Changes to NEHRS

Att B – Changes to the NEHRS Instrument

Current versions of the questions are in black; revisions are indicated in red.

Additions

The use of telemedicine was assessed in the 2018 and 2019 NEHRS data collections (i.e., Question 25). Continuation of the question (i.e., now Question 18) will allow for the observation of the use of this technology during the 2020 data collection. The word “audio” was added as an example by the Office of the National Coordinator for Health Information Technology. Six new sub-questions, Questions 18a-18f, on the 2020 NEHRS are designed to assess the use of telemedicine technology in response to the coronavirus disease (COVID-19) pandemic.

Telemedicine 18. Does your practice use telemedicine technology (e.g., audio, audio with video, web videoconference) for patient visits? □1 Yes □2 No (Skip to 19) □3 Don’t know (Skip to 19)

18a. Since January 2020, what percentage of your patient visits were through telemedicine technology?

□1 None □2 Less than 25% □3 25% to 49% □4 50% to 74% □5 75% or more □6 Don’t know

18b. What type(s) of telemedicine tools did you use for patient visits? Check all that apply.

□1 Telephone audio

□2 Videoconference software with audio (e.g., Zoom, Webex, FaceTime)

□3 Telemedicine platform NOT integrated with EHR (e.g., Doxy.me)

□4 Telemedicine platform integrated with EHR (e.g., update clinical documentation during telemedicine visit)

□5 Other tool(s):______________________________________________________

18c. What, if any, issues affected your use of telemedicine?

□1 Limited internet access and/or speed issues □2 Telemedicine platform not easy to use or did not meet our needs

□3 Telemedicine isn’t appropriate for my specialty/type of patients □4 Improved reimbursement and relaxation of rules related to use of ____________________________________________________________ telemedicine visits

□5 Limitations in patients’ access to technology □6 Patients’ difficulty using technology/telemedicine platform

(e.g., smartphone, computer, tablet, Internet)

18d. To what extent are you able to provide similar quality of care during telemedicine visits as you do during in-person visits?

□1 Fully □2 To a great extent □3 To some extent □4 To a small extent □5 Not at all

18e. Please rate your overall satisfaction with using telemedicine technology for patient visits?

□1 Very satisfied □2 Somewhat satisfied □3 Neither satisfied nor dissatisfied □4 Somewhat dissatisfied □5 Very dissatisfied

18f. Do you plan to continue using telemedicine visits (in addition to in-person visits) when appropriate once the COVID-19 pandemic is over?

□1 Yes □2 No □3 Don’t know

Modifications

Modifications to language are proposed to improve clarity, reduce burden, and update terminology. In addition, skip pattern logic has been updated to reflect the proposed modifications or removal of survey content. The modifications are provided below.

• Modified the burden statement to reflect minor revisions to wording, a reduction in the estimated average minutes per response from 30 minutes to 20 minutes, and an update to the CIPSEA confidentiality language.

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.

Original:

Revised:

NOTICE – CDC estimates the average public reporting burden for this collection of information as 20 minutes 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, 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 (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). 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

• Removal of the National Ambulatory Medical Care Survey (NAMCS) affiliation in the introduction. The National Electronic Health Records Survey (NEHRS) became a stand-alone survey in 2012. However, until recently, all content for NEHRS was on the NAMCS website making the statement necessary. In April 2020, NEHRS launched its own website: https://www.cdc.gov/nchs/nehrs/about.htm

Original introduction statement: 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 ...

Revised introduction statement: 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...

• Replace “ambulatory” with “outpatient, office-based” throughout the questionnaire to update the terminology and improve clarity. Feedback from the 2018 and 2019 computer assisted telephone interviewers stated that the term ambulatory was a source of confusion despite the definition that was provided.

Original introduction statement: 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.

Revised introduction statement: 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 outpatient, office-based care settings.

Original definition:

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

Revised definition:

This survey asks about outpatient, office-based care, that is, care for patients receiving health services without admission to a hospital or other facility.

Original Questions 2-5:

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

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

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

5. At which of the settings (1-8) in question 4 do you see the most ambulatory patients?

Revised Questions 2-5:

2. Do you directly provide outpatient, office-based care?

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

4. Do you see outpatient, office-based patients in any of the following settings? CHECK ALL THAT APPLY.

5. At which of the outpatient, office-based settings (1-8) in Question 4 do you see the most patients?

• Response options for Question 4 were modified to provide current terminology and improve clarity. “Non-federal Government Clinic” was revised to “Government clinic that is not federally funded.” “Health maintenance organization, health system or other prepaid practice” was revised to “Integrated Delivery System, health maintenance organization, health system or other prepaid practice.”

Original response options 5 and 7 for Question 4:

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

□7 Health maintenance organization, health system or other prepaid practice (e.g., Kaiser Permanente)

Revised response options 5 and 7 for Question 4:

□5 Government clinic that is not federally funded (e.g., state, county, city, maternal and child health, etc.)

□7 Integrated Delivery System, health maintenance organization, health system or other prepaid practice (e.g., Kaiser Permanente)

• Question 6 was revised to remove telephone number. Telephone number is no longer needed due to the proposed removal of the computer assisted telephone interview mode. Email address has been asked on previous NEHRS collections starting in 2014. Previously it was placed at the end of the survey. It has been moved up with the other contact information to improve flow and formatting.

Original Question 6:

6. What are the county, state, zip code, and telephone number of the reporting location?

Country	USA	County		State
Zip Code		Telephone

Revised Question 6:

6. What are the county, state, and zip code of the reporting location? What is the email address of the physician to whom this survey was mailed?

Country	USA	County		State
Zip Code		Email address

• Formerly Question 14, now Question 9, was revised from a question that asked the percent of Medicaid patients to asking whether the physician treated Medicaid patients. This question was changed based on review of the response to this question in the past. The response to this question was poor and may not be well suited for the physician to answer.

Original Question 14:

14. What percent of your patients are insured by Medicaid?

%

Revised Question 14 (now Question 9):

9. Do you treat patients insured by Medicaid?

□1 Yes □2 No □3 Don’t know

• Formerly Question 22, now Question 14, was revised to improve clarity and add a website resource for respondents to determine whether their system is certified or not.

Original Question 22 (now 14):

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?

Revised Question 14 (formerly 22):

14. Is your EHR system certified to meet U.S. Department of Health and Human Services requirements? Certified EHRs are necessary to meet the objectives of Meaningful Use/Promoting Interoperability Program. If unsure, see if your system meets the requirements here: https://chpl.healthit.gov/#/search

• Formerly Question 20, now Question 15, was modified to update the list of the top currently used EHR systems used by outpatient, office-based physicians. ONC provided the updated list. Two vendors were deleted from the list: Amazing charts and GE/Centricity. Sage/Vitera/Greenway is now Greenway so this change is reflected in the response option.

Original Question 20 (now Question 15):

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

Revised Question 15 (formerly Question 20):

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

□1 Allscripts □2 athenahealth □3 Cerner □4 eClinical Works

□5 e-MDs □6 Epic □7 Modernizing Medicine □8 NextGen

□9 Practice Fusion □10 Greenway □11 Other, specify: ___________________ □12 Unknown

Deletions

The removal of the computer-assisted telephone interview (CATI) mode is proposed as a strategy to improve physician response rates. As a result, the CATI interviewer script is no longer included in the package. Resources will be reallocated to physician tracing efforts.

The content proposed for deletion from the questionnaire is deemed nonessential to ONC’s current priorities or was not well suited for an outpatient, office-based physician to answer. Deletions to survey content are provided below.

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

9. How many advanced practice providers (i.e., nurse practitioners, physician assistants, and nurse midwives) are associated with the reporting location?

Advanced practice providers

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

□1 Single □2 Multi

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

□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?

	Yes	No	Don’t Know
1. Private insurance	□1	□2	□3
2. Medicare	□1	□2	□3
3. Medicaid/CHIP	□1	□2	□3
4. Workers’ compensation	□1	□2	□3
5. Self-pay	□1	□2	□3
6. No charge	□1	□2	□3

23. How frequently do you use template-based notes in your EHR system?

Template-based notes are generated through forms or pre-filled text in an EHR rather than free text alone.

□1 Often (Go to 23a) □2 Sometimes (Go to 23a) □3 Rarely (Go to 23a) □4 Never (Skip to 24)

□5 Don’t know (Skip to 24) □6 Not applicable (Skip to 24)

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

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

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 □4 Very difficult

24. Does the reporting location use a computerized system to…? (CHECK NO MORE THAN ONE BOX PER ROW):				Yes		No		Don’t Know
SAFETY	If prescriptions are ordered, Are warnings of drug interactions or contraindications provided?			□1		□2		□3
	Order lab tests?			□1		□2		□3
	Order radiology tests?			□1		□2		□3
	Provide reminders for guideline-based interventions or screening tests?			□1		□2		□3
PATIENT ENGAGEMENT	Create educational resources tailored to the patients’ specific conditions?			□1		□2		□3
	Exchange secure messages with patients?			□1		□2		□3
POPULATION MANAGEMENT	Generate lists of patients with particular health conditions?			□1		□2		□3
	Create reports on clinical care measures for patients with specific chronic conditions (e.g., HbA1c for diabetics)?			□1		□2		□3
	Create shared care plans that are available across the clinical care team?			□1		□2		□3
QUALITY MEASUREMENT	Send clinical quality measures to public and private insurers (e.g., blood pressure control, HbA1c, smoking status)?			□1		□2		□3
26. Does your EHR system allow patients to…		Yes	No		Don’t Know		Not Applicable
View their online medical record?		□1	□2		□3		□4
Download their online medical record to their personal files?		□1	□2		□3		□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

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

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 No (Go to 31) □3 Don’t know (Go to 31)

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

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) □2 No (Skip to 36) □3 Don’t know (Skip to 36) □4 Not applicable (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)

36. For providers outside your medical organization, do you regularly electronically send and receive, send only, or receive only the following types of patient health information?	Both Send and Receive Electronically	Send Electronically Only	Receive Electronically Only	Do not Send or Receive Electronically	Not Applicable
Progress/consultation notes	□1	□2	□3	□4	□5
Clinical registry data	□1	□2	□3	□4	□5
Emergency Department notifications	N/A	N/A	□3	□4	□5
Summary of care records for transitions of care or referrals	□1	□2	□3	□4	□5

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

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 □3 Don’t know □4 Not applicable

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.	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

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
“…improves my practice’s quality of care.”	□1	□2	□3	□4	□5
“…increases my practice’s efficiency.”	□1	□2	□3	□4	□5
“…prevents medication errors.”	□1	□2	□3	□4	□5
“…enhances care coordination.”	□1	□2	□3	□4	□5
“…reduces duplicate test ordering.”	□1	□2	□3	□4	□5

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

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

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