Proposed Changes to NEHRS 2017

Att D – Proposed Changes to the NEHRS Instrument
The 2019 or 2021 National Electronic Health Records Survey (NEHRS) version are in black; revisions are in red. All new
questions have either been used on previous: NEHRS data collections, American Board of Family Medicine physician
surveys or the American Hospital Association survey.

Changes to the Assurance of Confidentiality language in the 2021 NEHRS
(previously approved language is in black, updated language is in red).
2021 NEHRS version
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 EvidenceBased 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.
•

Due to changes to the confidentially language, there have been modifications to the Assurance of
Confidentiality. Please see the modifications below which include additions and deletions.

Modified version
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 H21-8 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 (44 U.S.C. 3561-3583).
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. In addition to the above cited laws, NCHS complied with the Federal Cybersecurity Enhancement Act of
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Att D – Proposed Changes to the NEHRS Instrument
2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by
screening their networks.

Questions deleted
•

The questions below were removed because the content is no longer a research priority or due to lack of
space. We want to maintain the 4-page questionnaire length used in 2021.

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

□1 Patient Centered Medical Home (PCMH)
□2 Accountable Care Organization (ACO) arrangement 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)
□5 Merit-Based Incentive Payment System
□6 Advanced Alternative Payment Model
□7 Do not participate in any of the above activities or programs
□8 Don’t know

18a. Since March 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

18c. What, if any, issues affected your use of telemedicine? CHECK ALL THAT APPLY.
□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 (e.g., smartphone, computer, tablet, Internet)
□6 Patients’ difficulty using technology/telemedicine platform

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

□1 Very satisfied

□2 Somewhat satisfied

□3 Neither satisfied nor dissatisfied

□1 Yes

□2 No

□3 Don’t know

□5 Not at all

18e. Please rate your overall satisfaction with using telemedicine technology for patient visits?
□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
coronavirus disease (COVID-19) pandemic is over?

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Att D – Proposed Changes to the NEHRS Instrument
Prescribing Controlled Substances
19. How frequently do you prescribe controlled substances?

□1 Often
□2 Sometimes
□5 Don’t know (Skip to 22)

□3 Rarely

□1 Often

□3 Rarely

□4 Never (Skip to 22)

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

□2 Sometimes

□4 Never

□5 Don’t know

21. 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 21a) □2 Sometimes (Go to 21a) □3 Rarely (Go to 21a)
□5 Don’t know (Skip to 22)

□4 Never (Skip to 22)

21a. 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

21b. 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

21c. 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 nonpharmacologic 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 coordinated with other members of the care team

Documentation and Burden Associated with Medical Record Systems (both paper-based and EHR systems)
28. 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
hours

□2 Less than 1 hour

□3 1 to 2 hours

□4 More than 2 hours to 4 hours

□5 More than 4

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

□1 Yes

□2 No

30. 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

31. Please indicate whether you agree or disagree with the following statement about using your medical record
system. The amount of time I spend documenting clinical care is appropriate.

□1 Strongly agree

□2 Somewhat agree

□3 Somewhat disagree

3

□4 Strongly disagree □5 Not applicable

Att D – Proposed Changes to the NEHRS Instrument

Modification to the Introduction
•

We plan to expand the outpatient, office-based settings to include hospital outpatient departments as
eligible settings. Hospital outpatient departments, while outpatient may not be office-based. Therefore,
we will modify the term “outpatient, office-based” to “outpatient or office-based”.

2021 NEHRS version
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. 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.
Proposed Modification
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 or office-based 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.

Modification to Question 2 and its help text
2021 NEHRS version
This survey asks about outpatient, office-based care, that is, care for patients receiving health services without
admission to a hospital or other facility.
2. Do you directly provide outpatient, office-based care?
Proposed Modification
This survey asks about outpatient or office-based care, that is, care for patients receiving health services without
admission to a hospital or other facility.
2. Do you directly provide outpatient or office-based care?

Modification to Question 3
•

We plan to expand the outpatient, office-based settings to include hospital outpatient departments as
eligible settings. Therefore, we will modify Question 3 to exclude only hospital emergency departments
and changing “outpatient, office-based” to “outpatient or office-based”.

2021 NEHRS version
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?

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Att D – Proposed Changes to the NEHRS Instrument
Proposed Modification
3.
Overall, at how many office locations (excluding hospital emergency or hospital outpatient
departments) do you see outpatient or office-based patients in a normal week?

Modification to Question 4
2021 NEHRS version
4. Do you see outpatient, office-based patients in any of the following settings? CHECK ALL THAT APPLY.
Proposed Modification
4. Do you see outpatient or office-based patients in any of the following settings? CHECK ALL THAT APPLY.

Modification to Question 5
•

We plan to expand the outpatient, office-based settings collected on the questionnaire. Question 5 is
updated to include two new categories, Indian Health Service, and Rural Health Clinic. Additionally, it
will include hospital outpatient departments as an eligible setting. Note that the new settings are added
to Question 4 and are listed in the “Additions” section of this document.

2021 NEHRS version
5. At which of the outpatient, office-based settings (1-8) in Question 4 do you see the most patients?
Proposed Modification
5. At which of the outpatient or office-based settings (1-11) in Question 4 do you see the most patients?

Modification to Question 14
•

Office of the National Coordinator for Health Information Technology (ONC) updated the electronic
health record system vendor list to reflect the top vendors being used for outpatient or office-based
care. As a result we removed e-MDs and added Meditech.

2021 NEHRS version
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

Proposed Modification
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 Epic
□6 Meditech
□7 Modernizing Medicine
□8 NextGen

5

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

Att D – Proposed Changes to the NEHRS Instrument

Modification to Questions 20, 21 & 23
•

Three interoperability questions were modified from asking if the physician sends, receives, searches or
queries patient health information to ask how often the physician sends, receives, searches or queries
patient health information. The changes will allow us to better understand the frequency with which
office-based physicians send, receive, search or query patient health information.

2021 NEHRS version
Electronic Exchange of Patient Health Information
22. 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

□2 No

□3 Don’t know

23. 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

□2 No

□3 Don’t know

24. 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

□2 No

□3 Don’t know

Proposed Modification
Electronic Exchange of Patient Health Information
20. How often 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 Often

□2 Sometimes

□3 Rarely

□4 Never

□5 Don’t know

21. How often 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 Often

□2 Sometimes

□3 Rarely

□4 Never

□5 Don’t know

23. When seeing a new patient or a patient who has previously seen another provider, how often 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 Often

□2 Sometimes

□3 Rarely

□4 Never

□5 Don’t know

Additions to Question 4
•

New outpatient, office-based settings were added to capture physicians who work at Indian Health
Service or Rural Health Clinic sites in Question 4. Hospital outpatient departments are now classified as
eligible settings to better understand physicians who work in these outpatient settings. The data will be
collected so that analysis can still be done using the original eligible settings for trend analyses. In
previous NEHRS collections, hospital outpatient departments and hospital emergency departments
were classified as one category that was ineligible. Hospital emergency departments remain ineligible.

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Att D – Proposed Changes to the NEHRS Instrument
2021 NEHRS version

Proposed Addition

Additions to Questions 9 & 10
•

The two new questions about whether the physician accepts Medicaid or Medicare insurance for
new patients were added back to the questionnaire in Questions 9 & 10. These questions provide
valuable data for a Congressional Report produced by the Medicaid Payment Advisory
Commission. These questions were last asked on the OMB approved 2019 NEHRS.

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Att D – Proposed Changes to the NEHRS Instrument
Addition
9. Do you treat patients insured by Medicaid?
□1Yes

□2 No (Skip to 10)

□3 Don't know (Skip to 10)

9a. Do you accept Medicaid insurance for new patients?
□1 Yes

□2 No

□3 Don't know

10. Do you treat patients insured by Medicare?
□1Yes

□2 No (Skip to 11)

□3Don't know (Skip to 11)

10a. Do you accept Medicare insurance for new patients?
□1Yes

□2 No

□3 Don't know

Addition of Questions 16, 17 & 18
•

Questions 16, 17, and 18 are new questions about social needs often referred to as the social
determinants of health (SDOH). They provide information important to ONC about the level of
standardization in the recording of social needs data. ONC’s work1,2 in this domain covers supporting
standards development, the development of a toolkit to support the development of infrastructure to
capture SDOH-based data as well as the implementation of tools to support the secondary use of SDOH
data, such as for clinical decision support. ONC has used data and published3 on the existing question on
the NEHRS related to the recording of SDOH; however, it doesn’t provide granular enough information
on the level of standardization of such data, which is needed for secondary use of the data (e.g.,
research, public health) and for electronic exchange of the information to other health care providers.
ONC needs to know the extent to which such data is recorded in clinical notes (unstandardized) versus
in a standardized manner via a check box/button or via a coding system such as ICD-10-CM. These
questions were previously used on the American Hospital Association Annual Survey Information

1

ONC Health IT Framework for Advancing SDOH Data Use and Interoperability Blog Post https://www.healthit.gov/buzzblog/interoperability/onc-health-it-framework-for-advancing-sdoh-data-use-and-interoperability
2

Social Determinants of Health https://www.healthit.gov/topic/health-it-health-care-settings/social-determinants-health

3

Richwine C., Dustin, C., & Patel, V. (August 2022). Electronic Public Health Reporting & Recording of Social & Behavioral
Determinants of Health Among Office-Based Physicians, 2019. ONC Data Brief, no.60. Office of the National Coordinator for
Health Information Technology: Washington DC. https://www.healthit.gov/data/data-briefs/electronic-public-healthreporting-recording-social-behavioral-determinants-health

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Att D – Proposed Changes to the NEHRS Instrument
Technology Supplement survey4. We have modified the questions so that they are applicable for the
outpatient and office-based settings of NEHRS or to improve clarity. Question 18 includes a new
response option that is relevant to our audience. We are leveraging these questions for the NEHRS to
apply it to a nationally representative sample of physicians.
2020 & 2021 American Hospital Association Information Technology Supplement Survey version

Proposed Additions

4

2020 American Hospital Association Annual Survey Information Technology Supplement: Public health and COVID-19
Focus. https://www.ahadata.com/system/files/media/file/2021/12/2020_AHAIT_Survey-Dec092021_0.pdf

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Att D – Proposed Changes to the NEHRS Instrument

Addition of Questions 22 & 22a
•

In light of the 2019 novel coronavirus disease (COVID-19) pandemic data on public health reporting was
useful in understanding the exchange of information. NEHRS is one of the only data collections with
data on this topic pre-pandemic. ONC has published5 and presented on these findings in various
national meetings such as AcademyHealth and the American Medical Informatics Association (AMIA)
and provided briefings with the Centers for Disease Control and Prevention (CDC). We are planning to
add this question back to the survey so we can assess changes in electronic public health reporting
levels across physicians prior to the pandemic. We have placed it with the interoperability send and
receive questions as it was originally presented so that the same context is presented to the
respondents. It was last asked in the OMB approved 2019 NEHRS; we are not revising the question or
responses except to update the skip pattern instructions as appropriate.

2019 NEHRS version

Proposed Addition

Addition of Questions 28 & 29
•

We have added questions that relate to the method used to access electronic health information from
outside sources because ONC needs to better understand the degree to which information is available
within the EHR as structured, standardized data versus available outside the EHR or as a scanned

5

Richwine C., Dustin, C., & Patel, V. (August 2022). Electronic Public Health Reporting & Recording of Social & Behavioral
Determinants of Health Among Office-Based Physicians, 2019. ONC Data Brief, no.60. Office of the National Coordinator for
Health Information Technology: Washington DC. https://www.healthit.gov/data/data-briefs/electronic-public-healthreporting-recording-social-behavioral-determinants-health

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Att D – Proposed Changes to the NEHRS Instrument
document. ONC’s work on improving interoperability focuses on the electronic exchange of information
used structured or standardized formats. ONC curates6,7 the United States Core Data for
Interoperability (USCDI), a standardized set of health data classes and constituent data elements for
nationwide, interoperable health information exchange, and incorporates the exchange of data using
USCDI into certified EHR technology. ONC also wants to better understand the extent to which
physicians encounter issues when trying to make use of information received from outside sources, to
identify key barriers that physicians may be facing and to develop technical or policy solutions to
address those barriers. The questions below are new and come from the American Board of Family
Medicine physician survey (which are limited to family physicians). The American Board of Family
Physicians survey preliminary analyses of over 2,000 respondents indicates that the level of “don’t
know” responses range from 2-8% for the methods items (scanned, electronic portal vs. integrated
information in EHR). Placing them in the NEHRS would allow ONC to better understand the extent to
which data is available as structured data within EHRs for specialists as well as for primary care
physicians.
American Board of Family Physicians Survey version

6

United States Core Data for Interoperability (USCDI) https://www.healthit.gov/isa/united-states-core-datainteroperability-uscdi
7
Thinking Outside the Box: The USCDI+ Initiative Blog Post https://www.healthit.gov/buzz-blog/health-it/thinking-outsidethe-box-the-uscdi-initiative

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Att D – Proposed Changes to the NEHRS Instrument
Proposed Addition

Addition of Questions 30 & 31
•

These questions were initially asked in the OMB approved 2019 NEHRS. We are adding them back with
no modifications.

2019 NEHRS version

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Att D – Proposed Changes to the NEHRS Instrument
Proposed Additions

Addition of Question 32
•

This question comes from the 2020 and 2021 American Hospital Associations’ IT Supplement Survey8.
Examining the level of automation in public health reporting is important to ONC and CDC’s efforts to
increase electronic public health reporting and reduce provider burden involved in doing so. Electronic
reporting may involve some manual processes (depending upon the level of standardization of the data and
workflow processes) and thus we are asking this additional question. This will allow us to report on the
extent to which physicians who are engaging in electronic public health reporting (based upon the earlier
question) is conducted using fully or primarily automated process (vs. mix or manual processes). Based
upon analyses of the 2020 data, about 1-5% of those who electronically reported indicated “don’t know,”
across the different reporting types and 1-3% missing rates across the different types of public health
reporting.
2020 & 2021 American Hospital Association Information Technology Supplement Survey version

8

2020 American Hospital Association Annual Survey Information Technology Supplement: Public health and COVID-19
Focus. https://www.ahadata.com/system/files/media/file/2021/12/2020_AHAIT_Survey-Dec092021_0.pdf

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Att D – Proposed Changes to the NEHRS Instrument
Proposed Addition

14