Attachment S - NHCS FAQ Brochure 010716

Attachment S: NHCS FAQ Brochure

Frequently
Asked
Questions
About the
National Hospital Care Survey

Attachment S: NHCS FAQ Brochure

Frequently
Asked
Questions
About the
National Hospital
Care Survey
1. What is the National Hospital Care Survey?
The National Hospital Care Survey (NHCS) provides nationally
representative data on inpatient hospital care, as well as care
delivered in emergency departments and outpatient
departments. More information about NHCS can be found at:
http://www.cdc.gov/nchs/nhcs.htm.

2. Who is sponsoring NHCS?

The Centers for Disease Control and Prevention’s (CDC) National
Center for Health Statistics (NCHS) is sponsoring NHCS. NCHS is the
Nation’s principal health statistics agency and is responsible for
assessing the health status and health care needs of people in the
United States. More information about NCHS can be found at:
http://www.cdc.gov/nchs/.

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Attachment S: NHCS FAQ Brochure

3. What are the benefits of participation?
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Compensation: Your facility will be paid $500 for setting up the
procedures to send electronic files to the contractor’s secure
network connection and for sending a test file. Additionally your
facility will receive $500 for each full year of data submitted
every year. That makes two $500 payments the first year and
$500 every year thereafter. Hospitals which agree to allow NHCS
project staff to abstract a sample of visits to ambulatory units will
be paid an additional $500.
CEU Credits: Health Information Management (HIM) professional
staff members are eligible for free continuing education credits
after completion of an on-line training about participating in
NHCS.
Data for Comparison: Selected summaries of your inpatient data
will be provided and/or comparative profiles showing statistics
for inpatients from similar types of hospitals may be provided.
National Statistics: By participating, your facility provides useful
data on hospital care which will inform policies to improve the
state of health care in the nation.
Improved Patient Care: Your participation will result in more
reliable statistics enabling researchers to better understand
health care provided by hospitals.

4. Will patient privacy and confidentiality be maintained?
Yes. NCHS is required by law to keep all data regarding patients and
hospitals confidential and to use these data only for research and
statistical purposes, as stated in Section 308(d) of the Public Health
Service Act [42 USC 242m(d)] and Section 513 of the Confidential
Information Protection and Statistical Efficiency Act (CIPSEA, PL
107–347). All protected health information will be kept confidential
and will be used only by NCHS staff, contractors, and agents—only
when required and with necessary controls. CIPSEA also includes
provisions for a felony conviction and/or a fine of up to $250,000 if
NCHS staff or any NCHS contractor staff violates the confidentiality
provisions.
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Attachment S: NHCS FAQ Brochure

The National Hospital Care Survey has been approved by the NCHS
Institutional Review Board (IRB). If you have questions about your
rights as a participant in this research study, please call the
Research Ethics Review Board at NCHS, toll-free, at 1–800–223–
8118. Please leave a brief message with your name and phone
number, and say that you are calling about Protocol 2009–21.

5. Does HIPAA permit health care facilities to provide this patient
information?
Yes. NHCS is being conducted under the auspices of CDC/NCHS
(federal government). Special provisions within HIPAA permit health
care facilities to provide data to public health entities such as
CDC/NCHS for public health purposes.
The HIPAA Privacy Rule recognizes 1) the legitimate need for public
health authorities and others responsible for ensuring the public’s
health and safety to have access to protected health information to
conduct their missions, and 2) the importance of public health
reporting by covered entities in identifying threats to the public and
individuals. The Privacy Rule permits 1) protected health
information disclosures without a written patient authorization for
specified public health purposes to public health authorities legally
authorized to collect and receive the information for such purposes,
and 2) disclosures that are required by state and local public health
or other laws [HIPAA regulations (45 CFR 164.501)].
Thus, HIPAA permits hospitals such as yours to participate in studies
of this nature, such as the NHCS, for public health purposes.
Because our contractors are serving as authorized agents of NCHS, it
is permissible to disclose data to them for the purposes of this
project. HIPAA also permits covered entities to obtain the
documentation and rely on the approval of one IRB or privacy
board. In this case, the hospital may rely on the approval of the
NCHS’ IRB.

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Attachment S: NHCS FAQ Brochure

6. Who is conducting NHCS?
NCHS has contracted with Westat for recruitment and data
collection activities of NHCS. Westat is an agent of NCHS. More
information about Westat can be found at:
http://www.westat.com.

7. What does participation in the NHCS entail?
Participation in NHCS includes the following:
• An eligibility interview to determine your hospital’s eligibility and
the eligibility of your hospital’s emergency department (ED)
and/or outpatient departments (OPDs).
• Completion of an annual inpatient hospital questionnaire on
hospital characteristics, total admissions, total births and total
number of beds.
• An ambulatory hospital interview completed every 15 months,
through in-person and telephone interviews with hospital
administrators and staff in eligible EDs and OPDs.
• Electronic submission of Uniform Bill (UB)-04 administrative claims
data or an electronic file in the same format as the file submitted
to the state. Medical record data can also be submitted
electronically from Electronic Health Records.
• Abstraction of medical records data from sampled visits to
ambulatory units.
Each of these activities will occur on separate time tables. The
submission of your electronic data will be continuous while the
completion of questionnaires and the abstraction of medical records
will be less frequent and in some cases not start for several months
following the submission of the data.
You may be asked to participate in special studies on occasion, and
you may choose to participate in these studies if you wish.

8. How many records from our hospital will we need to transmit to
you?

We are asking hospitals to submit electronic data for inpatient and
ambulatory visits from your hospital. A sample of visits from your ED
and OPDs for a specific reference period will be abstracted from
medical records data.
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Attachment S: NHCS FAQ Brochure

9. How much hospital staff time will participation require?
Once your hospital decides to participate in the survey, you will
be contacted to arrange the following:
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Eligibility Interview: A one-time interview to determine
eligibility and obtain general information about your
hospital. This may take up to one hour, including answering
any questions you may have.
Inpatient Hospital Questionnaire: An annual questionnaire
conducted either by telephone or mail, to obtain specific
information about hospital characteristics, total admissions,
total births and total number of beds. This will take about an
hour to complete.
Ambulatory Hospital Interview: Every 15 months, in-person
and telephone interviews will be conducted with hospital
administrators and staff in eligible EDs and OPDs. These
may take approximately two hours to complete.
Electronic Data Submission: The time to set up or complete
the submission process will vary by hospital but can take up
to four hours.
Medical Record Abstraction: Abstraction of a sample of medical
records from the ED and OPD. These data collection activities will
be conducted by NCHS and their agents. All protected health
information will be kept confidential and will be used only by
NCHS staff, contractors, and agents when required and with
necessary controls.

Not all of these activities will occur in the same time period. For
example, your hospital may be contacted and asked questions
concerning eligibility and begin transmitting electronic data and
then several months later be contacted again with questions about
your ambulatory services and to arrange for the abstraction of
medical record data for a sample of ambulatory visits. Throughout
the survey NCHS and its agents will remain respectful of your
hospital’s priorities and work closely with you to arrange for work to
be completed on a schedule that best accommodates your hospital.
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Attachment S: NHCS FAQ Brochure

10. How did you select our hospital to participate? Can another
hospital participate in our place?
Your health care facility was randomly chosen to provide
representative data not only for your hospital, but also for similar
hospitals of the same service type, bed size, and geographic
location. Selections were made to obtain enough facilities of
different sizes, service types, and geographical locations to ensure
that the hospitals in our study are nationally representative.
Unfortunately, for statistical reasons, it is not possible to substitute
another hospital. If we replaced your hospital with another
hospital, this might introduce bias or inaccuracies into the data we
collect. This would hinder our ability to make estimates about the
amount and types of care provided, as well as the types of patients
served, in the entire United States and in hospitals like yours.

11. Who else is participating in NHCS?
The identity of your hospital and other hospitals participating in this
study is confidential. Neither NCHS nor its agents may disclose the
identity of participants in the NHCS to anyone, including to other
participants. No data will be shared among hospitals.

12. What will happen with the information we give you?
All information collected will be the property of NCHS and will be
kept strictly confidential. The identity of specific hospitals or
individual patients will not be released in any manner except to
NCHS staff, contractors, and agents—only when required and with
necessary controls. Results of the study will be published only in an
aggregated manner that will not allow identification of any
individual hospital or patient.

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Attachment S: NHCS FAQ Brochure

13. How long will our hospital be in this study? Will we need to
provide information on an ongoing or long-term basis?
The survey is designed to collect data from your facility on an
ongoing basis, until a new sample is inducted. We do not know
when a new sample will be drawn, but it will not be for several
years.

14. Do we need to let our patients know that we are accessing their
records for the NHCS?
HIPAA and the Privacy Rule permit disclosure of protected health
information and medical record information without written patient
authorization, for specific public health purposes, to public health
authorities and their authorized agents, including federal public
health agencies such as CDC, of which NCHS is a part. Thus, HIPAA
regulations (45 CFR 164.501) do not require you to obtain patient
authorization prior to disclosing protected health information to
NCHS or to Westat, as an authorized agent of NCHS.
If a patient requests information about disclosures of his or her
protected health information, the Privacy Rule requires hospitals to
keep accounting documentation for 6 years. NCHS has developed an
accounting document for NHCS participating hospitals that
facilitates your response to patient requests regarding such
disclosures. An accounting document will be provided to your
hospital during the survey to simplify your recordkeeping and for
your convenience in complying with this requirement. Although
NHCS data collection will involve more than 50 records, hospitals are
not required to account for the disclosures of information about any
particular individual.

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Attachment S: NHCS FAQ Brochure

15. Why are you collecting Social Security numbers?
The Social Security number is collected to allow linkage with
administrative databases such as Medicare and with vital records
such as the National Death Index (NDI). For example, we plan to link
to NDI, a computerized central file of death record information, to
measure post-discharge mortality. NCHS compiles the NDI from
data collected by state vital statistics offices. Records are matched
using Social Security number and other variables such as name, date
of birth, sex, and state of residence. By law, your sharing of this
information is voluntary, and whether it is provided or not will have
no effect on a patient’s benefits. Only NHCS project staff,
contractors, and agents working directly on NHCS will have access
to this information.

16. OK, I’m interested in participating in NHCS. What’s the next step?
Please call Ms. Carolyn Almen, NHCS Recruitment Manager, at our
toll-free number, 888-377-7161, extension 4744, to talk about your
participation in the National Hospital Care Survey.
You may also contact Dr. Carol DeFrances, Branch Chief,
Ambulatory and Hospital Care Statistics Branch, NCHS, at 301–
458–4440.

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Attachment S: NHCS FAQ Brochure

National Hospital
Care Survey
Visit the survey website:

http://www.cdc.gov/nchs/nhcs.htm