Approved Uniform Data System Changes for 2012

Background

This Program Assistance Letter (PAL) provides information on the Health Resources and Services Administration’s (HRSA) changes to the calendar year (CY) 2012 Uniform Data System (UDS) to be reported by Health Center Program grantees in early 2013.  These changes were approved by the Office of Management and Budget on February 28, 2012.

The changes include: (1) a new staff tenure table; (2) three new clinical measures; (3) reporting on all (versus primary) diagnoses for selected conditions; and (4) questions about electronic health record capabilities and national quality recognition.

2012 Changes to Uniform Data System (UDS)

1.  Addition of New Table 5A, Tenure for Health Center Staff 

A new Table 5A, Tenure for Health Center Staff, is added to better assess workforce needs and improve efforts for workforce development and retention.  

Major features of Table 5A are:

  • Distinguishes full and part time staff from locum tenems, on call, and other staff that provide  limited or temporary staffing
  • Counts number of persons and their total months of service (since the start of their most recent employment) as of the last work day of the year for each category of key staff listed
  • Staff categories and line numbers are consistent with those in Table 5, Staffing and Utilization, but persons are counted as opposed to Full Time Equivalents  

UDS Table 5A – Tenure for Health Center Staff

Key Staff Full and Part Time Locum, On-call, etc.
Persons (a) Total months (b) Persons (c) Total months (d)
1 Family Physicians        
2 General Practitioners        
3 Internists        
4 Obstetrician/Gynecologists        
5 Pediatricians        
7 Other Specialty Physicians        
9a Nurse Practitioners        
9b Physician Assistants        
10 Certified Nurse Midwives        
11 Nurses        
16 Dentists        
17 Dental Hygienists        
20a Psychiatrists        
20a1 Licensed Clinical Psychologists        
20a2 Licensed Clinical Social Workers        
20a3 Other licensed mental health workers        
22a Ophthalmologist        
22b Optometrist        
30a1 Chief Executive Officer        
30a2 Chief Medical Officer        
30a3 Chief Financial Officer        
30a4 Chief Information Officer        

Instructions for these changes will be described in detail in the 2012 UDS Manual and in scheduled trainings on the 2012 UDS. 

2.  Addition of Three New Clinical Measures

The following three new clinical measures are approved for CY 2012 UDS data collection.

Coronary Artery Disease (CAD): Lipid Therapy

Drug Therapy for Lowering LDL Cholesterol: Percentage of patients 18 years and older with a diagnosis of CAD prescribed a lipid lowering therapy (based on current ACC/AHA guidelines).

Ischemic Vascular Disease (IVD): Aspirin Therapy

Percentage of  patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who had a diagnosis of Ischemic Vascular Disease (IVD) and who had documentation of use of aspirin or another antithrombotic during the measurement year.   

Colorectal Cancer Screening

Percentage of adults 50 to 75 years of age who had appropriate screening for colorectal cancer (includes colonoscopy ≤ 10 years, flexible sigmoidoscopy ≤ 5 years, or annual fecal occult blood test). 

The three new measures are added to Table 6B below as Sections I, J, and K, respectively.

Section I – Coronary Artery Disease: Lipid Therapy

Lipid Therapy 

Total Patients 18 and Older with CAD Diagnosis

( a )

Charts Sampled or EHR Total

( b )

Number of Patients Prescribed a Lipid Lowering Therapy

( c )

17

Patients aged 18 and older with a diagnosis of CAD prescribed a lipid lowering therapy      

Section J – Ischemic Vascular Disease: Aspirin or Antithrombotic Therapy

Aspirin or Other Antithrombotic Therapy

Total Patients 18 and Older With IVD Diagnosis or AMI, CABG, or PTCA Procedure

( a )

Charts Sampled or EHR Total

( b )

Number of Patients with Aspirin or Other Antithrombotic Therapy

( c )

18

Patients aged 18 and older with a diagnosis of IVD or AMI, CABG, or PTCA procedure with aspirin or another antithrombotic therapy      

Section K – Colorectal Cancer Screening

Colorectal Cancer Screening

Total Patients 51 to 75 Years Old

( a )

Charts Sampled or EHR Total

( b )

Number of Patients with Appropriate Screening for Colorectal Cancer

( c )

19

Patients age 51 to 75 years with appropriate screening for colorectal cancer      

3.  Change Reporting of Health Conditions on Table 6A from Primary to all Diagnoses

Reporting only primary diagnoses on Table 6A, Selected Diagnoses and Services Rendered, provides a picture of patient health conditions that is less complete than the patient complexity data reported for billing purposes.  In order to improve reporting of patient health conditions in the UDS, HRSA is proposing that Table 6A be revised to collect information on patients with multiple diagnoses.  The change is highlighted below.  Specifically, for all lines in each of the diagnostic categories listed, column a  is changed from number of visits by primary diagnosis to visits with noted diagnoses regardless of primacy and  column b is changed from number of patients with primary diagnoses to total patients with diagnoses regardless of primacy.

 

Proposed Changes to Table 6A – Selected Diagnoses and Services Rendered

Diagnostic Category

Applicable ICD-9-CM

Code

Visits with noted diagnosis Regardless of primacy

( a )

Total patients with diagnosis Regardless of primacy

( b )

II.     Selected Infectious and Parasitic Diseases
III.    Selected Diseases of the Respiratory System
IV.    Selected Other Medical Conditions
V.     Selected Childhood Conditions
VI    Selected Mental Health and Substance Abuse Conditions

4.  Questions about Grantee Electronic Health Record (EHR) Reporting Capabilities and Quality Recognition

The full set of questions in Appendix D is below. 

  1. Does your health center currently have an Electronic Health Record (EHR) system installed and in use?
    1. Yes, at all sites and for all providers
    2. Yes, but only at some sites or for some providers
    3. No
      • If (c) break out to ask if planned and when (3 months, 6 months, 1 year+, add not planned)
      • Pop-up if (a) OR (b)
        1. Please select your EHR product from the list of systems or modules below, and enter the version information in the box that follows.  If other, please specify:
          • Allscripts
          • athena
          • GE Centricity
          • eClinicalWorks (eCW)
          • e-MDs
          • Epic
          • Greenway
          • CompuGroup (HealthPort)
          • IMS
          • Logician
          • McKesson
          • Medinformatix
          • Medinotes
          • MicroMD
          • NextGen
          • Resource Patient Management System (RPMS)
          • Sage
          • Sevocity
          • SuccessEHS
          • Other
    • Pop-up if (b)
        1. How many sites have the EHR in use?
        2. How many providers use the EHR system?
    • Do you use your EHR to electronically extract and submit data for your UDS clinical reporting (Table 6B and 7)?
        1. Yes
        2. No
  2. For each of the core Meaningful Use criteria for computerized capabilities below, please indicate whether your practice has and uses this capability, does not have the capability, or does have the capability but the function is turned off such that it is not used:

Yes/Yes, but turned off or not used/No/Unknown

Patient history and demographic information?

  • If yes, does this include a patient problem list?
  • If yes, does it record and chart changes in vital signs?
  • If yes, does it record weight screening and follow-up?
  • If yes, does it include housing status?

Clinical notes?

  • If yes, do they include a list of the medications that the patient is taking?
  • If yes, does this include a comprehensive list of the patient’s allergies (including allergies to medications)?

Computerized provider order entry (CPOE)?

  • For lab tests?
  • For radiology tests?
    • If yes, are orders sent electronically?
    • If yes, are results incorporated into EHR?
    • If yes, are out of range levels highlighted?

Electronic entry of prescriptions?

  • If yes, are warnings of drug allergies, interactions or contraindications provided?
  • If yes, are prescriptions sent electronically to the pharmacy?

Reminders for guideline-based interventions or screening tests?

  • If yes, does it record smoking status?
  • If yes, does it prompt for and record the tobacco cessation intervention?

Capability to exchange key clinical information among providers of care and patient-authorized entities electronically?

Notifiable diseases sent electronically to state or local health departments?

Reporting to immunization registries done electronically?

Capability to provide patients with an electronic copy of their health information upon request?

Capacity to provide clinical summaries for patients for each office visit?

Does the system protect electronic health information?

  1. Are providers at your health center Meaningful Users of HIT?
    1. Yes.  Providers are receiving Meaningful Use incentive payments from CMS due to their use of health center’s EHR system.
    2. Not yet, but providers at my health center plan to apply to receive Meaningful Use incentive payments from CMS in the coming year.
    3. Providers at health center do not meet the requirements to receive Meaningful Use incentive payments from CMS, or do not plan to apply.
  1. Has your health center received national and/or state quality recognition, either accreditation or patient centered medical home recognition, for one or more sites?
    1. Yes
    2. No
  1. If yes, which third party organization(s) deemed recognition status?  (Can identify more than one)
    1. AAAHC
    2. The Joint Commission
    3. NCQA
    4. State Based Initiative
    5. Private Payer Initiative
    6. Other Recognition Body (write in name)

The above changes to the UDS will be described in detail in scheduled trainings and in the 2012 UDS manual.  

Date Last Reviewed:  August 2018


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