NHAMCS Hospital Induction Form

ATTACHMENT H.1:
NHAMCS Hospital Induction Form

OMB No. 0920-0278; Exp. Date: ________ 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?        Enter 999 to start the induction interview
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?        Enter 1 to update the hospitals 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?         Enter 1 to update the hospitals address
MAILADD
Text:	Is this also the mailing address?       (Facility Address)
1.	Yes
2.	No
MHSP_STRET
Text:	What is the correct mailing address?           Enter the number and street or press enter if same
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 (conduct 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?   Read answer categories out loud
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?
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?           Enter name
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:	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. Does this hospital have locations that perform ambulatory surgery?
1.	Yes
2.	No
ELIGREQ
Text:	** Not displayed **
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 locations.         (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.          (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.              Press F1 for points to be covered
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?           Enter CTRL-D if unknown
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?           Read answer categories.
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 hospitals that demonstrate "meaningful use of Health IT".  Does your hospital have plans to apply for Stage 1 of 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
MUSTAGE2
Text:	Are there plans to apply for Stage 2 incentive payments?
1.	Yes
2.	No
3.	Maybe
4.	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
CINFO
Text:	What is the name of the person with whom I should speak?            Enter 1 to enter/update hospital contact information           Enter 2 to enter/update department contact information
1.	Hospital level contact
2.	Department contact
3.	Continue interview
THANK_RESP
Text:	Thank current respondent for his/her time and cooperation
CONTACT_DEPT
Text:	(All eligible departments are complete. Enter 9 to wrap up the case./All eligible departments are complete or refusals. Press F10 if you plan to fol                     Department    Status                      ED         (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig/DK-Followup - AUs created/DK-Followup - AUs NOT created/Complete - AUs NOT create  ((Dk Follow-up)/ )                           OPD        (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) ((Dk Follow-up)/ )                      ASL        (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) ((Dk Follow-up)/ )
1.	ED
2.	OPD
3.	ASL
4.	Department refusal
5.	Department callback
9.	Induction Interview Complete - Wrap up case
WHICH_DEPT
Text:	Which department (is refusing/are you setting a callback for)?
1.	ED
2.	OPD
3.	ASL
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?)          Enter 999 for no more
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 on the previous sampling plan?                    ESA            Visits      Visits Previous         (ESA NAME Current visits Previous 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 on the previous sampling plan?                ESA          Visits        Visits Previous         (ESA NAME Current visits Previous 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
EMEDRECE
Text:	Does your ED use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system?  Do not include billing record systems.             Read answer categories
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 current EHR/EMR system?
HHSMUE
Text:	Does your current system meet meaningful use criteria as defined by the Department of Health and Human Services?
EHRNAME13
Text:	What is the name of your current EHR/EMR 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.	NextGen
12.	Practice Fusion
13.	Sage/Vitera
14.	Other - Specify
15.	Unknown
EHRNAMOTHE
Text:	Enter name of EHR/EMR system
SECURCHCKE
Text:	Has your hospital made an assessment of the potential risks and vulnerabilities of your electronic health information within the last 12 months?  This would help identify privacy or security related issues that may need to be corrected.
1.	Yes
2.	No
3.	Unknown
DIFFEHRE
Text:	Does your EHR have the capability to electronically send health information to another provider whose EHR system is different from your system?
1.	Yes
2.	No
3.	Unknown
EHRINSE
Text:	Does your ED have plans for installing a new EHR/EMR 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 and how often these capabilities are used.      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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.  Recording 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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.             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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.           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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.              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:	Recording 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
EMEDIDE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         Reconciling lists of patient 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
EREMINDE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.           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
ECPOEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.  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
EWARNE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.  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
EFORMULAE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.           Are drug formulary checks performed?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
ECTOEE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 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
ERESULTE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. 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
ERADIE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used. Ordering radiology tests?
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 and how often these capabilities are used.         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
EPTEDUE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         Identifying educational resources for patients' specific 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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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
EIDPTE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         Identifying patients due for preventive or follow-up care in order to send patients reminders?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
EGENLISTE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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
ESUME
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.           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
EPTRECE
Text:	Indicate whether your ED has each of the following computerized capabilities and how often these capabilities are used.         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
ESHAREE
Text:	The next questions are about sharing (either sending or receiving) patient health information. Does your hospital share any patient health information electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?
1.	Yes
2.	No
ESHAREHOWE
Text:	How does your hospital electronically share patient health information?           Read answer categories         Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method (not fax)
ESHAREHOWOTHE
Text:	Specify other electronic method
EHRTOEHRE
Text:	Is the patient health information that you share electronically sent directly from your EHR system to another EHR system?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown
ESHAREPROVE
Text:	With what types of providers do you electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)?  Enter all that apply.
1.	Ambulatory providers inside your hospital
2.	Ambulatory providers outside your hospital
3.	Hospitals with which you are affiliated
4.	Hospitals with which you are not affiliated
5.	Behavioral health providers
6.	Long-term care providers
7.	Home health providers
EDPRIM
Text:	When patients with identified primary care physicians arrive at the Emergency Department, how often do you electronically send notifications 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.	Don't know
OBSUNITS
Text:	Does your ED have an observation or clinical decision unit?
1.	Yes
2.	No
3.	Unknown
OBSSEP
Text:	Is this observation or clinical decision unit physically separate from the ED?
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:	Does your ED allow some admitted patients to move from the ED to inpatient corridors while awaiting a bed ("boarding") - sometimes called a "full capacity protocol?"
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
CATRIAGE
Text:	Does your ED use -    Computer-assisted triage?
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
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:
1.	General
2.	Adult
3.	Pediatric
4.	Urgent care/Fast track
5.	Psychiatric
6.	Other
ESA_EVISITS
Text:	** SHOW ONLY **
ASL_ONSITE
Universe:	DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS = 1-99999
Text:	Is (AU Name) on-site?
1.	Yes
2.	No
ESA_STRET
Text:	What is (ESA name)'s address?            Enter number and street.
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
GENERIC_NAME
Text:	What is the generic name of the clinic?              Enter XXX if clinic is not listed
CLIN_SELECTGROUP
Text:	What is (Clinic Name)'s specialty group?
1.	General Medicine
2.	Surgery
3.	Pediatrics
4.	Obstetrics/Gynecology
5.	Substance Abuse
6.	Other
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
EMEDRECO
Text:	Does your OPD use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system?  Do not include billing record systems.
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 current EHR/EMR system?
HHSMUO
Text:	Does your current system meet meaningful use criteria as defined by the Department of Health and Human Services?
EHRNAMO13
Text:	What is the name of your current EHR/EMR 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.	NextGen
12.	Practice Fusion
13.	Sage/Vitera
14.	Other - Specify
15.	Unknown
EHRNAMOTHO
Text:	Enter name of EHR/EMR system
SECURCHCKO
Text:	Has your hospital made an assessment of the potential risks and vulnerabilities of your electronic health information within the last 12 months?  This would help identify privacy or security related issues that may need to be corrected.
1.	Yes
2.	No
3.	Unknown
DIFFEHRO
Text:	Does your EHR have the capability to electronically send health information to another provider whose EHR system is different from your system?
1.	Yes
2.	No
3.	Unknown
EHRINSO
Text:	Does your OPD have plans for installing a new EHR/EMR 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 and how often these capabilities are used.      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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.  Recording 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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.             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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.           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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.              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:	Recording 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
EMEDIDO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         Reconciling lists of patient 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
EREMINDO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.           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
ECPOEO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.  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
EWARNO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.  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
EFORMULAO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.           Are drug formulary checks performed?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
ECTOEO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.  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
ERESULTO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. 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
ERADIO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used. Ordering radiology tests?
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 and how often these capabilities are used.         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
EPTEDUO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         Identifying educational resources for patients' specific 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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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
EIDPTO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         Identifying patients due for preventive or follow-up care in order to send patients reminders?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
EGENLISTO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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
ESUMO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.           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
EPTRECO
Text:	Indicate whether your OPD has each of the following computerized capabilities and how often these capabilities are used.         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
REFOUTO
Text:	Do you refer any patients to providers outside of your clinic?
1.	Yes
2.	No
REFOUTSO
Text:	Do you send the patient's clinical information to the other providers?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
REFOUTSEO
Text:	Do you send it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
REFINO
Text:	Do you see any patients referred by providers outside of your clinic?
1.	Yes
2.	No
REFINSO
Text:	Do you send a consultation report with clinical information to the other providers?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
REFINSEO
Text:	Do you send it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
INPTCAREO
Text:	Does your clinic take care of patients after they are discharged from an inpatient setting?
1.	Yes
2.	No
DISSUMO
Text:	Do you receive a discharge summary with clinical information from the hospital?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
DISSUMEO
Text:	Do you receive it electronically (not fax)?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
INCORINFOO
Text:	Can you automatically incorporate the received information into your EHR system without manually entering the data?
1.	Yes
2.	No
3.	Not applicable, do not have an EHR system
ESHAREO
Text:	The next questions are about sharing (either sending or receiving) patient health information. Does your OPD share any patient health information electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?
1.	Yes
2.	No
ESHAREHOWO
Text:	How does your OPD electronically share patient health information?           Read answer categories         Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method (not fax)
ESHAREHOWOTHO
Text:	Specify other electronic method
EHRTOEHRO
Text:	Is the patient health information that you share electronically sent directly from your EHR system to another EHR system?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown
ESHAREPROVO
Text:	With what types of providers do you electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)?  Enter all that apply.
1.	Ambulatory providers inside your hospital
2.	Ambulatory providers outside your hospital
3.	Hospitals with which you are affiliated
4.	Hospitals with which you are not affiliated
5.	Behavioral health providers
6.	Long-term care providers
7.	Home health providers
CLIN_GROUP
Text:
1.	General Medicine
2.	Surgery
3.	Pediatrics
4.	Obstetrics/Gynecology
5.	Substance Abuse
6.	Other
ASL_ONSITE
Universe:	DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS = 1-99999
Text:	Is (AU Name) on-site?
1.	Yes
2.	No
CLIN_CONTACT
Text:	Enter clinic director/contact person's name
TE
Text:	** NOT DISPLAYED **
RS
Text:	** NOT DISPLAYED **
ASL_INTRO
Text:	To develop the sampling plan, I would like to (collect/verify) more specific information about this facility or hospital 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 ^centerslocations
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          Enter 999 for no more
ASL_SPEC_GRP
Text:	What is ASL Name's specialty group?
1.	General Surgery
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)?
ANYMORE_ASLS
Text:	The max of (15/13) (ASCs/ASLs) were entered.      Are there any more (ASCs/ASLs)?
1.	Yes
2.	No
EXTRA_ASLS
Text:	How many other (ASCs/ASLs) are there?
TWICELYAS
Text:	Is the number of expected visits to any of the ASLs more than twice the     number shown on the previous sampling plan?                    ASL            Visits      Visits Previous          (ASL NAME Current visits Previous visits)
1.	Yes
2.	No
TWICELYAS_SPEC
Text:	Specify why visits have increased this year or were too low the last time     the ASL participated
HALFLYAS
Text:	Is the number of expected visits to any of the ASLs less than half of the     number of visits shown on the previous sampling plan?                ASL         Visits        Visits Previous         (ASL NAME Current visits Previous visits)
1.	Yes
2.	No
HALFLYAS_SPEC
Text:	Specify why visits have decreased this year or were too high the last        time the ASL participated
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
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
EBILLRECA
Text:	Now I would like to ask you some questions about your (ASC/ambulatory surgery location).   If ASLs vary with respect to their use of the EHR/EMR systems, then ask these questions of the ASL with the largest number of expected visits during the reporting period. Does your (ASC/ambulatory surgery location) submit any CLAIMS  electronically (electronic billing)?
1.	Yes
2.	No
3.	Unknown
EMEDRECA
Text:	Does your (ASC/ambulatory surgery location) use an electronic HEALTH record (EHR) or electronic MEDICAL record (EMR) system?  Do not include billing record systems.             Read answer categories
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 current EHR/EMR system?
HHSMUA
Text:	Does your current system meet meaningful use criteria as defined by the Department of Health and Human Services?
EHRNAMA13
Text:	What is the name of your current EHR/EMR 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.	NextGen
12.	Practice Fusion
13.	Sage/Vitera
14.	Other - Specify
15.	Unknown
EHRNAMOTHA
Text:	Enter name of EHR/EMR system
SECURCHCKA
Text:	Has your hospital made an assessment of the potential risks and vulnerabilities of your electronic health information within the last 12 months?  This would help identify privacy or security related issues that may need to be corrected.
1.	Yes
2.	No
3.	Unknown
DIFFEHRA
Text:	Does your EHR have the capability to electronically send health information to another provider whose EHR system is different from your system?
1.	Yes
2.	No
3.	Unknown
EHRINSA
Text:	At your (ASC/ambulatory surgery location), are there plans for installing a new EHR/EMR system within the next 18 months?
1.	Yes
2.	No
3.	Maybe
4.	Unknown
MUINCA
Text:	Medicare and Medicaid offer incentives to facilities that demonstrate "meaningful use of health IT."  Does your facility have plans to apply for Stage 1 of 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
APPLYYRA
Text:	When did you first apply?
1.	2011
2.	2012
3.	2013
4.	2014 or later
5.	Unknown
INTENDYRA
Text:	When do you intend to first apply?
1.	2012
2.	2013 or later
3.	Unknown
EDEMOGA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.      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:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. Recording 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:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used.   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:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.   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:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.   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:	Recording 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
EMEDIDA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         Reconciling lists of patient 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
EREMINDA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.           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
ECPOEA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. 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
EWARNA
Text:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. 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
EFORMULAA
Text:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used.   Are drug formulary checks performed?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
ECTOEA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.          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:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. 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
ERESULTA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. 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
ERADIA
Text:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used. Ordering radiology tests?
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 (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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 (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         Identifying educational resources for patients' specific conditions?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
ECQMA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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
EIDPTA
Text:	Indicate whether your ASL has each of the following computerized capabilities and how often these capabilities are used.         Identifying patients due for preventive or follow-up care in order to send patients reminders?
1.	Yes, used routinely
2.	Yes, but not used routinely
3.	Yes, but turned off or not used
4.	No
5.	Unknown
EGENLISTA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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
ESUMA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.           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
EPTRECA
Text:	Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities and how often these capabilities are used.         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
ESHAREA
Text:	The next questions are about sharing (either sending or receiving) patient health information. Does your (ASC/ambulatory surgery location) share any patient health information electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?
1.	Yes
2.	No
ESHAREHOWA
Text:	How does your (ASC/ambulatory surgery location) electronically share patient health information?           Read answer categories         Enter all that apply, separate with commas
1.	EHR/EMR
2.	Web portal (separate from EHR/EMR)
3.	Other electronic method (not fax)
ESHAREHOWOTHA
Text:	Specify other electronic method
EHRTOEHRA
Text:	Is the patient health information that you share electronically sent directly from your EHR system to another EHR system?
1.	Yes, routinely
2.	Yes, but not routinely
3.	No
4.	Unknown
ESHAREPROVA
Text:	With what types of providers do you electronically share patient health information (e.g., lab results, imaging reports, problem lists, medication lists)?  Enter all that apply.
1.	Ambulatory providers inside your hospital
2.	Ambulatory providers outside your hospital
3.	Hospitals with which you are affiliated
4.	Hospitals with which you are not affiliated
5.	Behavioral health providers
6.	Long-term care providers
7.	Home health providers
ASL_ONSITE
Text:	Is (AU Name) on-site?
1.	Yes
2.	No
MULTIASCFLAG
Text:	** Not Displayed **
NUMSAS
Text:	** NOT DISPLAYED **
NUMCLINS
Text:	** NOT DISPLAYED **
NUMASLS
Text:	** NOT DISPLAYED  **
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)
THANKYOU
Text:	This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.
SET_REINT
Text:	** Non Displayed **
HOSPREF
Text:	**  Not displayed **
REFUSED_FOR
Text:	Is this refusal for the hospital, ED department, OPD department and/or Ambulatory Surgery?             Enter all that apply, separate with commas
1.	Hospital
2.	ED Department
3.	OPD Department
4.	Ambulatory Surgery
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 location?
1.	Yes
2.	No
VSASC101
Text:	Enter number of expected visits
VSASCLY
Text:	Enter number of ambulatory surgery visits last year
WHOMHOSP
Text:	Who refused for the hospital?
1.	Hospital administrator
2.	Approval board or official
3.	Other hospital official
WHOMHOSPSPEC
Text:	Specify the name of the other hospital official who refused for the hospital
TELPERHO
Text:	Was the refusal by telephone or in person for the hospital?
1.	Telephone
2.	In person
WHOMED
Text:	Who refused for the ED Department?
1.	Hospital administrator
2.	ED/OPD/Ambulatory Surgery Director
3.	Approval board or official
4.	Other hospital official-Specify
WHOMEDSPEC
Text:	Specify the name of the other hospital official who refused for the ED
TELPERED
Text:	Was the refusal by telephone or in person for the ED?
1.	Telephone
2.	In person
WHOMOP
Universe:	3 selected in REFUSED_FOR
Text:	Who refused for the OPD Department?
1.	Hospital administrator
2.	ED/OPD/Ambulatory Surgery Director
3.	Approval board or official
4.	Other hospital official-Specify
WHOMOPSPEC
Text:	Specify the name of the other hospital official who refused for the OPD
TELPEROP
Text:	Was the refusal by telephone or in person for the OPD?
1.	Telephone
2.	In person
WHOMAS
Text:	Who refused for Ambulatory Surgery?
1.	Hospital administrator
2.	ED/OPD/Ambulatory Surgery Director
3.	Approval board or official
4.	Other hospital official-Specify
WHOMASSPEC
Text:	Specify the name of the other hospital official who refused for the ASL
TELPERAS
Text:	Was the refusal by telephone or in person for the ASL?
1.	Telephone
2.	In person
REASON
Text:	Specify what reason was given for the refusal/breakoff
CONVHOSP
Text:	Was conversion attempted for the hospital?
1.	Yes
2.	No
CONVED
Text:	Was conversion attempted for the ED Department?
1.	Yes
2.	No
CONVOP
Text:	Was conversion attempted for the OPD Department?
1.	Yes
2.	No
CONVAS
Text:	Was conversion attempted for the Ambulatory Surgery?
1.	Yes
2.	No

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