Non-Substantive Change Request

Request for Approval of a Non-Substantive Change to the

National Electronic Health Records Survey

OMB No. 0920-1015

(Expiration: 12/31/2022)

Contact Information:

Brian W. Ward, Ph.D.

Branch Chief, Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road

Hyattsville, MD 20782

301-458-4568

301-458-4032 (fax)

ijz8@cdc.gov

June 30, 2020

Table of Contents

1. Circumstance Making the Collection of Information Necessary…………………………2

2. Purpose and Use of Information Collected……………………………………………….3

3. Use of Improved Information Technology and Burden Reduction………………………4

12. Estimate of Annualized Burden Hours and Costs………………………………………4

14. Annualized Cost to the Government……………………………………………………5

15. Explanation for Program Changes or Adjustments……………………………………..6

Attachments

Att A1 – 2020 NEHRS Questionnaire (clean copy)

Att A2 – 2020 NEHRS Questionnaire (track changes)

Att B – Changes to the NEHRS Instrument

Att C1 – 2020 NEHRS recruitment email and advanced letters (clean copy)

Att C2 – 2020 NEHRS recruitment email and advance letters (track changes)

1. Circumstances Making the Collection of Information Necessary

This request is for a nonsubstantive change to an approved data collection - the National Electronic Health Records Survey (NEHRS) (OMB No. 0920‑1015 Exp. Date 12/31/2022). On December 29, 2019, OMB approved the NEHRS annual data collection. The supporting statements requested approval to collect data in 2020, 2021, and 2022 NEHRS cohorts using the updated instrument. In addition, the statements included approval to submit non-substantive change packages, as needed, for modifications occurring throughout the 2020-2022 study period.

In collaboration with the study sponsor, the Office of the National Coordinator for Health Information Technology (ONC), the National Center for Health Statistics (NCHS) is proposing the modification of survey content for the 2020 NEHRS, and subsequent cohorts, for the following reasons:

1. The addition of six telemedicine technology questions to assess the use of telemedicine to provide clinical services to patients in response to the COVID-19 pandemic.

2. The removal of survey content (i.e., 26 questions) that is deemed nonessential for the current priorities of ONC and is no longer well-suited for an outpatient, office-based physician to answer.

3. The removal of the computer-assisted telephone interview (CATI) mode of data collection, to improve physician response rates. The allocation of these resources will be reallocated to efforts focused on tracing physicians prior to fielding to ensure accurate contact information.

4. Key content on the survey are retained to collect necessary trend and practice data in order to evaluate the health information exchange (HIE)-expanded content and Meaningful Use/Promoting Interoperability incentive program goals. This content contains information that will help provide insights on physician attitudes and experiences with electronic health record (EHR) systems, particularly about EHR-related impacts (e.g., patient engagement, documentation in her systems and physician burden, financial benefits, and patient care).

5. Minor modifications to language are proposed to improve clarity, update the burden statement to show the reduced burden, and update terminology.

This document proposes the addition, modification, and removal of questions on the currently approved data collection content for the 2020 NEHRS. A clean version of the modified 2020 questionnaire is provided in Attachment A1. A track changes version of the questionnaire is shown in Attachment A2. Please note that the web component of the questionnaire will mirror the paper questionnaire, but at this time NCHS is unable to provide screen shots of the web survey until a contractor is selected and designs the content. A detailed outline of the changes made to the currently-approved content is presented in Attachment B, highlighted below and described in more detail in section 2. These modifications include a description of changes to improve clarity and update terminology and confidentiality language. Additionally, the computer assisted telephone interview (CATI) mode of administration will be removed, and subsequently the CATI interviewer script will no longer be utilized. Recruitment emails and advanced letters are modified to reflect the reduced completion/burden time, an update in confidentiality language, and the change in NCHS signature (Attachment C1). A track changes version of the emails and letters is presented in Attachment C2. Overall, the changes reduce the currently approved average response time for the NEHRS. Consequently, the 5,151 total burden hours are significantly reduced to 3,434 burden hours.

2. Purpose and Use of Information Collected

The purpose of this study is to collect information on office-based physicians’ adoption and use of EHR systems, practice information, patient engagement, controlled substances prescribing practices, use of HIE, and the documentation and burden associated with medical record systems (which include both paper-based and EHR systems). ONC uses NEHRS data for benchmarking EHR adoption and use across the United States, and for evaluating progress toward Health Information Technology for Economic and Clinical Health (HITECH) Act program goals. NEHRS data also support efforts to access the burden outlined in Section 4001(a) of the 21st Century Cures Act (Public Law 114-255, 42 USC 201). This Act directs DHHS to develop a report outlining how the department could reduce regulatory and administrative burden related to the use of EHRs. NEHRS samples 10,302 physicians annually. As the priorities of ONC evolve for future iterations of the NEHRS, NCHS may submit a non-substantive change or revision package as needed. The National Center for Health Statistics’ Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) was consulted for cognitive testing. However, due to the global COVID-19 pandemic creating safety issues and placing extreme burden on our target survey population of outpatient office-based physicians, this is problematic. ONC frequently consults a team of office-based physicians to inform survey questions and responses. Therefore, we have instead utilized expert review by these physicians to ensure that the modifications to be implemented will not result in any problems.

Six additional questions and a few minor modifications to content, as well as deletions of questions and removal of recruitment material, are proposed for the 2020 NEHRS; they are summarized in Attachment B and below.

The use of telemedicine was assessed in the 2018 and 2019 NEHRS data collections. Continuation of the question will allow the observation of trends in the use of this technology over time. Six new questions on the 2020 NEHRS are designed to assess the use of telemedicine technology in direct response to the COVID-19 pandemic. Telemedicine technology has increasingly become a powerful tool for delivering clinical services to patients as a result of COVID-19. While protecting themselves, patients, and office staff, physicians are overwhelmed with providing clinical services. Telemedicine provides a safe, real-time visit with a health care provider. ONC has reviewed and approved the proposed questions.

To ensure necessary trends and practice data are collected, only a few modifications in the approved questions from the 2020 NEHRS are proposed for this submission. These changes are described in Attachment B. The rationale for these changes is to improve clarity, update the burden statement, reduce the burden, and update terminology.

NCHS proposes to delete content from the questionnaire deemed nonessential for the current priorities of ONC or not well suited for an office-based physician to answer, as these topics are no longer a priority for ONC. Deletions are described in Attachment B. CCQDER was consulted for cognitive testing. However, the COVID-19 pandemic has placed extreme burden on our target survey population. As a result, ONC and NCHS have relied on expert review by office-based physicians to inform survey content. The proposal to reduce content is an effort to improve physician response rates and reduce respondent burden. The proposed changes have been made in collaboration with ONC. Overall, the changes reduce the currently approved average response time and total burden hours for the NEHRS.

3. Use of Improved Information Technology and Burden Reduction

The currently approved NEHRS uses a mixed-mode approach to data collection, which includes self-administered mail, web, and the CATI. NCHS proposes continued use of the mail and web modalities in data collection and discontinuation of the CATI because of low response to this mode. The percentage of respondents who successfully completed the survey via the CATI was 11.8% in 2017, 18.6% in 2018, and only 7.5% in 2019. These estimates are based on final report values from the 2017-2018 NEHRS and the draft final report for 2019 NEHRS. With only mail and web modes of administration, resources will be reallocated to physician tracing efforts, which is expected to simultaneously decrease burden while also increasing response rates.

The web instrument incorporates skip patterns and logic checks. The skip patterns use responses to initial survey questions by a respondent to determine if other survey questions are not applicable, allowing a respondent to automatically skip over them. This instrument design feature allows for a reduction in response burden, where applicable.

In recent years that NEHRS has been conducted, there has been an increasing number of physicians who have responded through the self-administered web instrument compared to earlier years. As such, beginning with the 2019 NEHRS there has been added emphasis on locating physician email addresses. Tracing of these email addresses is projected to increase the number of physician responses. In addition, tracing of physical mailing addresses is projected to increase the number of respondents who self-administer the survey via mail. Recruitment will start with email invitations to a web-based survey and will then be followed by three mailings.

12. Estimates of Annualized Burden Hours and Costs

A. Burden Hours

This non-substantive proposal requests OMB approval for changes to the approved 2020 NEHRS

form (OMB No. 0920‑1015 Exp. Date 12/31/2022). The 2020, 2021, and 2022 NEHRS are expected to sample 10,302 physicians each year. Given the proposed shortening of the 2020 NEHRS, the 5,151 hours of burden associated with administration of the survey have been removed resulting in a new total burden value of 3,434 hours.

Table 1 below represents estimates for each year of data collection over the approval period (2020-2022). NEHRS will be administered to 10,302 physicians each year of the approval.

Table 1. Estimated Annualized Burden Hours

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (Hours)	Total Burden (Hours)
Office-based physicians	NEHRS	10,302	1	20/60	3,434
Total					3,434

B. Burden Cost

Accounting for the reduction in burden, the average annual cost for office-based physicians and office staff to participate over the data collections will also decrease and is estimated to be $273,243.38. The hourly wage estimates for completing the forms mentioned in Table 1 are based on information from the Bureau of Labor Statistics website (http://www.bls.gov). The tables used for this calculation are the “May 2019 National Occupational Employment and Wage Estimates” for (1) healthcare practitioners and technical occupations, physicians, all other; and ophthalmologists, except pediatric, (2) surgeons, except ophthalmologists, and (3) office and administrative support occupations. The total burden hours were evenly divided between the physicians, surgeons, and administrative staff based on information from the 2019 NEHRS data collection. As a result, the hourly wage rate of $79.57 in Table 2 is an average of the mean hourly wages for physicians (i.e., $97.81), surgeons (i.e., $121.17) and administrative and support staff (i.e., $19.73).

Table 2. Estimated Annualized Respondent Costs

Type of Respondent	Response Burden (in hours)	Average Hourly Wage	Total Cost
Office-based physicians, mail survey	3,434	$79.57	$273,243.38
Total			$273,243.38

14. Annualized Cost to the Government

The estimate of the average annual cost to the government for the 2020-2022 NEHRS is given below.

Table 3. Annualized Cost to the Government

Cost	Item
$690,237.00	Contract costs for contract staff salaries, data collection, data entry and data processing for NEHRS
$149,744.50	Federal employee salaries
$839,981.50	Average total cost for 12 months

15. Explanation for Program Changes or Adjustments

Currently, the approved annualized burden is 5,151 hours and the proposed annualized burden is 3,434 hours. The decrease of 1,717 total burden hours is the result of an adjustment in response burden from 30 minutes to 20 minutes for each respondent.