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INTRODUCTION TO THE
UNIFORM DATA SYSTEM
Calendar Year 2012
Bureau of Primary
Health Care
Agenda
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Introducing the UDS
Importance of the UDS
Critical dates in the UDS process
Available Assistance
Overview of UDS Tables and Definitions
Cross Table Consistency in Reporting
Strategies for Successful Reporting
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What is the Uniform Data
System (UDS)?
• Standardized set of data reported by
federally funded programs:
– Section 330 Grantees – Community Health
Center (CHC), Health Care for the Homeless
(HCH), Migrant Health Care (MHC) and Public
Housing Primary Care Program (PHPC)
– FQHC Look-Alike (LAL) agencies
– Urban Indian Health programs
• “Scope of Project” for the period January
1, 2012 - December 31, 2012
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12 Tables: Snapshot of
Performance
• Patients you serve
• Types and quantities of services you
provide
• Staffing mix and tenure
• Quality of the care you deliver
• Costs to provide services to patients
• Revenue sources
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Why is the UDS Important?
• UDS data are used by the BPHC to:
– Ensure compliance with legislative and
regulatory requirements
– Report program achievements
– Monitor performance and identify TA needs
• UDS data are used by programs to monitor
and improve performance
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Critical Dates in the UDS
Process
• DATA ENTRY: Report through EHB (“Electronic
Handbook”) beginning January 1, 2013
https://grants.hrsa.gov/webexternal/login.asp
• EHB training available through HELP in application and
online training module
• EHB incorporates 100s of edits to alert you to possible
problems that require follow-up.
• REPORT DUE DATE: February 15, 2013
• REPORT FINALIZATION: March 31, 2013
• REPORT FEEDBACK: Trend and Comparison
reports available August
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Review Process
• 1:1 Technical Assistance: Report is
assigned to a reviewer who works with you
to correct your data from February 15March 31.
• Reviews tables to identify inconsistencies
and possible errors
• Prepares a summary of issues
• Works with you by phone and email to
correct your data
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Available Assistance
• Regional trainings
• Webinars–LAL, clinical, sampling, changes
• On-line training modules, manual, & fact
sheets available at http://www.bphcdata.net
– Data and reports at
http://bphc.hrsa.gov/healthcenterdatastatistics/r
eporting/index.html
• Telephone and email helpline: 866-UDS-HELP
or udshelp330@bphcdata.net
• Technical support to review submission
– EHB Support (see handout)
• HRSA Call Center: 877-464-4772
• BPHC Help Desk: 301-443-7356
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Twelve UDS Reporting Tables
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Who Reports Which Tables
More than 1 BPHC
Funded program –
Universal + Special Pop.
Grant Reports
Table
1 BPHC Funded
Program –
Universal Report
Look-A-Like Designee
–
Universal Report
ZIP Codes
Yes
3A, 3B, 4
Yes
Yes
No Managed Care or
HCH detail
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Yes
Visits & Patients, only
Yes
5A
Yes
6A
Yes
6B
Yes
Yes
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Yes
No Race/Ethnicity
detail
8A
Yes
Yes
9D
Yes
No Managed Care or
retros
9E
Yes
No 330 grants
Yes
Yes
Yes
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Detailed Tables
• Patient Profile Tables (ZIP Code, T3A, T3B,
and 4)
• Utilization and Staffing (T5 and T5A)
• Clinical Tables (T6A, T6B, and T7)
• Financial Tables (T8A, T9D, and T9E)
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4 Patient Profile Tables
• Patients by Zip Code
• Table 3A: Patients by Age
and Gender
– Tables 3A, 3B, and 4: Grant
report completed for each
additional funding stream
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4 Patient Profile Tables—
continued
• Table 3B: Patients by
Race and Ethnicity
• Table 4: Patients by
Income, Insurance, and
Special Populations
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Data Uses and Accuracy
Checks of Patient Profile
• Uses of Patient Profile Data:
– Describes the patients you serve compared to
target vulnerable populations
– Maps your service area in UDS Mapper
– Calculates indicators such as cost per patient,
visits per patient, etc.
• Data Checks:
– ZIP codes, Table 3A, 3B, and 4 describe the
SAME patients; totals must be equal
– Grant tables are subsets of the universe
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2 Staffing and Utilization
Profile Tables
• Table 5: Types and
quantities of services
provided and staff who
provide these services
– Columns b and c
completed for each
additional funding
stream (include all
activity for patients
reported on grant Tables
3A,3B, and 4)
– Report FTEs, visits, and
patients
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2 Staffing and Utilization
Profile Tables—continued
• Table 5A: Tenure of
Health Center Staff
– From personnel records
– Head count of persons
– Months of service for
selected staff categories
and positions
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Data Uses and Accuracy
Checks of Staffing and
Utilization Profile
• Uses of Staffing and Utilization Data:
– Calculate indicators such as cost per visit,
continuity of care, staffing levels, etc.
– Continuity of staffing
• Data Checks:
– Total patients on Tables 3A, 3B, and 4 cannot
exceed patients on Table 5, nor can Table 5
patients be less than the total on those tables
– Staffing relates to costs on Table 8A
– Visits relate to revenues reported on Table 9D
– Grant tables are subsets of the universe.
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3 Clinical Profile Tables and
EHR Info
• Table 6A: Selected
Diagnoses and Services
– Completed for each
additional funding
stream
– Not reported by LALs
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3 Clinical Profile Tables and
EHR Info
• Table 6B: Quality of
Care Indicators
– “Process measures”: If
patients receive
timely routine and
preventive care, then
we can expect
improved health.
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Early entry into prenatal care
Childhood immunizations
Pap tests
Weight assessment & counseling
on nutrition and activities for
children
Adult weight screening & followup
Tobacco use assessment
Tobacco cessation intervention
Asthma drug therapy
Lipid lowering therapy for those
with coronary artery disease
(CAD)
Aspirin or other anti-thrombotic
therapy for those with ischemic
vascular disease (IVD)
Colorectal cancer screening
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3 Clinical Profile Tables and
EHR Info—continued
• Table 7: Health
Outcomes and
Disparities
 Normal birthweight (≥2500 grams)
 Controlled hypertension (BP<140/90)
 Controlled diabetes (Hba1c ≤ 9)
– “Intermediate outcome
measures”: If this
measurable
intermediate outcome is
improved, then later
negative health
outcomes will be less
likely.
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3 Clinical Profile Tables and
EHR Info Reporting
• Column a: Universe – All patients who meet the
reporting criteria.
• Column b: Universe or sample of 70 patients
– Must report universe when universe is less than 70
patients and for prenatal care and delivery outcome
measures.
• Column c: Compliance – Report number of charts
whose clinical record indicates that the
measurement rules and criteria have been met.
Universe
Sample or
Universe
Records in
Compliance
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Electronic Health Record
(EHR) Addendum
• Series of questions on the adoption of
EHRs, certification of systems, and how
widely adopted the system is throughout
the health center’s providers
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Data Uses and Accuracy
Checks of Clinical Profile
• Uses of Clinical Data:
– Evaluate quality of care provided to patients
– Monitoring for health improvement activities
• Data Checks:
– Patients reported by health condition relates
to patients by age and gender (T3A) and race
and ethnicity (T3B)
– Birth outcomes related to prenatal patients
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3 Financial Profile Tables
• Table 8A – Financial
Costs
– Column a = Accrued
costs of delivering
services
– Coloumn b = total
facility and nonclinical support costs
(Line 16 col a)
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3 Financial Profile Tables–
continued
• Table 9D – Patient Related
Revenue
– Cash income received during
the year for charged services
– Revenues reported by payor:
Medicaid, Medicare, Other
Public, Private, Self Pay
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3 Financial Tables—continued
• Table 9E – Other
Revenues
– Cash income received
during the year from
grants, contracts, and
other non-patient
related sources
– Do not duplicate
revenues reported on
Table 9D
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Data Uses and Accuracy
Checks of Financial Profile
• Uses of Financial Data:
– Evaluate financial viability (e.g., costs vs.
revenues; fee structure, payor mix)
• Data Checks:
– Revenues by payor are related to insurance
enrollment on Table 4, including managed care
– Charges on 9D relate to visits on T5
– Costs on 8A relate to revenues on 9D and 9E
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Key Definitions
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Patient Defined: Who Counts?
• Patient = “Head Count” – total number of
individuals who receive at least one visit
during reporting year
– Patients count once and only once regardless
of the number or scope of visits.
– Not all contacts count as a visit.
– Must have at least one visit that is reported on
Table 5 to count as a patient.
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Visits Defined: What Counts?
• Visit (column b)
– Not all staff report visits
• Physicians, NP, PAs, CNM,
Nurses, Dentists,
Hygienists, BH, vision,
case managers, and
health educators
• No visits: ancillary,
medical assistants,
transportation, eligibility
assistance, non-health
related services, nonclinical support staff
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Visit Defined: What Counts?
• Face to face, one to one between patient and
provider
– Exception: behavioral health (group and telemedicine)
– No group health education, diabetes, etc.
• Licensed provider for medical, dental, vision, etc.
– Include volunteer and contracted provider
• The service must be documented in a chart.
• Providers act independently.
• Use professional judgment unique to their training
and education
– Note: Not all contacts are “visits”
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Visit Defined—continued
• Only 1 visit/patient/provider type/day
– Unless 2 different providers at 2 different sites
• Only 1 visit/provider/patient/day regardless
of the number of services provided
• Count paid referral, nursing home, hospital
visits
• Do not count immunization only, lab only,
dental varnishing, mass screenings, health
fairs, outreach, or pharmacy visits
• Count visits provided by both paid and
volunteer staff
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Full-time Equivalent (FTE)
Defined
• Who is counted? All personnel who contribute
to the operations of the health center at
approved locations
– Employees, contracted staff, residents, and
volunteers
– Do not count paid referral provider FTEs
• How is FTE calculated?
– 1.0 FTE is equivalent to one person working fulltime for one year; prorate part-time and part-year
• CANNOT USE STAFF LIST AS OF DECEMBER 31
– Report FTE based on work performed; FTEs can be
allocated across multiple categories
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Tenure for Health Center
Staff Defined
• Reporting FTEs and Tenure –
are NOT the same thing.
– Selected staff employed by
the health center
• Full- and part-time, part-year,
contract, NHSC
• Locums, on-call, residents, and
volunteers
– Combined tenure
• In consecutive months (not FTE)
• As of last work day of year
• By job title
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Strategies for Successful
Reporting
• Work as a team
– Tables are interrelated
• Adhere to definitions and instructions
– Read manual and apply definitions
• Check your data before submitting
– Relationships exist across tables.
– Address edits in EHB by correcting or providing
explanations that demonstrate your
understanding.
• “Data “says so” does not cut it!”
– Report timely, accurate data.
• Work with your reviewer.
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Thank you for attending this webinar
and for all of your hard work to provide
comprehensive and accurate data to BPHC!
Ongoing questions can be addressed to
UDSHelp330@BPHCDATA.NET
866-UDS-HELP
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