Hospital Induction Interview

Attachment E 2014 HOSPITAL INDUCTION INTERVIEW
OMB No. 0920-0278; Expiration 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).

NAMECHEK
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
What is your hospital's name?
Enter 1 to update the hospitals name
1. Enter 1 to update information
2. Continue

ADDCHEK
Is your hospital located at
(Facility Address)
1. Yes
2. No

HSP_ADDRESS
What is the correct address?
Enter 1 to update the hospitals address
1. Enter 1 to update information
2. Continue

MAILADD
Is this also the mailing address?
(Facility Address)

1. Yes
Page 1 of 8

2. No

MHSP_STRET
What is the correct mailing address?
Enter the number and street or press enter if same

MHSP_STRET2
What is the correct mailing address?
Enter the second line of address or press enter if same/none

MHSP_CITY
What is the correct mailing address?
Enter city or press enter if same

MHSP_ST
What is the correct mailing address?
Enter state or press enter if same

MHSP_ZIP
What is the correct mailing address?
Enter zipcode or press enter if same

INTRO_AB
(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:
Page 2 of 8

1. Enter 1 to Continue

LICHOSP
Is this facility a licensed hospital?
1. Yes
2. No

OWN101
1
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
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
Is this a teaching hospital?
1. Yes
2. No

MERGER
? [F1]
Did this hospital either merge or separate from any OTHER hospital in the past 2 years?
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1. Merged or separated
2. No
3. Unknown

MERSEP
Was this a merger or a separation?

MERGMEDR
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
What is the name and address of this OTHER hospital?
Enter name

OTHSTRET
What is the name and address of this OTHER hospital?
Enter number and street

OTHSTRET2
What is the name and address of this OTHER hospital?
Enter the second line of address or press enter if same/none

OTHCITY
What is the name and address of the OTHER hospital?
Enter city

Page 4 of 8

OTHSTATE
What is the name and address of this OTHER hospital?
Enter state

OTHZIP
What is the name and address of this OTHER hospital?
Enter zip code

ESA24
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
Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?
1. Yes
2. No

TRAUMA
? [F1]

1

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
Does this hospital operate an organized outpatient department either at this hospital or
elsewhere?
Page 5 of 8

1. Yes
2. No

PHYSSERV
Does this OPD include physician services?
1. Yes
2. No

AMBSURG
1
Ambulatory surgery locations include a general or main operating room, dedicated ambulatory
surgery room, satellite operating room, cystoscopy room, endoscopy room, cardiac catherization
lab, laser procedures room, or a pain block room.
Does this hospital have locations that perform ambulatory surgery?

1. Yes
2. No

ELIGREQ
** Not displayed **

STUDY_DESC
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
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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.
1. Enter 1 to Continue

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

1. Enter 1 to Continue

THANK_MERGSEP
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.
Page 7 of 8

Thank you for your cooperation.

1. Enter 1 to Continue

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

1. Enter 1 to Continue

THANK_B1
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.
1. Enter 1 to Continue

THANK_B2
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.
1. Enter 1 to Continue

Page 8 of 8

REVIEW
? [F1]
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
1. Enter 1 to Continue

SURGDAY
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
[?] F1

Does your hospital have a bed coordinator, sometimes referred to as a bed czar?
1. Yes
2. No
3. Unknown

BEDDATA
2
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
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5. Every 24 hours
6. Other
7. Unknown

HLIST
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
Do the hospitalists on staff at your hospital admit patients from your ED?
1. Yes
2. No
3. Unknown

EMEDRES
Does this hospital have an emergency medicine residence program?
1. Yes
2. No
3. Unknown

MUINC
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

Page 2 of 4

MUSTAGE2
Are there plans to apply for Stage 2 incentive payments?
1. Yes
2. No
3. Maybe
4. Unknown

PERMPART
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
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
Thank you for your help.

1. Enter 1 to Continue

RO_PERMISSION
Call the Regional Office to inform them of the additional steps needed to
obtain permission
1. Enter 1 to Continue

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VSREPPER
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
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
Thank current respondent for his/her time and cooperation
1. Enter 1 to Continue

Page 4 of 4

INTRO_ED
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
1. Enter 1 to Continue

ESA_NUM
** Show only **

DEL_ESA
(Does (ESA name) still exist and is it still operational?)
(Enter 97 to delete this ESA / If No, Enter 97 to delete If Yes, Press END to move to number of visits)

ESA_NAME
(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
? [F1]
What type of ESA is (ESA name)?
1. General
2. Adult
3. Pediatric
4. Urgent care/Fast track
5. Psychiatric
6. Other

ESA_EVISITS
What is the expected number of visits from (Reporting period begin date) to (Reporting period
Page 1 of 66

end date) for (ESA name)?

I_ESA
** Not Displayed **

I_ESA_VISITS
** Not Displayed **

ESA_EVISITS_TOTAL
** Not displayed **

TOTVSED
** Not displayed **

TWICELY
Is the number of expected visits to any of the ESAs more than twice the
number on the previous sampling plan?
ESA
(ESA NAME

Visits
Visits Previous
Current visits
Previous visits)

1. Yes
2. No

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

HALFLY
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
(ESA NAME

Visits
Visits Previous
Current visits
Previous visits)

1. Yes
2. No
Page 2 of 66

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

ED_EMR
Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

EBILLRECE
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
2
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
In which year did your ED install the EHR/EMR system?

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

EHRNAME13
2
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
Enter name of EHR/EMR system

SECURCHCKE
Has your hospital conducted or reviewed a security risk analysis of your EHR system? This
would help identify privacy or security related issues that may need to be corrected.
1. Yes
2. No
3. Unknown

DIFFEHRE
Does your EHR have the capability to electronically send health information to another provider
Page 4 of 66

whose EHR system is different from your system?
1. Yes
2. No
3. Unknown

EHRTOEHRE
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

EHRINSE
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
3
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

Page 5 of 66

EPROLSTE
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
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
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
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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
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
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
Indicate whether your ED has each of the following computerized capabilities and how often these
capabilities are used.
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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
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
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
Are warnings of drug interactions or contraindications provided?

1. Yes, used routinely
2. Yes, but not used routinely
Page 8 of 66

3. Yes, but turned off or not used
4. No
5. Unknown

EFORMULAE
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
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
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
Page 9 of 66

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
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
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
Indicate whether your ED has each of the following computerized capabilities and how often these
capabilities are used.
Viewing imaging results?

Page 10 of 66

1. Yes, used routinely
2. Yes, but not used routinely
3. Yes, but turned off or not used
4. No
5. Unknown

EPTEDUE
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
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
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
Page 11 of 66

2. Yes, but not used routinely
3. Yes, but turned off or not used
4. No
5. Unknown

EGENLISTE
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
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
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
Page 12 of 66

4. No
5. Unknown

EMSGE
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
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
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
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2. No

ESHAREHOWE
2
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
Specify other electronic method

ESHAREPROVE
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 office/group
2. Ambulatory providers outside your office/group
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
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
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5. Do not know

EDINFO
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
Does your ED have an observation or clinical decision unit?
1. Yes
2. No
3. Unknown

OBSSEP
Is this observation or clinical decision unit physically separate from the ED?
1. Yes
2. No
3. Unknown

OBSDECMD
5
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

Page 15 of 66

BOARD
? [F1]
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
? [F1]
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
Did your ED go on ambulance diversion in TOTHRDIV_FILL?
1. Yes
2. No
3. Unknown

TOTHRDIV
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
Is ambulance diversion actively managed on a regional level versus each hospital adopting
diversion if and when it chooses?
1. Yes
2. No
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3. Unknown

ADMDIV
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
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
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
In the last two years, did your ED increase the number of standard treatment spaces?
1. Yes
2. No
3. Unknown

PHYSSPACE
In the last two years, did your ED's physical space expand?
1. Yes
2. No
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3. Unknown

EXPAND
Do you have plans to expand your ED's physical space within the next two years?
1. Yes
2. No
3. Unknown

BEDREG
5
Does your ED use Bedside registration?
1. Yes
2. No
3. Unknown

KIOSELCHK
Does your ED use Kiosk self check-in?
1. Yes
2. No
3. Unknown

CATRIAGE
Does your ED use Computer-assisted triage?
1. Yes
2. No
3. Unknown
Page 18 of 66

IMBED
Does your ED use Immediate bedding (no triage when ED is not at capacity)?
1. Yes
2. No
3. Unknown

ADVTRIAG
Does your ED use Advanced triage (triage-based care) protocols?
1. Yes
2. No
3. Unknown

PHYSPRACTRIA
Does your ED use Physician/Practitioner at triage?
1. Yes
2. No
3. Unknown

FASTTRAK
Does your ED use Separate fast track unit for nonurgent care?
1. Yes
2. No
3. Unknown

Page 19 of 66

EDPTOR
Does your ED use Separate operating room dedicated to ED patients?
1. Yes
2. No
3. Unknown

DASHBORD
Does your ED use Electronic dashboard (i.e., displays updated patient information
and integrates multiple data sources)?
1. Yes
2. No
3. Unknown

RFID
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
Does your ED use Wireless communication devices by providers?
1. Yes
2. No
3. Unknown
Page 20 of 66

ZONENURS
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
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

FREDIND
** Not Displayed **

ESA_NUM
** SHOW ONLY **

ESA_NAME
*** SHOW ONLY **

ESA_TYPE
** SHOW ONLY **
1. General
2. Adult
3. Pediatric
4. Urgent care/Fast track
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5. Psychiatric
6. Other

ESA_EVISITS
** SHOW ONLY **

ASL_ONSITE
Is (AU Name) on-site?
1. Yes
2. No

ESA_STRET
What is (ESA name)'s address?
Enter number and street.

ESA_STRET2
What is (ESA name)'s address?
Enter the second line of address or press enter if same/none

ESA_CITY
What is (ESA name)'s address?
Enter city

ESA_STATE
What is (ESA name)'s address?
Enter state

ESA_ZIP
What is (ESA name)'s address?
Enter zipcode
Page 22 of 66

ESA_PHONE
What is (ESA name)'s telephone number?

ESA_PHTYP
Enter phone type
0. Main
1. Home
2. Work
3. Mobile
4. Pager, Beeper, Answering Service
5. Public Pay Phone
6. Toll Free
7. Other
8. Fax
9. Unknown

ESA_CONTACT
Enter ESA contact person's name

TE
** NOT DISPLAYED **

RS
** NOT DISPLAYED **

EDDK_CHECK
Are there any Don't Know items that you need to callback for?
Press Ctrl-M to review DKs and RFs
Press Shift-F5 to review all DK Follow-up remarks
If you MUST close this case now, due to pending close-out, and you will not be collecting your remaining
DKs and RFs, please select 2 "No", and make any required explanation in the case notes.

1. Yes
Page 23 of 66

2. No

DONE_ED
Enter 1 to continue to the next department
WARNING: once you pass this screen, the ED portion of the induction interview will be closed, and you
will not be allowed to re-enter to change any answers or add additional AUs. If you need to go back, use
your up arrow to go back now, or press F10 to come back in later. DO NOT press 1 if you need to come
back to this department section later.

1. Enter 1 to Continue

I_EDMIN
** Not displayed **

I_EDMAX
** Not displayed **

TOT_GOODESA
** NOT Displayed **

INTRO_OPD
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
1. Enter 1 to Continue

CLIN_NUM
** NOT DISPLAYED **

DEL_CLIN
Page 24 of 66

(Does (clinic name) still exist and is it still operational?)
(Enter 97 to delete this clinic / If Yes, Press END to move to number of visits If No, Enter 97 to
delete )

CLIN_NAME
11-16
(What is the name of the (first/next) clinic? /Are there any other clinics?)
Enter 999 for no more

GENERIC_NAME
11-16
What is the generic name of the clinic?
Enter XXX if clinic is not listed

CLIN_SELECTGROUP
What is (Clinic Name)'s specialty group?
1. General Medicine
2. Surgery
3. Pediatrics
4. Obstetrics/Gynecology
5. Substance Abuse
6. Other

CLIN_GROUP
**Not displayed **

CLIN_GROUP_SHOW
** SHOW ONLY **

CLIN_EVISITS
Page 25 of 66

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

I_CLIN
** Not Displayed **

SAMPLE_QUESTION
You have completed data entry for the OPD.
Enter 1 to have the system perform sampling.
-orEnter 2 to return to the previous screen to enter additional clinics.
1. verifies clinic list is complete, ready to sample
2. returns to clinic list to add additional clinics before sampling

CLIN_NUM
** NOT DISPLAYED **

SAMPLED
** Not Displayed **

Probability
** NOT DISPLAYED **

SU
** NOT DISPLAYED **

CLIN_EVISITS_TOTAL
** Not Displayed **

TOTAL_CLIN
Page 26 of 66

** Not Displayed **

TOTVSOP
** Not Displayed **

MORECLINSPEC
List clinics that have opened or should have been included previously

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

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

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

OPD_EMR
Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

EBILLRECO
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
Page 27 of 66

EMEDRECO
2
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
In which year did your OPD install the EHR/EMR system?

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

EHRNAMO13
2
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
Page 28 of 66

15. Unknown

EHRNAMOTHO
Enter name of EHR/EMR system

SECURCHCKO
Has your hospital conducted or reviewed a security risk analysis of your EHR system? This
would help identify privacy or security related issues that may need to be corrected.
1. Yes
2. No
3. Unknown

DIFFEHRO
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

EHRTOEHRO
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

EHRINSO
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
Page 29 of 66

EDEMOGO
3
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
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
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
Page 30 of 66

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
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
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
Indicate whether your OPD has each of the following computerized capabilities and how often these
capabilities are used.
Page 31 of 66

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
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
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
Are prescriptions sent electronically to the pharmacy?

Page 32 of 66

1. Yes, used routinely
2. Yes, but not used routinely
3. Yes, but turned off or not used
4. No
5. Unknown

EWARNO
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
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
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
Page 33 of 66

5. Unknown

EORDERO
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
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
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
Ordering radiology tests?

Page 34 of 66

1. Yes, used routinely
2. Yes, but not used routinely
3. Yes, but turned off or not used
4. No
5. Unknown

EIMGRESO
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
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
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
Page 35 of 66

3. Yes, but turned off or not used
4. No
5. Unknown

EIDPTO
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
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
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
Page 36 of 66

4. No
5. Unknown

ESUMO
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
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
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
Page 37 of 66

3. Yes, but turned off or not used
4. No
5. Unknown

REFOUTO
Does your clinic refer any patients to providers outside of your office group?

1. Yes
2. No

REFOUTSO
Do you send the patient's clinical information to the other providers?

1. Yes, routinely
2. Yes, but not routinely
3. No

REFOUTSEO
Do you send it electronically (not fax)?

1. Yes, routinely
2. Yes, but not routinely
3. No

Page 38 of 66

REFINO
Does your clinic see any patients referred to you by providers outside of your office group?

1. Yes
2. No

REFINSO
Do you send a consultation report with clinical information to the other providers?

1. Yes, routinely
2. Yes, but not routinely
3. No

REFINSEO
Do you send it electronically (not fax)?

1. Yes, routinely
2. Yes, but not routinely
3. No

INPTCAREO
Does your clinic take care of patients after they are discharged from an inpatient setting?

Page 39 of 66

1. Yes
2. No

DISSUMO
Do you receive a discharge summary with clinical information from the hospital?

1. Yes, routinely
2. Yes, but not routinely
3. No

DISSUMEO
Do you receive it electronically (not fax)?

1. Yes, routinely
2. Yes, but not routinely
3. No

INCORINFOO
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

Page 40 of 66

ESHAREO
The next questions are about sharing (either sending or receiving) patient health information.
Does your OPD share any patient health information electronically with any other providers,
including hospitals, ambulatory providers, or labs?

1. Yes
2. No

ESHAREHOWO
2
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
Specify other electronic method

ESHAREPROVO
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 office/group
2. Ambulatory providers outside your office/group
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

Page 41 of 66

CLIN_NUM
** SHOW ONLY **

CLIN_NAME
*** SHOW ONLY **

CLIN_GROUP
** SHOW ONLY **
1. General Medicine
2. Surgery
3. Pediatrics
4. Obstetrics/Gynecology
5. Substance Abuse
6. Other

CLIN_EVISITS
** SHOW ONLY **

ASL_ONSITE
Is (AU Name) on-site?
1. Yes
2. No

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

CLIN_STRET2
What is (Clinic Name)'s address?
Enter the second line of address or press enter if same/none

CLIN_CITY
Page 42 of 66

What is (Clinic Name)'s address?
Enter city

CLIN_STATE
What is (Clinic Name)'s address?
Enter state

CLIN_ZIP
What is (Clinic Name)'s address?
Enter zipcode

CLIN_PHONE
What is (Clinic Name)'s telephone number?

CLIN_PHTYP
Enter phone type
0. Main
1. Home
2. Work
3. Mobile
4. Pager, Beeper, Answering Service
5. Public Pay Phone
6. Toll Free
7. Other
8. Fax
9. Unknown

CLIN_CONTACT
Enter clinic director/contact person's name

TE
** NOT DISPLAYED **
Page 43 of 66

RS
** NOT DISPLAYED **

OPDDK_CHECK
Are there any Don't Know items that you need to call back for?
Press Ctrl-M to review DKs and RFs
Press Shift-F5 to review all DK Follow-up remarks
If you MUST close this case now, due to pending close-out, and you will not be collecting your remaining
DKs and RFs, please select 2 "No", and make any required explanation in the case notes.

1. Yes
2. No

DONE_OPD
Enter 1 to continue to the next department
WARNING: once you pass this screen, the OPD portion of the induction interview will be closed, and
you will not be allowed to re-enter to change any answers or add additional AUs. If you need to go back,
use your up arrow to go back now, or press F10 to come back in later. DO NOT press 1 if you need to
come back to this department section later.
1. Enter 1 to Continue

I_OPDMIN
** Not displayed **

I_OPDMAX
** Not displayed **

I_TOTCLIN
** Not displayed **

TOT_GOODCLIN
** NOT Displayed **

Page 44 of 66

ASL_INTRO
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
Dedicated ambulatory surgery rooms
Satellite operating rooms
Cystoscopy rooms

Endoscopy rooms
Cardiac catheterization labs
Laser procedures rooms
Pain block rooms

1. Continue
2. No in-scope ^centerslocations

ASL_NUM
** SHOW ONLY **

DEL_ASL
(Does (ASL name) still exist and is it still operational?)
(Enter 97 to delete this ASL entered by mistake/ If Yes, Press END to move to expected visits If
No, Enter 97 to delete )

ASL_NAME
[?] F1
( 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
[?] F1
Page 45 of 66

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
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
** Not Displayed **

I_ASL_VISITS
** Not Displayed **

TOT_GOODASL
** NOT Displayed **

ANYMORE_ASLS
The max of (15/13) (ASCs/ASLs) were entered.
Are there any more (ASCs/ASLs)?
1. Yes
2. No

EXTRA_ASLS
How many other (ASCs/ASLs) are there?

Page 46 of 66

TOT_GOODASL2
** NOT Displayed **

CHECK_EVISITS
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
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.
1. Enter 1 to Continue

ASL_EVISITS_TOTAL
** Not displayed **

TOTVSAS
** Not displayed **

TWICELYAS
Is the number of expected visits to any of the ASLs more than twice the
number shown on the previous sampling plan?
ASL
(ASL NAME

Visits
Visits Previous
Current visits
Previous visits)

1. Yes
2. No

TWICELYAS_SPEC
Page 47 of 66

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

HALFLYAS
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
(ASL NAME

Visits
Visits Previous
Current visits
Previous visits)

1. Yes
2. No

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

ASCLISTA
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
What is the name of the IT contact?

IT_CTITLE
What is (IT contact name)'s title?

IT_CSTRET
Page 48 of 66

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

IT_CSTRET2
What is (IT contact name)'s address?
Enter second line of address or press enter for none/same

IT_CCITY
What is (IT contact name)'s address?
Enter city or press enter if same

IT_CSTATE
What is (IT contact name)'s address?
Enter state or press enter if same

IT_CZIP
What is (IT contact name)'s address?
Enter zipcode or press enter if same

IT_CPHONE
What is (IT contact name)'s phone number?

IT_CPHTYP
Enter phone type

0. Main
1. Home
2. Work
3. Mobile
4. Pager, Beeper, Answering Service
Page 49 of 66

5. Public Pay Phone
6. Toll Free
7. Other
8. Fax
9. Unknown

UPDATE_BCONTACTS
** Not Displayed **

ASL_NUM
** SHOW ONLY **

ASL_NAME
** SHOW ONLY **

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

ASL_EMR
Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

EBILLRECA
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)?
Page 50 of 66

1. Yes
2. No
3. Unknown

EMEDRECA
2
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
In which year did your ASL install the EHR/EMR system?

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

EHRNAMA13
2
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
Page 51 of 66

9. Greenway Medical
10. McKesson / Practice Partner
11. NextGen
12. Practice Fusion
13. Sage/Vitera
14. Other - Specify
15. Unknown

EHRNAMOTHA
Enter name of EHR/EMR system

SECURCHCKA
Has your hospital conducted or reviewed a security risk analysis of your EHR system? This
would help identify privacy or security related issues that may need to be corrected.
1. Yes
2. No
3. Unknown

DIFFEHRA
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

EHRTOEHRA
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

EHRINSA
Page 52 of 66

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
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
When did you first apply?
1. 2011
2. 2012
3. 2013
4. 2014 or later
5. Unknown

INTENDYRA
When do you intend to first apply?
1. 2012
2. 2013 or later
3. Unknown

EDEMOGA
3
Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized
capabilities and how often these capabilities are used.
Page 53 of 66

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
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
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
Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized
capabilities and how often these capabilities are used.

Page 54 of 66

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
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
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
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?

Page 55 of 66

1. Yes, used routinely
2. Yes, but not used routinely
3. Yes, but turned off or not used
4. No
5. Unknown

EREMINDA
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
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
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
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4. No
5. Unknown

EWARNA
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
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
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

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EORDERA
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
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
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
Ordering radiology tests?

1. Yes, used routinely
2. Yes, but not used routinely
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3. Yes, but turned off or not used
4. No
5. Unknown

EIMGRESA
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
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
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
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5. Unknown

EIDPTA
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
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
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
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ESUMA
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
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
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

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ESHAREA
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
with any other providers, including hospitals, ambulatory providers, or labs?

1. Yes
2. No

ESHAREHOWA
2
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
Specify other electronic method

ESHAREPROVA
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 office/group
2. Ambulatory providers outside your office/group
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

Page 62 of 66

AU_NUMBER
** NOT DISPLAYED **

AU_TYPE
** NOT DISPLAYED **

AU_VISITS
** NOT DISPLAYED **

AU_NAME
Enter facility name where the PRF data will be collected.

Ambulatory Surgery Locations
(Names of ASL's with the same AU Number)

ASL_ONSITE
Is (AU Name) on-site?
1. Yes
2. No

ASL_STRET
What is (AU Name)'s address or the address where the abstractions will be done?
Enter number and street.

ASL_STRET2
What is (AU 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
What is (AU Name)'s address or the address where the abstractions will be done?
Enter city.

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ASL_STATE
What is (AU Name)'s address or the address where the abstractions will be done?
Enter state.

ASL_ZIP
What is (AU Name)'s address or the address where the abstractions will be done?
Enter zipcode.

ASL_PHONE
What is (AU Name)'s telephone number or the telephone number where the abstractions will be
done?

ASL_PHTYP
Enter phone type
0. Main
1. Home
2. Work
3. Mobile
4. Pager, Beeper, Answering Service
5. Public Pay Phone
6. Toll Free
7. Other
8. Fax
9. Unknown

ASL_CONTACT
Enter contact person's name

TE
** NOT DISPLAYED **

Page 64 of 66

RS
** NOT DISPLAYED **

PRF_WKLD
** NOT DISPLAYED **

MULTIASCFLAG
** Not Displayed **

AU_ASL_NUMS
**Not Displayed **

ASCDK_CHECK
Are there any Don't Know items that you need to callback for?
Press Ctrl-M to review DKs and RFs
Press Shift-F5 to review all DK Follow-up remarks
If you MUST close this case now, due to pending close-out, and you will not be collecting your remaining
DKs and RFs, please select 2 "No", and make any required explanation in the case notes.

1. Yes
2. No

DONE_ASC
Enter 1 to continue to the next department
WARNING: once you pass this screen, the ASL portion of the induction interview will be closed, and you
will not be allowed to re-enter to change any answers or add additional AUs. If you need to go back, use
your up arrow to go back now, or press F10 to come back in later. DO NOT press 1 if you need to come
back to this department section later.
1. Enter 1 to Continue

I_ASCMIN
** Not displayed **

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I_ASCMAX
** Not displayed **

Page 66 of 66