Hospital Induction Form

8-27-12

Attachment A:
2013 NHAMCS Hospital Induction Form

OMB No. 0920-0278; Exp. Date: 12/31/2014
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).
Notice – Public reporting burden for this collection of information is estimated to average 90 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).

INTRO_APPT

Text:

Hello,
This is ... from the U.S. Census Bureau.
I'm (calling/visiting) to let you know that this hospital will be included in our study. I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?

NAMECHEK

Text:

Let me verify that I have the correct name and address for your hospital. Is the correct name (facility name)?

1.

Yes

2.

No

HSP_NAME

Text:

What is your hospital's name?

1.

Enter 1 to update information

2.

Continue

ADDCHEK

Text:

Is your hospital located at (Facility Address)

1.

Yes

2.

No

HSP_ADDRESS

Text:

What is the correct address?

MAILADD

Text:

Is this also the mailing address? (Facility Address)

1.

Yes

2.

No

MHSP_STRET

Text:

What is the correct mailing address?

INTRO_AB

Text:

(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it. The National Center for Health Statistics of the Centers for Disease Control and Prevention is (conducting an/continue its) annual study of hospital-based ambulatory care.  (Intro for the survey) Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study.  First, concerning licensing:

LICHOSP

Text:

Is this facility a licensed hospital?

1.

Yes

2.

No

OWN101

Text:

Is this hospital nonprofit, government, or proprietary?

1.

Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)

2.

State or local government (includes state, county, city, city-county, hospital district or authority)

3.

Proprietary (includes individually or privately owned, partnership or corporation)

OWNHCC

Text:

Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?

1.

Yes

2.

No

3.

Unknown

TEACHOSP

Text:

Is this a teaching hospital?

1.

Yes

2.

No

MERGER

Text:

Did this hospital either merge or separate from any OTHER hospital in the past 2 years?

1.

Merged or separated

2.

No

3.

Unknown

MERSEP

Text:

Was this a merger or a separation?

1.

Merger

2.

Separation

MERGMEDR

Text:

Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?

1.

Yes

2.

No

3.

Unknown

OTHNAME

Text:

What is the name and address of this OTHER hospital?

ESA24

Text:

Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?

1.

Yes

2.

No

ESANOT24

Text:

Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?

1.

Yes

2.

No

TRAUMA

Text:

What is the trauma level rating of this hospital?

1.

Level I

2.

Level II

3.

Level III

4.

Level IV

5.

Level V

6.

Other/unknown

7.

None

OOOPD

Text:

Does this hospital operate an organized outpatient department either at this hospital or elsewhere?

1.

Yes

2.

No

PHYSSERV

Text:

Does this OPD include physician services?

1.

Yes

2.

No

AMBSURG

Text:

Does this hospital have locations that perform ambulatory surgery?
Ambulatory surgery locations include a general or main operating room, dedicated ambulatory surgery room, satellite operating room, cystoscopy room, endoscopy room, cardiac catheterization lab, laser procedures room, or a pain block room.

1.

Yes

2.

No

3.

Unknown

STUDY_DESC

Text:

Thank you.  
       Explain the following ONLY if this is a new hospital.  Provide the administrator or other hospital representative with a brief description of the study.  Cover the following points
Now I would like to provide you with further information on the study.
        (1)    NHAMCS is the only source of national data on health care provided in hospital emergency and outpatient departments and ambulatory surgery centers.
        (2)    NHAMCS is endorsed by the: 
                       American College of Emergency Physicians
                       Emergency Nurses Association
                       Society for Academic Emergency Medicine
                       American College of Osteopathic Emergency Physicians
                       Federation of American Hospitals        
                       Ambulatory Surgery Center Association
                       American College of Surgeons
                       American Health Information Management Association
                       American Academy of Ophthalmology
                       Society for Ambulatory Anesthesia
         (3)  Nationwide sample of about 600 hospitals and 246 freestanding ambulatory surgery centers.
         (4)  Four-week data collection period
         (5) Brief form completed for a sample of patient visits.
As one of the hospitals that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory care.

INDUCTION_APPT

Text:

I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?  
            Record day, date and time of appointment
            Enter 999 if the respondent wants to continue with the induction now

SCREENER_THK

Text:

Thank you for your cooperation.  I am looking forward to our meeting.

THANK_MERGSEP

Text:

Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed.  I will call you back within a week and let you know which parts of your hospital will be in the survey.  Thank you for your cooperation. 

CALLRO_MERGSEP

Text:

   Call your RO and inform them of the situation.
     Await resolution from the RO before continuing with this case.

THANK_B1

Text:

Thank you, but it seems that our information is incorrect.
Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.

THANK_B2

Text:

Thank you, but it seems that our information is incorrect.
Since (facility name) does not have 24-hour emergency services, outpatient clinics, or ambulatory surgery centers, it should not have been chosen for our study.  Thank you very much for your cooperation.

REVIEW

Text:

I would like to begin with a brief review of the background for this study.
   Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures.

SURGDAY

Text:

Now I would like to ask you a few more questions about your hospital.
How many days in a week are inpatient elective surgeries scheduled?
 

BEDCZAR

Text:

Does your hospital have a bed coordinator, sometimes referred to as a bed czar?

1.

Yes

2.

No

3.

Unknown

BEDDATA

Text:

How often are hospital bed census data available?

1.

Instantaneously

2.

Every 4 hours

3.

Every 8 hours

4.

Every 12 hours

5.

Every 24 hours

6.

Other

7.

Unknown

HLIST

Text:

Does your hospital have hospitalists on staff?
A hospitalist is a physician whose primary professional focus is the general care of hospitalized patients.  He/she may oversee ED patients being admitted to the hospital.

1.

Yes

2.

No

3.

Unknown

HLISTED

Text:

Do the hospitalists on staff at your hospital admit patients from your ED?

1.

Yes

2.

No

3.

Unknown

EMEDRES

Text:

Does this hospital have an emergency medicine residence program?

1.

Yes

2.

No

3.

Unknown

MUINC

Text:

Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?

1. Yes, we already applied

2. Yes, we intend to apply

3. Uncertain if we will apply

4. No, we will not apply

MUYEAR

Text:

When did you first apply?

1.

2011

2.

3.

2012

2013

4.

2014 or later

5.

Unknown

PERMPART

Text:

As I mentioned earlier, I would like to discuss the plan for conducting the study.  This hospital has been assigned to a 4-week data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for the study. Are there any additional steps needed to obtain permission for the hospital to participate in the study?

1.

Yes

2.

No

PERMPARTSPEC

Text:

  Specify the necessary steps needed to obtain permission for the hospital
to participate in the study.    Include the name, address, phone and title of the person(s) who can grant approval

PERM_THANK

Text:

Thank you for your help.

RO_PERMISSION

Text:

  Call the Regional Office to inform them of the additional steps needed to
    obtain permission

VSREPPER

Text:

Now I would like to make arrangements to obtain the information needed for sampling. I will need to (know/verify) how your (emergency department and/or outpatient department and/or ambulatory surgery location) (is/are) organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period.  Would you prefer I (get/verify) this information from you or someone else?

1.

Respondent

2.

Someone else

CWHO

Text:

What is the name of the person I should talk to?

1.

Existing Contact

2.

New Contact

3.

Continue interview

CINFO

Text:

What is the name of the person I should talk to?

1.

New contact

2.

Continue interview

THANK_RESP

Text:

       Thank current respondent for his/her time and cooperation

CONTACT_DEPT

Text:

• All eligible departments are complete.

Department    Status
ED      (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
OPD   (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
ASL    (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)

1.

ED

2.

OPD

3.

ASL

4.

Department refusal

5.

Department callback

9.

Wrap up case

INTRO_ED

Text:

       If necessary, introduce yourself and explain the survey
       Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department

ESA_NAME

Text:

(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?)

ESA_TYPE

Text:

What type of ESA is (ESA name)

1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other

ESA_EVISITS

Text:

What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?

TWICELY

Text:

  Is the number of expected visits to any of the ESAs more than twice the
    number shown on the previous sampling plan?
                   ESA            Visits       Visits Previous
        ESA_NAME       ESA_VISITS  I_ESA_VISITS

1.

Yes

2.

No

TWICELY_SPEC

Text:

  Specify why visits have increased this year or were too low the last time
    the ED participated

HALFLY

Text:

  Is the number of expected visits to any of the ESAs less than half of the
    number of visits shown on the previous sampling plan?
               ESA          Visits        Visits Previous
        ESA_NAME     ESA_VISITS    I_ESA_VISITS

1.

Yes

2.

No

HALFLYSPEC

Text:

   Specify why visits have decreased this year or were too high the last 
      time the ED participated

EBILLRECE

Text:

Now I would like to ask you some questions about your ED.

 If ESAs within the ED vary with respect to their use of the EHR/EMR systems, then ask these questions of the ESA with the largest number of expected visits during the reporting period.
Does your ED submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSE

Now I would like to ask you some questions about your ED.

 If ESAs within the ED vary with respect to their use of the EHR/EMR systems, then ask these questions of the ESA with the largest number of expected visits during the reporting period.

Text:

Does your ED verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWE

Text:

How does your ED electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTE

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the ED?

1.

Yes

2.

No

3.

Unknown

EMEDRECE

Text:

Does your ED use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRE

Text:

In which year did your ED install the EMR/EHR system?

HHSMUE

Text:

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

1.

Yes, all electronic

2.

No

3.

Unknown

EHRNAME13

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Amazing Charts

3.

Athenahealth

4.

Cerner

5.

eClinicalWorks

6.

e-MDs

7.

Epic

8.

GE/Centricity

9.

Greenway Medical

10.

McKesson/Practice Partner

11.

Practice Fusion

12.

NextGen

13.

Sage

14.

Other - Specify

15.

Unknown

EHRNAME13_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSE

Text:

Does your ED have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGE

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTE

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALE

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEE

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESE

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGE

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEE

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPE

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOE/ EHRWHOE

Text:

At your ED, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?          Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNE

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDE

Text:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSE

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEE

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERE

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOE

Text:

At your ED, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTE

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for: Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHE

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESE

Text:

Indicate whether your ED has each of the following computerized capabilities Does your ED have a computerized system for: Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCE

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTEDUE

Text:

Identifying education resources for specific patient conditions? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQME

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTE

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGE

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPE

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUME

Text:

Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGE

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOE

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTRECE

Text:

Providing patients the ability to view online, download or transmit information from their medical record?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDIDE

Text:

Reconciling lists of patient’s medications to identify the most accurate list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUME/ESHAREE

Text:

Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1E/ESHAREHOWE

Text:

How do you electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESE

Text:

Please indicate whether your ED electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPE

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

PTPROBE

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTE

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTE

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

EDPRIM

Text:

When patients with identified primary care physicians arrive at the Emergency Department, how often do you electronically send notification to the patients' primary care physicians?

1.

Always

2.

Sometimes

3.

Rarely

4.

Never

5.

Do not know

EDINFO

Text:

When patients arrive at the Emergency Department, are you able to query for patients' healthcare information electronically (e.g. medications, allergies) from outside sources?

1.

Yes

2.

No

3.

Do not know

OBSUNITS

Text:

Does your ED have an physically separate observation or clinical decision unit?

1.

Yes

2.

No

3.

Unknown

OBSSEP

Text:

Does your ED have an observation or clinical decision unit?

1.

Yes

2.

No

3.

Unknown

OBSDECMD

Text:

What type of physicians make decisions for patients in this observation or clinical decision unit?
    Enter all that apply, separate with commas

1.

ED physicians

2.

Hospitalists

3.

Other physicians

4.

Unknown

BOARD

Text:

Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?

1.

Yes

2.

No

3.

Unknown

BOARDHOS

Text:

If the ED is critically overloaded, are admitted ED patients ever "boarded" in inpatient hallways or in another space outside the ED?

1.

Yes

2.

No

3.

Unknown

AMBDIV

Text:

Did your ED go on ambulance diversion in TOTHRDIV_FILL?

1.

Yes

2.

No

3.

Unknown

TOTHRDIV

Text:

What is the total number of hours that your hospital's ED was on ambulance diversion in TOTHRDIV_FILL?
     Enter CTRL-D if data not available

REGDIV

Text:

Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?

1.

Yes

2.

No

3.

Unknown

ADMDIV

Text:

Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?

1.

Yes

2.

No

3.

Unknown

NUMSTATX

Text:

As of last week, how many standard treatment spaces did your ED have?
Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs.
              Enter CTRL-D if data not available

NUMOTHTX

Text:

As of last week, how many other treatment spaces did your ED have?
Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times.
            Enter CTRL-D if data not available

EDSPACES

Text:

In the last two years, did your ED increase the number of standard treatment spaces?

1.

Yes

2.

No

3.

Unknown

PHYSSPACE

Text:

In the last two years, did your ED's physical space expand?

1.

Yes

2.

No

3.

Unknown

EXPAND

Text:

Do you have plans to expand your ED's physical space within the next two years?

1.

Yes

2.

No

3.

Unknown

BEDREG

Text:

Does your ED use -   Bedside registration?

1.

Yes

2.

No

3.

Unknown

KIOSELCHK

Text:

Does your ED use -   Kiosk self check-in?

1.

Yes

2.

No

3.

Unknown

IMBED

Text:

Does your ED use -   Immediate bedding (no triage when ED is not at capacity)?

1.

Yes

2.

No

3.

Unknown

ADVTRIAG

Text:

Does your ED use -   Advanced triage (triage-based care) protocols?

1.

Yes

2.

No

3.

Unknown

PHYSPRACTRIA

Text:

Does your ED use -   Physician/Practitioner at triage?

1.

Yes

2.

No

3.

Unknown

CATRIAGE

Text:

Does your ED use -   Computer-assisted triage?

1.

Yes

2.

No

3.

Unknown

FASTTRAK

Text:

Does your ED use -   Separate fast track unit for nonurgent care?

1.

Yes

2.

No

3.

Unknown

EDPTOR

Text:

Does your ED use -   Separate operating room dedicated to ED patients?

1.

Yes

2.

No

3.

Unknown

DASHBORD

Text:

Does your ED use -   Electronic dashboard (i.e., displays updated patient information and integrates multiple data sources)?

1.

Yes

2.

No

3.

Unknown

RFID

Text:

Does your ED use -   Radio frequency identification (RFID) tracking (i.e., shows exact location of patients, caregivers, and equipment)?

1.

Yes

2.

No

3.

Unknown

WIRELESS

Text:

Does your ED use -   Wireless communication devices by providers?

1.

Yes

2.

No

3.

Unknown

ZONENURS

Text:

Does your ED use -   Zone nursing (i.e., all of a nurse's patients are located in one area)?

1.

Yes

2.

No

3.

Unknown

POOLNURS

Text:

Does your ED use -   Pool nurses (i.e., nurses that can be pulled to the ED to respond to surges in demand)?

1.

Yes

2.

No

3.

Unknown

ESA_NAME

Text:

*** SHOW ONLY **

ESA_TYPE

Text:

** SHOW ONLY **

1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other

ESA_EVISITS

Text:

** SHOW ONLY **

ESA_ONSITE

Text:

  Is (ESA name) on-site?

1.

Yes

2.

No

ESA_STRET

Text:

What is (ESA name)'s address?

ESA_PHONE

Text:

What is (ESA name)'s telephone number?

ESA_CONTACT

Text:

  Enter ESA contact person's name       

INTRO_OPD

Text:

  If necessary, introduce yourself and explain the survey
  Explain that in order to develop a sampling plan, you would like to collect
    more specific information about this hospital's outpatient department

CLIN_NAME

Text:

(What is the name of the (first/next) clinic? /Are there any other clinics?)
             Enter 999 for no more. Enter XXX if clinic is not listed

CLIN_GROUP

Text:

What is (Clinic Name)'s specialty group?

1.

General Medicine

2.

Surgery

3.

Pediatrics

4.

Obstetrics/Gynecology

5.

Substance Abuse

6.

Other

7.

Out of scope

CLIN_EVISITS

Text:

What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (Clinic Name)?

MORECLINSPEC

Text:

  List clinics that have opened or should have been included previously

TWICECLINSPEC

Text:

  Explain why visits have increased this year or were too low previously

LESSCLINSPEC

Text:

  There are fewer clinics this year than in previous panel
     Specify which clinics have closed or should not have been included previously

HALFCLINSPEC

Text:

  Specify why visits have decreased this year or were too high last year

EBILLRECO

Text:

Now I would like to ask you some questions about your OPD.

 If clinics within the OPD vary with respect to their use of the EHR/EMR systems, then ask these questions of the clinic with the largest number of expected visits during the reporting period.
Does your OPD submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSO

Text:

Does your OPD verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWO

Text:

How does your OPD electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTO

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the OPD?

1.

Yes

2.

No

3.

Unknown

EMEDRECO

Text:

Does your OPD use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRO

Text:

In which year did your OPD install the EMR/EHR system?

HHSMUO

Text:

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

1.

Yes, all electronic

2.

No

3.

Unknown

EHRNAMO13

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Amazing Charts

3.

Athenahealth

4.

Cerner

5.

eClinicalWorks

6.

e-MDs

7.

Epic

8.

GE/Centricity

9.

Greenway Medical

10.

McKesson/Practice Partner

11.

Practice Fusion

12.

NextGen

13.

Sage

14.

Other - Specify

15.

Unknown

EHRNAMO13_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSO

Text:

Does your OPD have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTO

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALO

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEO

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESO

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGO

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEO

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPO

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOO/ EHRWHOO

Text:

At your OPD, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNO

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSO

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEO

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERO

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOO

Text:

At your OPD, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHO

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCO

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTEDUO

Text:

Indicate whether your OPD has each of the following computerized capabilities Does your OPD have a computerized system for: Identifying education resources for specific patient conditions? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQMO

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTO

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGO

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPO

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUMO

Text:

Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGO

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOO

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTRECO

Text:

Providing patients the ability to view online, download or transmit information from their medical record?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDIDO

Text:

Reconciling lists of patient’s medications to identify the most accurate list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUMO/ESHAREO

Text:

Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1O/ESHAREHOWO

Text:

How do you electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESO

Text:

Please indicate whether your OPD electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPO

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

PTPROBO

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTO

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTO

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

REFOUTO

Text:

Do you refer any patients to providers outside of your office group?

1.

Yes

2.

No

REFOUTRO

Text:

Do you receive a report back from the other provider with results of the consultation?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

REFOUTEO

Text:

Do you receive it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

REFINO

Text:

Do you see any patients referred to you by providers outside of your office group?

1.

Yes

2.

No

REFINRO

Text:

Do you receive notification of both the patient’s history and reason for consultation?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

REFINEO

Text:

Do you receive it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

INPTCAREO

Text:

Do you see any patients referred to you by providers outside of your office group?

1.

Yes

2.

No

INPTCARERO

Text:

Do you receive notification of both the patient’s history and reason for consultation?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

INPTCARETO

Text:

Is the information available when needed?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

INPTCAREEO

Text:

Do you receive it electronically (not fax)?

1.

Yes, routinely

2.

Yes, but not routinely

3.

No

CLIN_NAME

Text:

*** SHOW ONLY **

CLIN_GROUP

Text:

** SHOW ONLY **

1.

General Medicine

2.

Surgery

3.

Pediatrics

4.

Obstetrics/Gynecology

5.

Substance Abuse

6.

Other

7.

Out of scope

CLIN_EVISITS

Text:

** SHOW ONLY **

CLIN_STRET

Text:

What is (Clinic Name)'s address?
    Enter number and street.

CLIN_CONTACT

Text:

  Enter clinic director/contact person's name       

TE

Text:

** NOT DISPLAYED **

RS

Text:

** NOT DISPLAYED **

AU_TYPE

Text:

** NON_DISPLAYED **

TOT_GOODCLIN

Text:

** NOT Displayed **

ASL_INTRO

Text:

To develop the sampling plan, I would like to (collect/verify) more specific information about this facility's ambulatory surgery (centers/locations).
We are interested in the following types of (centers/locations):
General or main operating rooms                 Endoscopy rooms
Dedicated ambulatory surgery rooms          Cardiac catheterization labs
Satellite operating rooms                               Laser procedures rooms
Cystoscopy rooms                                           Pain block rooms

1.

Continue

2.

No in-scope locations

ASL_NUM

Text:

** SHOW ONLY **

ASL_NAME

Text:

( What is the name of the (first/next) ambulatory surgery location? /Are there any other ambulatory surgery locations?)
       Enter only IN_SCOPE (ASCs/ASLs)   (Press F1 for in-scope (centers/locations)).  Include any (ASCs/ASLs) that are located in satellite facilities

ASL_SPEC_GRP

Text:

What is ASL Name's specialty group?

1.

General

2.

Multi-specialty

3.

Gastroenterology

4.

Ophthalmology

5.

Orthopedics

6.

Pain Block

7.

Plastic Surgery

8.

Urology

9.

Other specialty

ASL_EVISITS

Text:

What is the expected number of ambulatory (outpatient) surgery cases for ASL Name from (Reporting period begin date) to (Reporting period end date)?

I_ASL

Text:

** Not Displayed **

TOT_GOODASL

Text:

** NOT Displayed **

ANYMORE_ASLS

Text:

  The max of 15 (ASCs/ASLs) were entered. Are there any more (ASCs/ASLs)?

1.

Yes

2.

No

EXTRA_ASLS

Text:

  How many other (ASCs/ASLs) are there?

TOT_GOODASL2

Text:

** NOT Displayed **

CHECK_EVISITS

Text:

You have indicated that none of your ambulatory surgery (centers/locations) will be seeing patients from (Reporting period begin date) to (Reporting period end date).
Is that correct?

1.

Yes

2.

No

THANK_INELIG

Text:

Since there are no in-scope ambulatory surgery (centers/locations) for (facility name), it should not have been chosen for our survey. Thank you very much for your cooperation.

ASCLISTA

Text:

Now I have some questions about generating a report for all ambulatory surgery patients for sampling. Would you or your IT staff be able to generate a single list of ambulatory surgery cases for any of the following (centers/locations)? 
(Name of all ASLs)

1.

Yes

2.

No - ONLY 2 LOGS

3.

No - More than 2 logs

ASCLISTB

Text:

For which of these (centers/locations) can lists be combined? 
        Enter all that apply, separate with commas

1.

ASL_NAME [1]

2.

ASL_NAME [2]

3.

ASL_NAME [3]

4.

ASL_NAME [4]

5.

ASL_NAME [5]

6.

ASL_NAME [6]

7.

ASL_NAME [7]

8.

ASL_NAME [8]

9.

ASL_NAME [9]

10.

ASL_NAME [10]

11.

ASL_NAME [11]

12.

ASL_NAME [12]

13.

ASL_NAME [13]

14.

ASL_NAME [14]

15.

ASL_NAME [15]

IT_CNAME

Text:

What is the name of the IT contact?

IT_CTITLE

Text:

What is (IT contact name)'s title?

IT_CSTRET

Text:

What is (IT contact name)'s address?
         Enter number and street or press enter if same

AU_NUMBER

Text:

  Assign AU number
    Assign the same AU number to each (center/location) where the ambulatory surgery cases can be combined into the one listing.

EBILLRECA

Text:

Now I would like to ask you some questions about your ASC.

Does your ASL submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSA

Text:

Now I would like to ask you some questions about your ASC.

Does your ASL verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWA

Text:

How does your ASL electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTA

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the ASL?

1.

Yes

2.

No

3.

Unknown

EMEDRECA

Text:

Does your ASL use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRA

Text:

In which year did your ASL install the EMR/EHR system?

HHSMUA

Text:

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

1.

Yes, all electronic

2.

No

3.

Unknown

EHRNAMA13

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Amazing Charts

3.

Athenahealth

4.

Cerner

5.

eClinicalWorks

6.

e-MDs

7.

Epic

8.

GE/Centricity

9.

Greenway Medical

10.

McKesson/Practice Partner

11.

Practice Fusion

12.

NextGen

13.

Sage

14.

Other - Specify

15.

Unknown

EHRNAMA13_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSA

Text:

Does your ASL have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTA

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALA

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEA

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESA

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGA

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEA

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPA

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOA/ EHRWHOA

Text:

At your ASL, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?          Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNA

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSA

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEA

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERA

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOA

Text:

At your ASL, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHA

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTEDUA

Text:

Indicate whether your ASL has each of the following computerized capabilities Does your ASL have a computerized system for: Identifying education resources for specific patient conditions? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCA

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQMA

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTA

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGA

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPA

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUMA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:
   Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGA

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOA

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPTRECA

Text:

Providing patients the ability to view online, download or transmit information from their medical record?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDIDA

Text:

Reconciling lists of patient’s medications to identify the most accurate list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUMA/ESHAREA

Text:

Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1A/ESHAREHOWA

Text:

How do you electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESA

Text:

Please indicate whether your ASL electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPA

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

PTPROBA

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTA

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTA

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which you are affiliated

2.

Other departments inside your hospital

3.

Hospitals with which you are not affiliated

4.

Ambulatory providers outside your hospital

ASL_ONSITE

Text:

  Is [ASL Name] on-site?

1.

Yes

2.

No

ASL_STRET

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
            Enter number and street.

ASL_STRET2

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
           Enter the second line of address or press enter if same/none

ASL_CITY

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
          Enter city.

ASL_STATE

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
          Enter state.

ASL_ZIP

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
         Enter zip code.

ASL_PHONE

Text:

What is [ASL Name's] telephone number or the telephone number where the abstractions will be done?

ASL_CONTACT

Text:

  Enter ambulatory surgery (center/location) contact person's name       

EXIT_REFUSAL

Text:

  Are you exiting this case because of a refusal?

1.

Yes

2.

No

CALLBACKNOTES

Text:

I'd like to schedule a DATE to (conduct/complete) the interview.
What DATE AND TIME would be best to visit again?
           Today is:  ^IntDate                        

THANKCB

Text:

Thank you. I will call/come back at the time suggested
      Revisit   (Callback information)

FOLLOW_UP

Text:

  The following departments have refused. Do you plan to follow-up on these department(s)?

1.

Yes, will follow-up on department(s)

2.

No , wrap case up

CALLBACKNOTES

Text:

I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?    Today is:  ^IntDate                       

THANKCB

Text:

Thank you. I will call/come back at the time suggested   Revisit   (Callback information)

THANKYOU

Text:

This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.

ELIGED

Text:

  Does this hospital have an eligible ED?

1.

Yes

2.

No

VSED101

Text:

  Enter number of expected visits for the ED

VSEDLY

Text:

  Enter the number of visits to the department last year

ELIGOPD

Text:

  Does this hospital have an eligible OPD?

1.

Yes

2.

No

VSOPD101

Text:

  Enter number of expected visits for this OPD.

VSOPDLY

Text:

  Enter number of OPD visits last year

ELIGASC

Text:

  Does this hospital have an eligible ambulatory surgery center?

1.

Yes

2.

No

VSASC101

Text:

  Enter number of expected visits

VSASCLY

Text:

  Enter number of ambulatory surgery visits last year

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