Modernization of NCHS’ National Health Care 

Surveys to Meet Continually Evolving Data Needs for 

the 21st Century

Brian W. Ward, Carol J. DeFrances, and Manisha Sengupta

Division of Health Care Statistics

National Center for Health Statistics

2022 FCSM Research & Policy Conference 

October 25, 2022

National Center for Health Statistics
Overview of the National Health Care Surveys
NCHS Data Collections

NCHS fulfills its mission through various data collections

National 

Health 

Interview 

Survey

National 

Health and 

Nutrition 

Examination 

Survey

National Vital 

Statistics 

System

National 

Health Care 

Surveys

National 

Survey of 

Family 

Growth
 Produce accurate objective, nationally-representative statistics on 

health care to inform health care policy and serve a variety of 

research needs.

 Are establishment surveys, not household surveys.

 Provide estimates about the universe of encounters with providers, 

not the population.

 Historically, patient-level data largely abstracted from medical or 

administrative data.

 Include health care provider surveys to understand this population's 

experience providing care.
National Health Care Surveys Spectrum of Care

National Ambulatory 

Medical Care Survey 

(NAMCS)

1973-ongoing

National Hospital 

Ambulatory Medical 

Care Survey (NHAMCS)

1992-2022

National Hospital 

Discharge Survey 

(NHDS) 

1965-2010

National Hospital Care Survey (NHCS) 

2011-ongoing

National Study of Long-Term 

Care Providers (NSLTCP)

2012-2018

Ambulatory and Hospital Care Long-Term Care

• Physician offices

• Community health 

centers

• Emergency dept.

• Outpatient dept.

• Ambulatory surgery 

locations

• Inpatient dept. • Residential care • Adult day services

• Nursing homes • Home health

• Hospice care

Plus...

• Inpatient rehab facilities

• LTC hospitals

National Post-Acute and LongTerm Care Study (NPALS)

2020-ongoing

National Electronic 

Health Records 

Survey (NEHRS)

2008-2021, 2024
 Developing and leveraging EHR standards

 Moving to EHR data and modernizing NHCS, NAMCS, and NPALS

 Building cloud-based infrastructure for EHR data collection

 Utilizing new and timely manners of data dissemination

Overview of Improvements and Modernization Strategies for 

the National Health Care Surveys 
Developing and Leveraging EHR Standards
Leveraging Healthcare Data & Interoperability Standards to 

Enable EHR Data Collection

 Consolidated Document Architecture (CDA): HL7 CDA National Health Care Surveys 

Implementation Guide (IG)

• Early releases aligned with older data element lists and added all medications, lab 

results, and procedures.

• Latest Release is streamlined by dropping lower importance data elements but most 

EHRs already implemented earlier releases and are unable to move to latest release.

 Fast Healthcare Interoperability Resources (FHIR): HL7 Health Care Surveys Content 

Implementation Guide (IG)

• Highly aligned with the United States Core Data for Interoperability (USCDI) standard.

• This content IG uses the technical infrastructure of the HL7 MedMorph Reference 

Architecture IG, most notably the MedMorph app, which is also used in CDC 

elsewhere:

o electronic Case Reporting (eCR)

o Centralized Cancer Registry Reporting

o Other public health and research use cases
 Pilot tasks:

• Select providers

o 2 Ambulatory physician/provider groups

o 1 Federally qualified health center (FQHC)

o 1 Hospital

• With each Provider, co-implement

o MedMorph Reference Architecture IG

 MedMorph App inside provider’s firewall

o National Health Care Surveys Content IG

 USCDI/17 HL7 FHIR US Core Profiles

• Build data lake to process and store EHR data collected.

• Build data governance structure to allow sharing of EHR data with other Centers 

throughout CDC.

National Health Care Surveys FHIR Application Pilot in 2022-2023
Leveraging Healthcare Interoperability Regulations to Enable 

EHR Data Collection

 CMS Promoting Interoperability (PI) Program

• Provider participation (data submission via Certified EHR Technology) in the 

National Health Care Surveys fulfills a Public Health Reporting measure.

• Approximately 110,000 providers and 365 hospitals have registered their intent to 

send EHR data to NCHS in the National Health Care Surveys Registry.

• 100+ EHR products are certified to the PI health care surveys measure.

 ONC’s Cures Act Final Rule (2020)

• HL7 National Health Care Surveys CDA IG – standard/format named as part of 

the EHR Certification Program Criteria in the rule.

• International collaboration among CDC Programs to name Public Health FHIR IGs, 

including the Health Care Surveys (FHIR) Content IG, in near-term future 

regulations for inclusion in PI.
Moving to EHR Data and Modernizing NHCS, 

NAMCS, and NPALS
National Hospital Care Survey (NHCS)

 Purpose: Provide reliable and timely health care utilization data for hospital-based 

settings.

 Sample: Non-federal, non-institutional hospitals with 6+ staffed inpatient beds.

 Mode: Administrative claims data and electronic health record (EHR) data transmitted 

electronically to NCHS or its data collection agent.

 Questionnaire: Annual Hospital Interview collects facility information needed for 

statistical weighting.

 Data collection: January-December annually, restricted-use files.

 Sample size: 608 hospitals in sample; all inpatient and ED encounters (i.e., entire calendar 

year) requested; 150-200 hospital respondents per year.

 Linkage capability: Personally-identifiable information (PII) is collected, which allows data 

linkage across hospital settings and to external data sources such as the NDI, CMS, and 

HUD data.
National Hospital Care Survey: Modernization

 Purchase of data to supplement data collection

• American College of Emergency Physicians (ACEP)

• Premier

 Conducting new methodological work

• Use data collected directly from hospitals and purchased data for modelling of 

national estimates.

• Explore use of synthetic data for public use and RDC files.

 Data linkage work

• NHCS data have been linked to the NDI, various CMS data sets, HUD data; and VA 

data is now in progress.

 Natural Language Processing (NLP) Work

• Using EHR clinical notes to identify opioid-involved hospitalizations.
National Ambulatory Medical Care Survey (NAMCS) - Health Center 

Component

 Purpose: Designed to meet the need for objective, reliable information about the 

provision and use of ambulatory medical care services in the United States.

 Sample: Federally qualified health centers (FQHCs) and FQHC look-alikes as classified by 

the Health Resources and Services Administration (HRSA).

 Mode: Electronic health record (EHR) data transmitted electronically to NCHS or its data 

collection agent.

 Questionnaire: Facility Interview collects HC information needed for statistical 

weighting.

 Data collection: January-December annually, restricted-use files.

 Sample size: 50 HCs in 2021; +50 HCs in 2022 (total of up to 100); +50 HCs in 2023 (total 

of up to 150).

 Linkage capability: PII is collected which allows linkage to NDI, HUD and Medicaid data.
NAMCS – Health Center Component: Modernization

 Transition from abstraction to EHR data collection

• Working with HRSA to recruit up to 50 FQHCs or FQHC look-a-likes to transmit EHR data in 

HL7 CDA format or customized report to NCHS for 2021 and moving forward.

 Additional recruitment and data availability

• Funding will be used for 2023 data collection to increase the sample for an additional 50 

FQHCs or FQHC look-a-likes to bring total sample up to 150 and build interactive dashboard 

for preliminary and final national estimates.

 Incentivize participation

• Provide up to $10,000 for set-up to activate module on their system or have vendor send 

customized report to NCHS.

 Data linkage work

• Assessment/exploration of linkage to the NDI and HUD administrative data beginning Fall 

2022.
National Post-Acute Long-Term Care Study (NPALS)

 Purpose: Designed to estimate the supply, use, characteristics, and practices of paid, 

regulated post-acute and long-term care providers and services users in the United 

States.

 Sample: Residential care communities and adult day services centers that meet study 

definition.

 Mode: Multi-mode surveys using web and mail questionnaires with non-response 

follow-up by telephone.

 Questionnaire: Provider questionnaire collects information about providers and 

aggregated information about services users; alternate year services user questionnaire. 

 Data collection: Biennial, restricted-use files.

 Sample size: About 11,600 residential care communities and 5,500 adult day services 

centers for state and national estimates; alternate years about 2,100 residential care 

communities and 1,700 adult day services centers for national estimates only.
NPALS: Modernization

 Purpose

• Identify existing EHR platforms/systems that may serve as alternative sources of data 

on adult day services centers and residential care communities as well as their services 

users. 

• Determine what information about providers and service users may be available on 

these EHR platforms: 

o Whether the data are available on a consistent basis across geographic areas and 

provider types.

o Whether the data are aggregated, or do they have identifiable information that can 

be used to link these data to the NPALS respondents; and 

o Whether the data are collected on a regular basis and how often the data are 

collected/updated (including lag time). 

 Mode

• Electronic search of EHR literature; interviews with subject matter experts.
Building Cloud-based Infrastructure for EHR 

Data Collection
HEHR Cloud Migration Overview
Utilizing New and Timely Manners of Data 

Dissemination
Traditional Data Dissemination: Data Files

 Public use files and associated documentation

• Reviewed by NCHS Disclosure Review Board

• Available for download on NCHS website

 Restricted use files

• Available through the NCHS Research Data Center (RDC) Network
Traditional Data Dissemination: Reports and Articles

 NCHS publications

• NCHS Data Briefs, National Health Statistics Reports, Vital and Health Statistics 

Series reports, MMWR QuickStats, web tables

 Peer-reviewed journal articles

• Examples: JAMA, Health Affairs, AJPH, AJPM

 Official government reports

• CDC's Morbidity and Mortality Weekly Report (MMWR)

• NCHS' Health, United States

• AHRQ's National Healthcare Quality and Disparities Report
New Data Dissemination: Preliminary Release of COVID-19 Data
Example: Long-term Care and COVID-19 Preliminary and 

Final Data
Example of Preliminary NPALS Data
Expansion of Dashboard Releases: Preliminary and Final Data
Giving Data Back to Providers: Annual Hospital Report Portal

 Developed a data visualizations web portal for NHCS participating sampled hospitals to view 

transmitted data to NCHS, including aggregate 30-, 60-, 90-day post-acute mortality.
Moving Forward...
Moving Forward...

 Develop and leverage EHR standards

• Have Health Care Surveys (FHIR) Content IG, included in Promoting 

Interoperability regulations

• Conduct and build on the FHIR Pilot

 Moving to EHR data and modernizing NHCS, NAMCS, and NPALS

• Continue to release NHCS preliminary data and supplement the data 

collected directly in the NHCS to make reliable national estimates.

• Continue to expand the sample for FQHCs in NAMCS for collection of EHR 

data and produce preliminary and reliable national estimates.

• Explore collection of EHR visit data for physicians and other advance care 

providers' visits in NAMCS, and residential care communities and adult day 

service centers in NPALS.
Moving Forward (cont.)

 Building cloud-based infrastructure for EHR data collection

• Migrate infrastructure from an on-premises architecture to MS Azure 

cloud.

• Incorporate cloud-native capabilities.

 Utilizing new and timely manners of data dissemination

• Explore additional means of disseminating preliminary and final data via 

Dashboards and new products

• Continue NDI, CMS, and HUD data linkages

• Explore other data set linkages (e.g., Veterans Affairs)

• Continue NLP and algorithm development work for opioid and other 

drug encounters, social determinants of health, and other medical 

conditions

• Explore development of synthetic data for public and restricted use files.
Thank you!

For questions: 

Brian Ward (bwward@cdc.gov) 

For more information on the National Health Care Surveys:

https://www.cdc.gov/nchs/dhcs/index.htm

The findings and conclusions in this presentation are those of the authors and do not necessarily 

represent the official position of the NCHS or the Centers for Disease Control and Prevention.
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov