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OMB No. 0920-0234: Expiration date 07/31/2012 NOTICE - Public reporting burden of this collection of information is estimated to average 20 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 (0920-0234). Assurance of Confidentiality - All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). 1. Physican’s address: NAMCS-1 FORM (11-19-2010) U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU ACTING AS DATA COLLECTION AGENT FOR THE RECORD ON CONTROL CARD NATIONAL CENTER FOR HEALTH STATISTICS CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL AMBULATORY MEDICAL CARE SURVEY 2011 PANEL 2. Physician’s telephone and FAX numbers (Area code and number) Office 1 Telephone RECORD ON CONTROL CARD FAX RECORD ON CONTROL CARD Office Telephone 2 FAX RECORD ON CONTROL CARD RECORD ON CONTROL CARD 3. Progress Record Activity Date Completed FR Code Notes Telephone Screener Induction Interview Patient Record Forms Completed Final Disposition and Summary Section I – TELEPHONE SCREENER 4. Record of telephone calls Call Date Time Results 1 2 3 4 5 6 7 8 9 USCENSUSBUREAU RECORD ON CONTROL CARD FR INSTRUCTION If interview is with a CHC provider, start with Section II on page 7, but remember to complete the office hours on page 5. If CHC provider refuses to complete the survey, obtain answers to item 13 in Section I, on page 6. 5a. Has the physician moved out of the United States? 1 2 Yes – SKIP to CHECK ITEM A on page 6 No b. Is the physician retired or deceased? 1 2 Yes – SKIP to CHECK ITEM A on page 6 No 6. Introduction Hello, Dr. . . ., I am (Your name). I’m calling for the Centers for Disease Control and Prevention regarding their study of ambulatory care. You should have received a letter from the Director of the National Center for Health Statistics, explaining the study. (Pause) You’ve probably also received a letter from the Census Bureau. We are acting as data collection agents for the study. IF DOCTOR DOES NOT REMEMBER NCHS LETTER; THE LETTER STATES: The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the National Ambulatory Medical Care Survey (NAMCS). This annual study, which has been in the field since 1973, collects information about the large portion of ambulatory care provided by physicians and mid-level providers throughout the United States. Research utilizing the NAMCS helps to inform physicians, health care researchers, and policy makers about the changing characteristics of ambulatory health care in this country. The information that will be requested includes data about the patient visit (e.g., demographics, diagnoses, services, and treatments), physician practice characteristics (e.g., practice type), and the use of electronic medical records. Many organizations and leaders in the health care community, including those providing the enclosed letter of endorsement, have expressed their support and join me in urging your parti­ cipation in this meaningful study. You will be asked to complete a onepage questionnaire on a sample of about 30 patient encounters during a randomly assigned one-week reporting period. Additionally, there is a short interview (approximately 30 minutes) with you about the nature of your practice. Participation is voluntary, and you or your staff may refuse to answer any question or may stop participating at any time without penalty or loss of benefits. The following are some key points about the survey: • Data collection for the NAMCS is authorized by Section 306 of the Public Health Service Act (Title 42, U.S. Code, 242k). • All information collected will be held in the strictest confidence according to Section 308(d) of the Public Health Service Act (42, U.S. Code, 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (Title 5 of PL 107-347). This information will be used for statistical purposes only. No patient names, social security numbers, or addresses are collected. • This study conforms to the Privacy Rule as mandated by HIPAA, because disclosure of patient data is permitted for public health purposes, the NCHS Research Ethics Review Board has approved NAMCS. • U.S. Census Bureau employees, who administer the study, have taken an oath to abide by Title 13, U.S. Code, Section 9, which requires them to keep all information about your practice and patients confidential. A representative of the Census Bureau, acting as our agent, will be calling you to schedule anappointment regarding the details of your participation. If you have any questions regarding your participation, please call a NAMCS representative at (800) 392–2862. Additional informa­ tion on the survey may be obtained by visiting the NAMCS participant Web site at www.cdc.gov/namcs. We greatly appreciate your cooperation. Page 2 FORM NAMCS-1 (11-19-2010) Section I – TELEPHONE SCREENER – Continued 7. Specialty a. Your specialty is _______________________________ , 1 is that right? 2 Yes – SKIP to item 7c No Edit b. What is your specialty (including general practice)? (Name of specialty) Code Refer to the NAMCS-21, pages 3 and 4 for codes. FR INSTRUCTION Do not classify cases solely on the basis of specialty. Complete all items on the NAMCS-1 and have the physician fill out PRFs if appropriate. If the physician’s specialty is listed as eligible to complete item 14, as determined in Appendix E of the NAMCS-26 Instruction Booklet, please check the "Yes" box on the front of the 2011 Patient Record folio. If physician’s specialty makes them ineligible, check "No." In both instances, please inform the physician/staff of their eligibility before leaving the office. c. What is your ethnicity? 1 2 d. What is your race? Mark (X) one or more. 1 2 3 4 5 8. Which of the following categories best describes your professional activity – patient care, research, teaching, administration, or something else? 1 2 3 4 5 9a. Do you directly care for any ambulatory patients in your work? 1 2 3 b. PROBE: We include as ambulatory patients, any patients coming to see you for personal health services who are not currently on the premises. Does your work include any such individuals? 1 2 c. Do you work as an employee or a contractor in a federally operated patient care setting or in a hospital emergency or outpatient department? 1 2 d. In addition to working in a federally patient care setting, hospital emerency or outpatient department, do you also see any ambulatory patients in another setting? FORM NAMCS-1 (11-19-2010) Edit 1 2 Hispanic or Latino Not Hispanic or Latino White Black/African-American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaska Native Patient care Research Teaching Administration Something else – Specify Yes – SKIP to item 9c No – does not give direct care [9b PROBE] No longer in practice – SKIP to item 11 on page 4 Yes, cares for ambulatory patients No, does not give direct care –Determine reason, then read item 11 on page 4 Yes No – SKIP to item 10a on page 4 Yes No – SKIP to item 11 on page 4 If "Yes" to item 9d, all of the following questions are concerned with the private patients. Page 3 Section I – TELEPHONE SCREENER – Continued 10a. We have your address as (Read address shown 1 in item 1). Is that the correct address for your office? b. What is the (correct) address and telephone 2 Yes – SKIP to item 12 No, incorrect address – Ask item 10b } Number and street number of your office? RECORD ON CONTROL CARD City RECORD ON CONTROL CARD State ZIP Code RECORD ON CONTROL CARD Telephone (Area code and number) RECORD ON CONTROL CARD 11. Thank you, Dr. . . ., but I believe that since you do not (see any ambulatory patients/practice any longer), our questions would not be appropriate for you. I appreciate your time and interest. (Go to Check Item A on page 6.) 12. I would like to arrange an appointment with you within the next week or so to discuss the study. It will take about 30 minutes. What would be a good time for you, before Friday,________________(last Friday before the assigned reporting week)? Weekday Month Day Year SKIP to item 12 Time a.m. p.m. Verify office location, if appropriate: RECORD ON CONTROL CARD Physician refused to participate –Go to the top of page 6. Thank you, Dr. . . . I’ll see you then. (Go to Check Item A on the bottom of page 6.) NOTES Page 4 FORM NAMCS-1 (11-19-2010) Section I – TELEPHONE SCREENER – Continued FR, PLEASE READ BEFORE CONTINUING FR Instruction – If you have made it to this point, it appears the physician will be cooperative. Please remember to show the physician the Data Use Agreement and remind them they need to keep this document for six years. If the physician or their staff are unwilling to complete the Patient Record forms themselves and request you to abstract the information, please remember that an Accounting Document must be placed in each of the medical records from which information has been abstracted. This document must also be kept for six years. If necessary, please show the physician the IRB approval. PROVIDER’S OFFICE SCHEDULE FR INSTRUCTION Monday Please complete the office schedule for the week the provider is in sample. Tuesday Wednesday Thursday Friday Saturday Sunday A.M. P.M. Office No. NOTES FORM NAMCS-1 (11-19-2010) Page 5 Section I – TELEPHONE SCREENER – Continued FR, PLEASE READ BEFORE CONTINUING FR Instruction – COMPLETE QUESTIONS BELOW FOR ALL IN-SCOPE PHYSICIANS WHO HAVE REFUSED TO PARTICIPATE. 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. 13a. At how many different office locations, do you see ambulatory patients? Do not include settings such as EDs, outpatient departments, surgicenters, and Federal clinincs. Number of office locations Number of weeks b. In a typical year, about how many weeks do you NOT see ambulatory patients (e.g., conferences, vacations, etc.)? c. You typically see patients fewer than half the weeks in each year. Is that correct? d. You typically see patients all 52 weeks of the year. Is that correct? 1 2 1 2 e. During your last normal week of practice, If > 26 weeks, ask item 13c. If = 0, SKIP to item 13d. If 1 to 26 weeks, SKIP to item 13e. Yes – SKIP to item 13e. No – Please explain SKIP to item 13e } Yes No – Please explain Number of patient visits how many patient visits did you have at all office locations? f. During your last normal week of practice, how many hours of direct patient care did you provide? Number of weekly hours NOTE – Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services. g. At the office location where you see the most Number of physicians ambulatory patients: (1) How many physicians are associated with you? If number of other physicians is 0, SKIP to item 13g(3). (2) Is this a single- or multi-specialty group practice? 1 (3) Are you a full- or part-owner, employee, or an independent contractor? 1 2 2 3 (4) Who owns the practice? 1 2 3 REFER TO FLASHCARD B. 4 5 6 7 Owner – Automatically mark "Physician or physician group" in item 13g(4) Employee Contractor Physician or physician group HMO Community Health Center Medical/Academic health center Other hospital Other health care corporation Other – Specify Final outcome of screening 1 Appointment MADE or Physician unavailable during reporting period –Go to Section II, page 7 2 Inscope, but REFUSED –Complete item 13, then go to Section III, page 19 3 Out-of-Scope/Other –Go to Section III, page 19 Edit ➤ CHECK ITEM A MUST BE COMPLETED BEFORE CONTINUING Page 6 ➤ CHECK ITEM A Multi-specialty practice Single-specialty practice FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW Before we begin, I would like to give you a little background about this study. Systematic information about the characteristics and problems of the people who consult providers in their offices is essential for medical researchers, educators, and others who are concerned with medical education, manpower needs, and the changing nature of health care delivery. In response to the demand for this information, the Centers for Disease Control and Prevention, in close consultation with representatives of the medical profession, developed the National Ambulatory Medical Care Survey. Your part in the study is very simple, carefully designed, 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 patients you see. Now, before we get to the actual procedures, I have some questions to ask you about your practice. The answers you give will be used only for classification and analysis. Of course, ALL information you provide for this study will be held in strict confidence. 14a. Overall, at how many office locations, do you see Number of locations ambulatory patients? Do not include settings such as EDs, outpatient departments, surgicenters, and Federal clinics. b. In a typical year, about how many weeks do you NOT see any ambulatory patients (e.g., Number of weeks If > 26 weeks ask item 14c. If = 0, SKIP to item 14d. If 1 to 26 weeks, SKIP to item 15a. conferences, vacations, etc.)? c. You typically see patients fewer than half the weeks in each year. Is that correct? d. You typically see patients all 52 weeks of the year. Is that correct? 1 2 1 2 Yes – SKIP to item 15a No – Please explain } SKIP to item 15a Yes No – Please explain 15a. This study will be concerned with the AMBULATORY patients you will see in your office(s) during the week of Monday, _______________ through Sunday,_______________. Are you likely to see any ambulatory patients in your office(s) 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, mark "Yes.") 1 2 Yes –SKIP to item 16a on page 8 No b. Why is that? Record verbatim. (If appropriate, read item 15c below and leave forms with physician. Otherwise, SKIP to item 16a on page 8.) c. Since it’s very important that we include any ambulatory patients that you might see in your office during that week, I’ll leave forms with you – just in case your plans change. I’ll check back with your office just before (Starting date) to make sure, and if necessary I can explain them in detail then. Give the doctor the folio and enter the folio number on page 17. Then continue with item 16a on page 8. FR, PLEASE READ BEFORE CONTINUING FORM NAMCS-1 (11-19-2010) FR Instruction – Even if the physician is not available during the reporting week, continue with item 16a on page 8. Page 7 Section II – INDUCTION INTERVIEW – Continued 16a. At what office 16b. Give FLASHCARD A (p. 15 Flashcard Booklet) and ask Looking at this list, choose ALL of the type(s) of settings that describe each location where you work. For each location mark all setting types that apply. For each location, also mark the appropriate "scope" status. If any even numbered settings are marked, then mark location as out-of-scope. location(s) will you see ambulatory patients during your practice’s 7-day reporting period Monday, through Sunday, __________________ ? If FLASHCARD number 3 (free-standing clinic/urgicenter) is marked, ask – Is this/that clinic in an institutional setting (#8), in an industrial outpatient facility (#10), or operated by the Federal Government (#12)? (If yes – Mark out-of-scope.) PROBE: Are there any other office locations at which you will see ambulatory patients during that 7-day reporting period? If FLASHCARD number 11 (family planning clinic) is marked, ask – Is this/that clinic operated by the Federal Government (#12)? (If yes – Mark out-of-scope.) If in doubt about any (clinic/facility/institution), PROBE – (1) Is this/that (clinic/facility/institution) part of a hospital emergency department or an outpatient department (#2, #4)? (If yes – Mark out-of-scope.) (2) Is this/that (clinic/facility/institution) operated by the Federal Government (#12)? (If yes – Mark out-of-scope.) NOTE – NON-PARTICIPATING PHYSICIANS: If refusal (Final=3) or unavailable (Final=4), record locations where ambulatory patients are normally seen. Office No. Office locations (Enter street address) 1 2 3 4 RECORD ON CONTROL CARD RECORD ON CONTROL CARD RECORD ON CONTROL CARD RECORD ON CONTROL CARD Edit Mark (X) Circle FLASHCARD number 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 9 9 9 9 10 10 10 10 Inscope 11 11 11 11 12 12 12 12 13 13 13 13 14 14 14 14 15 15 15 15 Out-of­ scope 1 2 1 2 1 2 1 2 FLASHCARD A (1) Private solo or group practice (3) Freestanding clinic/urgicenter (not part of a hospital outpatient department) (5) Community Health Center (e.g., Federally Qualified Health Center (FQHC), federally funded clinics or ‘look alike’ clinics) (7) Mental health center (9) Non-federal Government clinic (e.g., state, county, city, maternal and child health, etc.) (11) Family planning clinic (including Planned Parenthood) (13) Health maintenance organization or other prepaid practice (e.g., Kaiser Permanente) (15) Faculty Practice Plan (2) Hospital emergency department (4) Hospital outpatient department (6) Ambulatory surgicenter (8) Institutional setting (school infirmary, nursing home, prison) (10) Industrial outpatient facility (12) Federal Government operated clinic (e.g., VA, military, etc.) (14) Laser vision surgery 16c. Are there other office locations where you NORMALLY would see patients, even though you will not see any during your 7-day reporting period? Do not include settings such as EDs, outpatient departments, surgicenters, and Federal clinics. 1 2 Yes – SKIP to item 16d No – SKIP to Check Item B d. Of these locations where you will not be seeing patients during your 7-day reporting period, how many total office visits did you have during your last week of practice at these locations? CHECK ITEM B 1 2 Number of visits All locations listed in 16a are out-of-scope – Read CLOSING STATEMENT below All/Some locations listed in 16a are in-scope – Go to item 17a CLOSING Thank you, Dr. . . ., your practice is not within the scope of this study. STATEMENT We appreciate your time and interest. (Terminate interview and complete Sections III and IV on pages 19–21.) Page 8 FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW – Continued Ask item 17a ONCE to obtain total for ALL in-scope locations. 17a. During the week of Monday, ____________ through Sunday, ___________ How many days do you expect to see any ambulatory patients? (Only include days at in-scope locations.) NOTE – NON-PARTICIPATING PHYSICIANS: If refusal (Final=3) or unavailable (Final=4), enter the number of days in a normal week. Edit Estimated Number of Days Enter street name or town of in-scope location(s). Office location No. NOTE: Keep the location numbers the same as the office numbers in item 16a. RECORD ON CONTROL CARD #1 #2 #3 #4 _____ _____ _____ _____ b. During your last normal week of practice, approximately how many office visit encounters did you have at each office location? NOTE: If physician is in group practice, only include the visits to sampled physician. Edit Number of visits c. During the week of Monday, ____________ through Sunday ____________, do you expect to have about the same number of visits as you saw during your last normal week in each office taking into account time off, holidays, and conferences? Yes . . . No . . . 1 1 1 1 2 2 2 2 NOTE: Mark (X) response. If answer is "Yes", transcribe the number in 17b to 17d for that office location. If answer is "No" then ASK item 17d for that office location. d. Approximately how many ambulatory visits do you expect to have at this office location? Number of visits _____ _____ _____ _____ e. Tally of estimated number of visits NOTE: To obtain the total number of estimated visits, add the estimate for each office location in 17d. Number of visits _____ Now, I’m going to ask about your practice at (in-scope location). 18a. Do you have a solo practice, or are you associated with other physicians in a partnership, in a group practice, or in some other way (at this/that in-scope location)? Office Location #1 #2 #3 #4 Solo . . . . . . . . . . . . . 1 1 1 If Solo, SKIP to item 18d. 1 Nonsolo . . . . . . . . . . 2 2 2 2 b. How many physicians are associated with you (at this/that in-scope location)? How many c. Is this a single- or multi-specialty (group) practice (at this/that in-scope location)? FORM NAMCS-1 (11-19-2010) _____ _____ _____ _____ Multi . . . . . . . . . 1 1 1 1 Single . . . . . . . . 2 2 2 2 Page 9 Section II – INDUCTION INTERVIEW – Continued 18d. How many mid-level providers (i.e., nurse practitioners, physician assistants, and nurse midwives) are associated with you How many (at this/that in-scope location)? Are you a fullor part-owner, employee, or an e. Owner . . . . . . . . independent contractor (at this/that in-scope Employee . . . . . . location)? If "Owner" is marked then automatically Contractor . . . . . . mark "Physician or physician group" in item 18f. f. Give FLASHCARD B (p.16 Flashcard Booklet) and ask: Who owns the practice (at this/that in-scope location)? #2 #3 #4 _____ _____ _____ 1 1 1 1 2 2 2 2 3 3 3 3 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 #1 Office Location Physician or physician group . . . HMO . . . . . . . . . . Community Health Center . . . . . . . . Medical/ Academic health center . . . . Other hospital . . . Other health care corp Other . . . . . . . . . _____ g. Does your practice have the ability to perform any of the following on site (at this/that in-scope location)? 1. EKG/ECG 1 2 3 2. Lab testing 1 2 3 3. Spirometry 1 2 3 4. Ultrasound 1 2 3 5. X-Ray 1 2 3 h. Do you see patients in the office during the evening or on weekends? 1 2 3 i. What is your Federal Tax ID at each office location? Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 2 3 2 3 2 3 2 3 2 3 2 3 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 2 3 2 3 2 3 2 3 2 3 2 3 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 Yes No DK 1 2 3 2 3 2 3 2 3 2 3 2 3 Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK RECORD ON CONTROL CARD Notes Page 10 FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW – Continued 19a. During your last normal week of practice, how many hours of direct patient care did you provide? Number of weekly hours NOTE – Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services. b. During your last normal week of practice, Number of encounters per week about how many encounters of the following type did you make with patients: (1) Nursing home visits . . . . . . . . . . . . . . . . . . . (2) Other home visits . . . . . . . . . . . . . . . . . . . . . (3) Hospital visits . . . . . . . . . . . . . . . . . . . . . . . . (4) Telephone consults . . . . . . . . . . . . . . . . . . . (5) Internet/e-mail consults . . . . . . . . . . . . . . . Have provider answer items 20–27 for the in-scope location/practice with the most visits. 20. Does your practice submit any claims electronically (electronic billing)? 1 2 3 21. Do you or your staff verify an individual patient’s insurance eligibility electronically, with results returned immediately? 1 2 3 4 5 22. Does your practice use an electronic medical record (EMR) or electronic health record (EHR) system? Do not include billing record systems. 1 2 3 4 Yes No Unknown Yes, with a stand-alone practice management system Yes, with an EMR/EHR system Yes, using another electronic system No Unknown } Yes, all electronic Go to Question 22a. Yes, part paper and part electronic No Skip to Question 23. Unknown } a. In which year did your practice install your EMR/EHR system? b. What is the name of your practice’s current EMR/EHR system? Mark (X) only one box. Year 1 2 3 4 5 6 23. At your practice, are there plans for installing a new EMR/EHR system within the next 18 months? 1 2 3 4 Allscripts Cerner CHARTCARE eClinicalWorks Epic eMDs 7 8 9 10 11 GE Centricity Greenway Medical MED 3000 NextGen Sage 14 SOAPware Practice Fusion Other 15 Unknown 12 13 Yes No Maybe Unknown Notes FORM NAMCS-1 (11-19-2010) Page 11 Section II – INDUCTION INTERVIEW – Continued 24. Give FLASHCARD G (p.21 Flashcard Booklet): Please indicate whether your practice has each of the computerized capabilities listed below. Does your practice have a computerized system for: Mark (X) only one per row. Yes Yes, but turned off or not used No Unknown a. Recording patient history and demographic information? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Go to 24a(1) If Yes, ask – (1) Does this include a patient problem list? b. Recording clinical notes? . . . . . . . . . . . . . . . . . . . . . 1 c. Ordering prescriptions? . . . . . . . . . . . . . . . . . . . . . . . . 1 4 Skip to 24b 2 Skip to 24c 3 4 3 4 Skip to 24c Skip to 24c 1 2 3 4 1 2 3 4 Go to 24c(1) If Yes, ask – (1) Are prescriptions sent electronically to the pharmacy? 3 Skip to 24b 2 Go to 24b(1) If Yes, ask – (1) Do they include a comprehensive list of the patient’s medications and allergies? 2 Skip to 24b Skip to 24d Skip to 24d Skip to 24d 1 2 3 4 1 2 3 4 d. Providing reminders for guideline-based interventions or screening tests? . . . . . . . . . . . . . . . 1 2 3 4 e. Ordering lab tests? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 (2) Are warnings of drug interactions or contraindications provided? Go to 24e(1) Skip to 24f Skip to 24f Skip to 24f If Yes, ask – (1) Are orders sent electronically? 1 2 3 4 Providing standard order sets related to a particular condition or procedure? . . . . . . . . . . . . . . 1 2 3 4 g. Viewing lab results? . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 f. Go to 24g(1) Skip to 24h Skip to 24h Skip to 24h If Yes, ask – (1) Are results incorporated in EMR/EHR? 1 2 3 4 h. Viewing imaging results? . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 i. Viewing data on quality of care measures? . . . . . . . 1 2 3 4 j. Electronic reporting to immunization registries? . . 1 2 3 4 k. Public health reporting? . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Go to 24k(1) Skip to 24i 3 4 Skip to 24i Skip to 24i If Yes, ask – (1) Are notifiable diseases sent electronically? 1 2 3 4 Providing patients with clinical summaries for each visit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 m. Exchanging secure messages with patients? . . . . . 1 2 3 4 l. 25. At your practice, if orders for prescriptions or lab tests are submitted electronically, who submits them? 1 2 3 Mark all that apply. 4 Page 12 Prescribing practitioner Other Prescriptions and lab test orders not submmited electronically Unknown FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW – Continued 26. Does your practice exchange patient clinical 1 summaries electronically with any other providers? 2 3 4 5 a. How does your practice electronically send or receive 1 patient clinical summaries? 2 3 Mark all that apply. 4 5 27. Beginning in 2011, Medicare and Medicaid will offer incentives to practices that demonstrate "meaningful use of Health IT". Does your practice have plans to apply for Medicare or Medicaid incentive payments for meaningful use of Health IT? 1 2 3 a. In which year does your pactice expect to apply for 1 the meaningful use payments? 2 3 4 Yes, send summaries only Go to Yes, receive summaries only Question Yes, send and receive summaries 26a No Unknown Skip to question 27 } } Through EMR/EHR vendor Through hospital-based system Through Health Information Organization or state exchange Through secure email attachment Other/Unknown Yes, we intend to apply – Go to Question 27a Uncertain whether we Skip to will apply question 28a No, we will not apply } 2011 2012 After 2012 Unknown Give FLASHCARD C (p.17 Flashcard Booklet) and ask items 28–31 ONCE for ALL in-scope locations. I would like to ask a few questions about your practice revenue and contracts with managed care plans. Percent of patient care revenue 28a. Roughly, what percent of your patient care revenue comes from – (1) Medicare?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % (2) Medicaid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % (3) Private insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . % (4) Patient payments? . . . . . . . . . . . . . . . . . . . . . . . . . . % (5) Other? –(including charity, research, CHAMPUS, VA, etc.) % FR NOTE – Categories should sum close to 100%. Do not leave blank or use dash to indicate 0 percent, include value. b. Roughly, how many managed care contracts does this practice have such as HMOs, PPOs, IPAs, and point-of-service plans? If necessary read– Managed care includes any type of group health plan using financial incentives or specific controls to encourage utilization of specific providers associated with the plan. FR NOTE – Include Medicare managed care and Medicaid managed care, but not traditional Medicare and Medicaid. Include any private insurance managed care plans. Be sure the response is about contracts and not patients. Include all the different plans an insurance provider may have and for which the physician has a contract. For example, the physician may have a contract for each of the plans Aetna may offer: a PPO, IPA, and point-of-service plan. This would equal 3 contracts, not 1 contract. It may be necessary to obtain information from the billing office of the practice. FORM NAMCS-1 (11-19-2010) 1 2 3 4 None – SKIP to item 29 Less than 3 3 to 10 More than 10 Page 13 Section II – INDUCTION INTERVIEW – Continued Percent of revenue from c. Roughly, what percentage of the patient care managed care revenue received by this practice comes from (these) managed care contracts? Edit % 29. Give FLASHCARD D (p.18 Flashcard Booklet) and ask: Percent of patient care revenue Roughly, what percent of your patient care revenue comes from each of the following methods of payment? (1) Usual, customary and reasonable fee-for-service? % (2) Discounted fee for service?. . . . . . . . . . . . . . . . . . . . % (3) Capitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % (4) Case rates (e.g., package pricing/episode of care)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % (5) Other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % FR NOTE – Categories should sum close to 100%. Do not leave blank or use dash to indicate 0 percent, include value. 30a. Are you currently accepting "new" patients into your 3 Yes No – SKIP to item 31 Don’t know – SKIP to item 31 (a) Capitated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Yes 2 No 3 Don’t know (b) Non-capitated? . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Yes 2 No 3 Don’t know (2) Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Yes 2 No 3 Don’t know (3) Medicaid? 1 Yes 2 No 3 Don’t know (4) Workers compensation? . . . . . . . . . . . . . . . . . . . . . . 1 Yes 2 No 3 Don’t know (5) Self-pay? 1 Yes 2 No 3 Don’t know 1 Yes 2 No 3 Don’t know No 3 Don’t know practice(s) (at in-scope locations)? 1 2 b. From those "new" patients, which of the following types of payment do you accept (at in-scope locations)? (1) Private insurance – ................................. .................................. (6) No charge? ................................. 31a. Roughly, what percent of your daily visits are same day appointments? % b. Does your practice set time aside for same day appointments? c. On average, about how long does it take to get an appointment for a routine medical exam? 1 Yes 1 Within 1 week 1–2 weeks 3–4 weeks 1–2 months 3 or more months Do not provide routine medical exams Don’t know 2 3 4 5 6 7 2 CHECK ITEM C Is provider part of the community health center sample? 1 2 Page 14 Yes – Ask item 32 No – SKIP to FR Instruciton on page 15 FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW – Continued 32. Provider demographics – a. What is your year of birth? b. What is your sex? 1 9 1 2 c. Give FLASHCARD E (p.19 Flashcard Booklet) and ask: 1 2 What is your highest medical degree? 3 4 5 6 Male Female } MD Go to item 32d DO Nurse practitioner SKIP to Physician assistant FR INSTRUCTION Nurse midwife on page 15. Other } d. What is your primary specialty? Name of specialty Code Name of specialty Code e. What is your secondary specialty? f. What is your primary board certification? Board certification g. What is your secondary board certification? Board certification h. What year did you graduate medical school? Year i. Did you graduate from a foreign medical school? 1 2 FR INSTRUCTION Yes No If physician unavailable during reporting period, SKIP to item 34b on page 18. 33a. During the period Monday, ________________ through Sunday, ________________ will ANYONE be available to help you fill out the patient record forms for this study (at in-scope locations)? 1 2 Yes No – Go to Visit Sampling on page 17 FR NOTE – Explain to the physician that you would like to review some of the questions found on the patient record form. NOTES FORM NAMCS-1 (11-19-2010) Page 15 Section II – INDUCTION INTERVIEW – Continued 33b. Who will be helping you at each location? (Below enter the location and person’s name and position.) Office No. NOTE: Keep the location numbers the same as the office numbers in item 16a. Location Name (Enter street name) Position 1 RECORD ON CONTROL CARD 2 RECORD ON CONTROL CARD 3 RECORD ON CONTROL CARD 4 RECORD ON CONTROL CARD FR NOTE –Explain to the physician and to anyone helping the physician that you would like to review some of the questions found on the Patient Record form. Go to page 17. Visit Sampling To select a sample of patient visits, the physician’s office will need to know where to start sampling (Start With) and how to select subsequent patient visits (Take Every). To determine Take Every (TE) and Start With (SW) numbers follow these instructions. Read down the "Estimated visits for week" column to the line that corresponds to the total entry in ITEM 17e. Then, read across the "Days physician will see patients that week" line to the column that corresponds to the entry in ITEM 17a. Circle the appropriate number. This number is the physician’s Take Every number for all office locations. Then transcribe this number below, and onto the front of the folio, and to the Patient Visit Worksheet if it is used. TAKE EVERY NUMBER Days physician will see patients that week Estimated Visits for Week 1 2 3 4 5 6 7 0–12 . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 1 1 1 1 13–24. . . . . . . . . . . . . . . . . . . . . . . 2 1 1 1 1 1 1 25–39. . . . . . . . . . . . . . . . . . . . . . . 3 2 1 1 1 1 1 40–44. . . . . . . . . . . . . . . . . . . . . . . 4 2 2 1 1 1 1 45–49. . . . . . . . . . . . . . . . . . . . . . . 4 2 2 2 2 2 2 50–64. . . . . . . . . . . . . . . . . . . . . . . 5 3 2 2 2 2 2 65–74. . . . . . . . . . . . . . . . . . . . . . . 10 3 2 2 2 2 2 75–89. . . . . . . . . . . . . . . . . . . . . . . 10 4 3 2 2 2 2 90–104 . . . . . . . . . . . . . . . . . . . . . 10 4 3 3 3 3 3 105–114 . . . . . . . . . . . . . . . . . . . . 10 5 3 3 3 3 3 115–129 . . . . . . . . . . . . . . . . . . . . 10 5 4 3 3 3 3 130–134 . . . . . . . . . . . . . . . . . . . . 15 10 4 3 3 3 3 135–154 . . . . . . . . . . . . . . . . . . . . 15 10 4 4 4 4 4 155–174 . . . . . . . . . . . . . . . . . . . . 15 10 5 4 4 4 4 175–194 . . . . . . . . . . . . . . . . . . . . 15 10 5 5 5 5 5 195–209 . . . . . . . . . . . . . . . . . . . . 20 10 10 5 5 5 5 210–219 . . . . . . . . . . . . . . . . . . . . 20 10 10 10 5 5 5 220–254 . . . . . . . . . . . . . . . . . . . . 20 10 10 10 10 10 10 255–319 . . . . . . . . . . . . . . . . . . . . 25 15 10 10 10 10 10 320–364 . . . . . . . . . . . . . . . . . . . . 30 15 10 10 10 10 10 365+ . . . . . . . . . . . . . . . . . . . . . . . 30 30 30 30 30 30 30 Take Every Number Page 16 FORM NAMCS-1 (11-19-2010) Section II – INDUCTION INTERVIEW – Continued START WITH NUMBER To determine the Start With (SW) number read down the "If Take Every Number is" column and find the Take Every Number. The number to the right is the Start With Number. Transcribe this number onto line at the right, and to the front of the folio, and to the Patient Visit Worksheet if it is used. If the Take Every Number is: Then the Start With Number is: 1 2 3 4 5 Start With Number 10 15 20 25 30 Office number Edit Folio Number OFFICE USE ONLY Number of PRFs completed 1 2 3 4 Additional folio for Office # INSTRUCTIONS GIVE THE PHYSICIAN A FOLIO AND A COPY OF THE SAMPLE PATIENT RECORD FORM (NAMCS-73), AND EXPLAIN HOW TO COMPLETE THE FORMS. Cover the following points — (1) Who to list/who not to list on the Patient Visit Worksheet found in the back of the NAMCS-26 • List every ambulatory patient visit to all in-scope locations during the reporting period. • INCLUDE patients the physician doesn’t see but who receive care from an assistant, nurse, nurse practitioner, physician assistant, etc. • EXCLUDE patients who do not seek care or services (e.g., they come to pay a bill or leave a specimen). • EXCLUDE telephone contacts with patients. (2) Show doctor instruction card in folio pocket and go over Patient Record item by item, paying particular attention to — Item 2, Injury/Poisoning/Adverse Effect – If any part of this visit was related to an injury or poisoning or adverse effect of medical or surgical care or an adverse effect of medicinal drug, then mark the appropriate box. If this visit was not related to any of these, then mark the last option, "None of the above." Item 3, Reason for Visit – To be recorded in patient’s own words. We want the patient’s own complaint here, not the physician’s diagnosis. If the patient has no complaint, the physician should enter the reason for the visit. FORM NAMCS-1 (11-19-2010) Page 17 Section II – INDUCTION INTERVIEW – Continued INSTRUCTIONS – Continued Items 5a(1), Provider’s Primary Diagnosis for this Visit – Can be tentative or provisional or expressed as a problem. Physician should not record "Rule Out" diagnosis (R.O.). Enter any other diagnosis related to the visit (e.g., depression, obesity, asthma, etc.) in items 5a(2) and 5a(3). Items 5b, Chronic Disease Checklist – Mark all chronic diseases that the patient has, regardless of entry in item 5a. This item supplements the diagnoses reported in item 5a. If none of the conditions listed apply, then mark "None of the above." Item 6, Vital Signs – When possible, record specific values for the 4 vital signs. For height and weight, enter the value on the line next to the type or measurement system used. If height was not measured at this visit and patient is 21 years of age or over, enter the most recent height recorded. Item 8, Health Education – Mark all services ordered or provided at this visit. Item 9, Non-Medication Treatment – Mark and/or list all non-medical treatment including surgical or non-surgical procedures ordered or provided at this visit. Item 10, List medication/immunization names – Record up to 8 medications that were ordered, supplied, administered or told to continue at the visit. Include Rx and OTC medications, immunizations, allergy shots, anesthetics, chemotherapy, and dietary supplements. Use SPECIFIC BRAND OR GENERIC DRUG NAMES as entered on prescription or medical records. Do NOT enter broad drug classes such as "pain medication." Record if the medication/immunization was new or continued. Item 13, Time Spent with Provider – Best estimate of time spent in face-to-face contact with the patient and the sampled provider. The answer may be zero (0), if the patient was attended entirely by a registered nurse or technician and did not see the sampled physician/CHC provider. Item 14, Laboratory Test Results – If applicable, please make sure provider is aware of items on back of PRF and completes information about tests drawn within last 12 months. If primary medical specialty is listed in Appendix E in the NAMCS-26 Instruction Booklet, please complete checkbox on front of folio. Also, physician should complete Item 14. (3) Explain to the provider, where appropriate, that the receptionist, nurse, or assistant can list patients on the Patient Visit Worksheet as they enter the office. They may also complete items 1–4 on the Patient Record form. (4) Instruct provider to enter number of patients seen and number of PRF’s completed on front of folio – at the end of each day. 34a. CLOSING STATEMENT Thank you for your time and cooperation Dr. . . . I will call you on Monday,_____________________ to see if (everything is all right/your plans have changed). If you have any questions (Hand doctor your business card) please feel free to call me. My telephone number is also written in the folio. FR INSTRUCTIONS If applicable, complete Sections III through V before returning completed materials to office. 34b. CLOSING STATEMENT Thank you for your time and cooperation Dr. . . . The information you provided will improve the accuracy of the NAMCS in describing office-based patient care in the United States. FR INSTRUCTIONS Page 18 Complete Sections III through IV before returning completed materials to office. FORM NAMCS-1 (11-19-2010) Section III – NONINTERVIEW 35. What is the reason the provider did not participate in this study? 1 2 3 Explanations for noninterview codes 6 and 11 – 4 5 • Temporarily not practicing –Refers to duration of 3 months or more 6 • Unavailable during reporting period –Absence must be for duration of LESS than 3 months 9 7 8 10 11 Edit 36. Check all that apply to describe provider’s practice or medical activities which define him/her as ineligible or out-of-scope. 12 1 2 3 4 5 6 7 37a. At what point in the interview did the refusal/break-off occur? 1 2 (Mark (X) one.) 3 4 5 6 b. By whom? (Mark (X) one.) 1 2 3 4 5 6 Refused/Breakoff –SKIP to item 37a Non-office based SKIP to item 36 Sees no ambulatory patients Retired SKIP to item 40 on page 21 Deceased Temporarily not practicing –SKIP to item 38 on page 20 Can’t locate SKIP to item 40 on page 21 Not licensed Moved out of U.S.A. Other out-of-scope –SKIP to item 36 Unavailable during reporting period –SKIP to item 38 on page 20 Moved out of PSU –SKIP to item 39a on page 20 } } } Federally employed Radiology, anesthesiology or pathology specialist Administrator Work in institutional setting Work in hospital emergency department or outpatient department Work in industrial setting Other – Specify } SKIP to item 40 page 21 } During telephone screening Make sure item 13 has been completed During induction interview After induction but prior to assigned reporting days At reminder call During assigned reporting days or mid-week calls At follow-up contact Sampled provider Sampled provider through nurse Nurse/Secretary Receptionist Office manager/Administrator Other office staff – Specify c. What reason was given? (Verbatim) d. Date refusal/breakoff was reported to supervisor Month e. Conversion attempt result 1 2 3 FORM NAMCS-1 (11-8-2010) Day Year } No conversion attempt SKIP to item 40 on Sampled provider refused page 21 Sampled provider agreed to see Field Representative – Complete Section II Page 19 Section III – NONINTERVIEW – Continued 38. Why is provider unavailable or not in practice? } 39a. What is the provider’s new address? SKIP to item 40 on page 21 Number and street RECORD ON CONTROL CARD City, State, ZIP Code RECORD ON CONTROL CARD Telephone RECORD ON CONTROL CARD b. Name of Field Representative RO PSU Date transferred RECORD ON CONTROL CARD Continue with item 40 on page 21 NOTES Page 20 FORM NAMCS-1 (11-19-2010) Section IV – DISPOSITION AND SUMMARY 40. FINAL DISPOSITION 41. CASE SUMMARY (a) Eligible physician/provider 1 Completed Patient Record forms 2 Out-of-scope (Item 35, codes 2, 3, 4, 5, 6, 8, 9, or 10) Refused-Breakoff (Item 35, code 1) Unavailable during reporting period (Item 35, code 11) Moved out of PSU (Item 35, code 12–final) Can’t locate (Item 35 code 7) 3 4 5 6 } 1. Number of patient visits during reporting week . . . . . . ➜ 2. Number of days during reporting week on which patients were seen . . . . . . . . End of Interview –Make certain all items are accurately completed before returning materials to the office. 3. Number of patient record forms completed . . . . . . . . . . NOTE – For items 41(1) and 41(3), see FR instruction below. (b) Unused CHC NAMCS-1 7 Less than 3 providers sampled 8 Parent CHC Out-of-scope 9 Parent CHC Refused to participate (c) Transfer cases Moved out of PSU (Item 35, code 12 –pending) Edit FR, PLEASE READ BEFORE CONTINUING Edit Item 41(1) – Accurate determination of "Number of patient visits during reporting week" is EXTREMELY IMPORTANT! This count is to include any days the provider may have skipped or not participated. This information may be obtained from either the office staff or from the PRF Folio cover. Only inlcude visits to sampled provider and NOT the total number of visits to entire practice or clinic. Item 41(3) – If the number of Patient Record forms completed is less than 20 or greater than 40, then explain why in the NOTES section below. Items 17e and 41(1) – If applicable, record explanation of why items 17e and 41(1) differ significantly and any other information regarding this case which may help to understand it at a later date. Notes FORM NAMCS-1 (11-19-2010) Page 21 Section V – PATIENT RECORD FORM CHECK CHECK ITEM D 1. Who answered the questions in the Physician Induction Interview? Mark (X) all that apply. 1 Sampled provider 3 Other – Specify 2 Office staff 2. Who completed the Patient Record forms? Mark (X) all that apply. 1 Sampled provider 4 Other – Specify 2 Office staff 3 FR – abstraction 3. Did the sampled provider accept the Data Use Agreement? 1 Yes 2 No 4. If the FR abstracted the PRFs, were the Accounting Documents placed in each of the medical records used for abstraction? 1 2 Yes No – Explain 5. Did sampled provider (or staff) request to see the IRB approval? 1 2 Yes No 42. Verify that all items on the Patient Record form check list have been answered. DO NOT call the sampled provider regarding missing information on Patient Record form unless instructed by your supervisor or the FR Manual. Mark (X) when completed Field Representative check list Office check list (a) (b) a. Check for missing Patient Record forms (e.g., if the last completed Patient Record is number 1500051, do you have 1500001 through 1500050). List missing Patient Record forms in Section VI, Part I of chart. b. Item 1a – Date of visit recorded on each Patient Record form – If missing, complete 1 and 2 below. (1) Determine date of visit by referring to Patient Record forms immediately before and after. For example, if 1550087 through 1550092 are dated "1/12/2010" and the date on 1550088 is missing, enter "1/12/2010" in item 1a. (2) If the exact date of the patient visit cannot be determined, estimate the date and enter "EST" next to the entry. c. Items 1–13 –Verify that each of these items has been answered on the Patient Record form. List missing information in Section VI, Part 3 of chart on page 24. If applicable make sure item 14, laboratory values, was completed accuraterly. d. Check the sample provider’s office schedule against the dates on the Patient Record forms for survey week days with no completed Patient Record forms. Do the dates on the Patient Record forms include every day during the survey week that the sample provider’s office scheduled appointments? Yes No –List missing days in Section VI, Part 2 of chart on page 23. NOTES Page 22 FORM NAMCS-1 (11-19-2010) Section VI – MISSING INFORMATION CHART Part 1 — Missing Patient Record Forms 43a. Enter 7-digit Patient Record number(s) for missing forms. b. Contact provider regarding missing forms. Enter results of missing forms follow-up below: Forms/information obtained Forms/information not obtained – Explain why Part 2 — Missing Days or Blocks of Time c. List day(s) and blocks of time not reported, and check with the provider’s office for the reason. (If patients were seen during day(s)/hours not reported, arrange to obtain missing data. If not possible to obtain missing data, ask for the number of patients seen during day(s)/hours not reported.) Not reported Day(s) Blocks of time Reason Will physician’s office provide missing data? (Mark X) (d) (a) (b) FORM NAMCS-1 (11-19-2010) (c) Yes No Number of patients seen (e) Page 23 Part 3 — Missing Patient Record Form Items (1–13) 43d. List missing items, and refer to the FR manual for guidelines on retrieving missing information. Patient Record number Item number(s) Comments (b) (c) (a) 44. Was provider/office staff contacted for any reason during the editing process? Yes No 45. For all Final = 1 cases, transfer information from front of Patient Record Folio. FROM TO Month Day Month Day WEEK OF – SURVEY WEEK Complete a Patient Record for patient SW Mon. Tues. Wed. Thur. Fri. Sat. Sun. Total Number of patient visits and every TE nth patient thereafter. Number of records completed NOTES Page 24 FORM NAMCS-1 (11-19-2010)