Form 0920-0212 Att C - Annual Hospital Interview

Attachment C – Annual Hospital Interview

Form Approved

OMB No. 0920-0212

Exp. date XX/XX/XXXX

Notice – CDC estimates the average public reporting burden for this collection of information as 120 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 (0920-0212).

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) 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.

The National Center for Health Statistics is inviting you to complete the Annual Hospital Interview (AHI) for the National Hospital Care Survey. The AHI is a supplemental component of the National Hospital Care Survey. Data collected on the AHI will be used for statistical purposes to produce national estimates and obtain further insight on hospitals sampled in the National Hospital Care Survey.

We want to know how many patient visits this hospital had in the emergency department, outpatient department, and inpatient department between January 1 – December 31, 2021 (calendar year 2021).

1. Was this hospital open for the full calendar year 2021?

• Yes [Go to Q3]

• No [Go to Q2]

2. Please enter the date range this hospital was open in 2021:

[start date] – [end date]

<Programmer note Q2: two formatted date fields, e.g. calendar drop-downs>

3. For 2021, can this hospital separate counts of emergency department visits from counts of outpatient department visits?

• Yes [Go to Q4]

• No [Go to Q5]

4. For 2021, please provide the number of visits for the following:

Emergency department _[number only text box]____

Outpatient department _[number only text box]____

5. For 2021, please provide the number of visits for the following:

Outpatient and Emergency department _[number only text box]_____

6. For 2021, can this hospital separate counts of live births from counts of inpatient discharges?

• Yes [Go to Q7]

• No [Go to Q8]

7. For 2021, please provide the number of visits for the following:

Live births _[number only text box]____

Inpatient discharges _[number only text box]____

8. For 2021, please provide the number of visits for the following:

Inpatient discharges _[number only text box]____

Now we will ask a question about coronavirus disease (COVID-19) among inpatient discharges and a few questions about the use of telemedicine in this hospital in 2021.

9. For 2021, what percentage of this hospital’s inpatient discharges diagnosed with coronavirus disease (COVID-19) had not received the COVID-19 vaccine prior to admission?

   • Less than 25%

   • 25% to 49%

   • 50% to 74%

   • 75% or more

   • Don’t know

10. For 2021, did this hospital use telemedicine technology (e.g., audio, audio with video, web videoconference) for patient visits?

• Yes [Go to Q11]

• No  Finished!

• Don’t know  Finished!

10. For 2021, in what setting(s) did this hospital use telemedicine technology for patient visits? Select all that apply.

• Emergency department [Include Q12-13]

• Outpatient department [Include Q14-15]

• Inpatient department [Include Q16-17]

• Don’t know  Finished!

<Programmer note Q11: Include the follow-up questions for each answer choice selected.>

<Programmer note Q11: if Q11=”Don’t know,” then Q11 cannot equal “Emergency department,” ”Outpatient department,” or “Inpatient department.”>

<Programmer note Q12-13: Only present Q12 and Q13 if Q11=”Emergency department.”>

10. For 2021, in the emergency department, what types of telemedicine tools did this hospital use for patient visits? Select all that apply.

    • Telephone audio

• Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)

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

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

• Other tool(s): [text box]__

• Don’t know

10. For 2021, in the emergency department, what percentage of this hospital’s patient visits were through telemedicine technology?

• Less than 25%

• 25% to 49%

• 50% to 74%

• 75% or more

• Don’t know

<Programmer note Q14-15: Only present Q14 and Q15 if Q11=”Outpatient department.”>

10. For 2021, in the outpatient department, what types of telemedicine tools did this hospital use for patient visits? Select all that apply.

    • Telephone audio

• Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)

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

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

• Other tool(s): [text box]__

• Don’t know

10. For 2021, in the outpatient department, what percentage of this hospital’s patient visits were through telemedicine technology?

• Less than 25%

• 25% to 49%

• 50% to 74%

• 75% or more

• Don’t know

<Programmer note Q16-17: Only present Q16 and Q17 if Q11=”Inpatient department.”>

10. For 2021, in the inpatient department, what types of telemedicine tools did this hospital use for patient discharges? Select all that apply.

    • Telephone audio

• Videoconference software with audio (e.g., Zoom, WebEx, FaceTime)

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

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

• Other tool(s): [text box]__

• Don’t know

10. For 2021, in the inpatient department, what percentage of this hospital’s patient discharges were through telemedicine technology?

• Less than 25%

• 25% to 49%

• 50% to 74%

• 75% or more

• Don’t know

4