Spanish origin

RACE

What is (your/Physician name's) race? Enter all that apply, separate with commas

1. White

2. Black or African-American

3. American Indian or Alaska Native

4. Asian Indian

5. Chinese

6. Filipino

7. Japanese

8. Korean

9. Vietnamese

10. Other Asian

11. Native Hawaiian

12. Guamanian or Chamorro

13. Samoan

14. Other Pacific Islander

PRVBYEAR

N/A

PRVSEX

N/A

PRVDEGR

N/A

PRVPSPEC PRVPSPEC_SP

N/A

PRVSSPEC PRVSSPEC_SP

N/A

PRVPBC

N/A

PRVSBC

N/A

PRVYRGRD

N/A

PRVFMS

N/A

PHY_UNAVAIL

Thank you for your time and cooperation ^RESPNAME_FILL.  The information you provided will improve the accuracy of the NAMCS in describing office-based patient care in the United States.

I will call you on Monday, (Reporting period begin date) to see if your plans have changed.
If you have any questions (Hand respondent your business card) please feel free to call me.

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