60 Day FRN Public Comment

Att B2: 60-day Federal Register Notice Public Comment and Response
Public Comment #1

October 7, 2019
Jeffrey M. Zirger
Lead, Information Collection Review Office
Office of Scientific Integrity
Office of Science
Centers for Disease Control and Prevention
Re: National Electronic Health Records Survey (NEHRS) Revision; (OMB Control No. 0920-1015);
Docket No. CDC-2019-0061
Dear Mr. Zirger,
The American Association of Nurse Practitioners (AANP), representing more than 270,000 nurse
practitioners (NPs) in the United States, appreciates the opportunity to comment on ways to enhance the
quality, utility and clarity of the National Electronic Health Records Survey (NEHRS).
NPs are advanced practice registered nurses (APRNs) who are prepared at the masters or doctoral level to
provide primary, acute, chronic and specialty care to patients of all ages and walks of life. Daily practice
includes: assessment; ordering, performing, supervising and interpreting diagnostic and laboratory tests;
making diagnoses; initiating and managing treatment including prescribing medication and nonpharmacologic treatments; coordinating care; counseling; and educating patients and their families and
communities. NPs practice in nearly every health care setting including long-term care facilities, clinics,
hospitals, Veterans Affairs and Indian Health Care facilities, emergency rooms, urgent care sites, private
physician or NP practices (both managed and owned by NPs), schools, colleges, retail clinics, public
health departments, nurse managed clinics, and home health. NPs hold prescriptive authority in all 50
states and the District of Columbia. NPs complete more than one billion patient visits annually.
Nurse practitioners currently provide a substantial portion of the high-quality 1, cost-effective 2 health care
that our communities require, and will continue to do so to meet the needs of their communities. As of
2017, there were more than 130,000 NPs billing for Medicare services, making NPs the largest and fastest
growing Medicare designated provider specialty. 3 In the commercial health care market, between 20122016 the number of office visits to primary care physicians declined by 18% while the number of office
visits to NPs and PAs increased by 128%. 4 NPs have a particularly large impact on primary care as
approximately 73% of all NP graduates deliver primary care 5. NPs comprise approximately one quarter of
our primary care workforce, with that percentage growing annually. 6

https://www.aanp.org/images/documents/publications/qualityofpractice.pdf.
https://www.aanp.org/images/documents/publications/costeffectiveness.pdf.
3
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/CMSProgramStatistics/2017/Downloads/PROVIDERS/2017_CPS_MDCR_PROVIDERS_6.PDF
4
https://www.healthcostinstitute.org/research/publications/hcci-research/entry/trends-in-primary-care-visits.
5
https://www.aanp.org/about/all-about-nps/np-fact-sheet.
6
Rural and Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners, Hilary
Barnes, Michael R. Richards, Matthew D. McHugh, and Grant Martsolf, Health Affairs 2018 37:6, 908-914.
1
2

Administration: PO Box 12846 • Austin, TX 78711 • Email: admin@aanp.org • Website: aanp.org
Government Affairs: 225 Reinekers Lane, Suite 525 • Alexandria, VA 22314 • Email: governmentaffairs@aanp.org

The CDC requested feedback on ways to enhance the quality and utility of information collected through
the NEHRS, an important tool for collecting data regarding the adoption and utilization of electronic
health records. Unfortunately, the current NEHRS is focused on surveying office-based physicians and
does not include surveying office-based nurse practitioners. Approximately 95% of nurse practitioners
utilize electronic health records in their clinical setting. Over a third report having a role in purchasing an
electronic health records system for their primary work site. The most common practice settings for nurse
practitioners are the office-based settings that are included in this survey. To obtain an accurate
representation of the health care workforce it is essential that NPs are added to the sample of
providers in office-based settings.
Additionally, the NEHRS uses the term “mid-level provider” when referring to NPs and other health care
providers (question 9). NPs are licensed, independent practitioners who work throughout the entire health
care spectrum from health promotion and disease prevention to diagnosis and treatment of patients with
acute and chronic illnesses. AANP strongly disagrees with the use of this term and requests that the
CDC retire its usage in the NEHRS and all other surveys and communications.
This label originated decades ago and it is not compatible with NP licensure. The term fails to recognize
the established national scope of practice for the NP role and the authority of NPs to practice to the full
extent of their education and clinical preparation. HHS has recently stated they are not using the term
given the “increasingly critical and advanced roles that PAs and APRNs play within the clinic
environment.” 7 The term confuses health care consumers due to its vague nature and is not a true
reflection of the NP role. The term “mid-level provider” implies an inaccurate hierarchy within clinical
practice. Nurse practitioners have a steadfast reputation for safe practice and the provision of high quality
care. It is well established that patient outcomes for NPs are comparable to physicians. The CDC should
retire the use of this term as it is outdated language that does not reflect the quality of care
provided by NPs and their importance to the health care system.
We thank you for the opportunity to comment on the NEHRS. Should you have comments or questions,
please direct them to MaryAnne Sapio, V.P. Federal Government Affairs, msapio@aanp.org, 703-7402529.
Sincerely,

David Hebert
Chief Executive Officer

7

84 FR 7714, 7728 (see footnote 42).

Dear Mr. Hebert,
Thank you for your thoughtful letter requesting 1) the inclusion of nurse practitioners in the National Electronic
Health Records Survey (NEHRS) sample of providers in office-based settings, and 2) the removal and
replacement of the term “mid-level provider” in the NEHRS and all other surveys and communications.
Nurse practitioners do not currently fall under the scope of the NEHRS, which at this time is limited to officebased physicians. However, we have added your letter to our folder of items to consider for future NEHRS
planning. Meanwhile, we have replaced the term “mid-level provider” with “advanced practice provider” in
accordance with the Department of Health and Human Services’ definition given in 84 FR 7714.
Sincerely,
The National Electronic Health Records Survey (NEHRS) Investigative Team
The National Center for Health Statistics