UDS Summary of Revisions

Revised Uniform Data System Reporting Instruments

November 4, 2011

The proposed changes in UDS Tables and Questions for 2012 are shown in the following attachments:

Attachment 1 – Table 5A, Tenure for Health Center Staff

Attachment 2 – Table 6 A, Selected Diagnoses and Services Rendered

Attachment 3 - Table 6B, Quality of Care Indicators

Attachment 4 - Electronic Health Record (EHR) Capabilities and National Quality Recognition

Certain edits, format, and reporting changes are also made. These are shown as Attachment 5.

Attachment 1. 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 TABLE 5A – Tenure for Key Staff

Table 5A is reported on the Universal Report only. This table provides further information on the tenure of key health center leadership staff and of your providers. Providers are defined as falling into one of two categories – (1) Full and Part Time staff and (2) Locums, On-call and Others – as defined further below. The staffing information in Table 5a uses the same definitions as Table 5, and individuals on the selected lines on Table 5a are the same individuals that are reported on table 5. Line numbers on Table 5A correspond to those on Table 5. Not all Table 5 lines are reported. Specifically, lines for non-providers, other than key management staff, are excluded, as are other health providers and enabling services providers.

Definitions.

• Full and Part Time Staff. Full and part time staff are individuals who are considered regular employees of the health center. They may be paid in a number of different ways and may work different amounts of time. Future employment may be limited by the expiration of a contract or may be “open-ended” with no specific end date.

  • Full Time Staff. Are “employed” by the health center, receive benefits, have withholding taxes deducted from their paychecks, and have their income reported to IRS on a form W2.. Staff may or may not have a contract. Staff are considered to be full time when they are so defined in their contract and/or when their benefits reflect this status. (For example, if a full time employee gets eight hours off for a holiday, they get eight hours off.) They may have assigned work hours which are less than 40 per week, and may actually end up working more than those assigned hours.

  • Part Time Staff. Are “employed” by the health center, receive benefits consistent with their FTE, have withholding taxes deducted from their paychecks, and have their income reported to IRS on a form W2.. Staff may or may not have a contract. Staff are considered to be part time when they are so defined in their contract and/or when their benefits reflect this status. (For example, if a full time employee gets eight hours off for a holiday, a 75% part time staff person would get six hours off.) Part time staff may actually end up working more than their assigned hours.

  • Part Year staff. Persons employed full or part time for a specific period of at least three months per year because of a recurring special need. This is especially common in centers that serve fishing fleets, migrant workers, or recreation areas. To be included they must either be working at the time of the census or be under agreement to return to the clinic in the following year.

  • Contract staff. Are “contracted” by and work at the health center. They may or may not receive benefits appropriate to their FTE. They do not have withholding taxes deducted from their paychecks, and have their income reported to IRS on a form 1099.

  • NHSC assignees. Are members of the National Health Service Corps who are assigned by the Corps to the health center. This includes members of the “ready reserve.” These individuals are employees of the U.S. Government. The health center may or may not have a contract with the NHSC to pay a specific amount to cover the cost of their assignment.

• Locums, on-call, etc. Health centers often make use of individuals other than their regular staff to provide services to patients.

  • Locum tenens. Locums work at a health center on an “as needed” basis. They are most commonly used to fill in for a part time absence of another provider (i.e., on a day off or to cover for a vacation, sick leave, FMLA, etc.) but may also be used when the center is unable to hire a full- or part-time staff person for a position. Locums are uniquely identifiable because they work for an agency and the center pays the agency rather than the individual. They do not receive benefits from the health center (though they may from the agency they work for) and generally are not covered by the health center’s mal-practice insurance. Generally locums cannot be hired by the center as a full- or part-time employee without paying a fee to the agency.

  • On-call providers. On call providers also work at a health center on an “as needed” basis, and are also most commonly used to fill in for a part time absence of another provider (i.e., on a day off or to cover for a provider who is on vacation, sick leave, FMLA, etc.) but may also be used for an extended period when the center is unable to hire a full- or part-time staff person for a position. Unlike locums, on-call providers are paid by the health center. They may or may not receive benefits, and may or may not have payroll and income taxes withheld. On-call providers are generally not covered by FTCA though they may be covered by the centers gap insurance.

  • Volunteers. Health center volunteers may have a regular schedule which may include a large number of hours or just a few hours a month. They are generally scheduled by the session. Volunteer providers are not paid by the health center and do not receive benefits. They are not covered by FTCA though they may be covered by the centers gap insurance.

  • Residents / trainees. Many health centers are involved in training programs which involve the trainee working providing services at the health center under the supervision of a more senior person. Many of these trainees (especially medical and dental residents) are licensed in their own right:

    • In the case of medical residents, they are included on the line for which they are in training, so a family practice resident will be counted on the family practice line, even though they have not yet passed the boards for that additional certification.

    • In the case of mental health interns or residents, those who are licensed at a level other than that for which they are training are eligible to be reported. A Psychology resident may be a Licensed Clinical Social Worker, in which case they would be considered on the LCSW line. But an LCSW trainee who holds no independent license would not be reported on this table at all.

    • An individual who is not licensed is not to be counted.

  • Off-site Contract Providers. In some instances health centers contract for the services of providers who work at a location that is not an in-scope site as defined in their application. This may be because the center does not have the critical mass to be able to establish a service (e.g., a dental contract) or because they are serving a wider area than their existing sites can reach (especially in migrant voucher or homeless programs.)

    • If the provider is contracted for a specific time (e.g., Monday and Wednesday afternoons or two days per week) they are to be considered for this table.

    • If the provider is paid by the visit they are not to be considered for this table.

  • Administrative Consultants. Some organizations – especially smaller and more remote organizations – fill administrative positions because they are unable to recruit administrative staff or are unable to support a full time person in an administrative role. These individuals may be considered for inclusion on lines 30a1, 30a2, 30a3, and 30a4.

• Persons. Unlike Table 5 Table 5A is a census of staff as of the last work day of the year. Include only individuals who are working on that day or who are current employees / contractors / etc who have that day off, but are scheduled to return on a specific day. (In other words, include someone who has the day off or who is on vacation or sick leave, but do not include individuals who will be used again in the future, but are not regular staff.)
  
  Also unlike Table 5 count each individual that serves in one of the roles identified on Table 5A as 1 person. FTEs are not to be considered, and Columns a and c only permit the entry of whole numbers. In order to be included in the count of persons an individual must meet one or more of the following criteria:

  • Be employed full time

  • Be employed part time on a regular basis with a regular schedule that includes no less than two days per month

  • Be an NHSC clinician who is assigned to the health center

  • Be contracted on a regular basis with a regular schedule that includes no less than two days per month

  • B e an on-call, locum, or volunteer provider who has worked a regular schedule of no less than two days per month for at least six months
    
    DO NOT count individuals who may work many days, but do not work a regular schedule, such as a locum or on-call provider who is called in any time one of the many physicians on staff are sick.
    
    

• Months. For each person being included on Table 5A, count the number of continuous months (rounded to the closest whole number) that that person has been in their current position. For example:

  • Persons who have been continuously employed (contracted for) in their current position, regardless of whether or not the census day is a regular work day: Report the number of months since they were hired.

  • Persons who have been employed more than once and whose employment was terminated between the two (or more) periods: Report the number of months since they were most recently hired.

  • Persons who have served multiple positions in a health center (e.g., a long term physician who was recently promoted to medical director): Report the number of months since they began the position they are being counted for.

  • Persons who are counted on Table 5A in two or more positions (e.g., a pediatrician/medical director of CEO/CFO): Report the number of continuous months they have been holding each position. (So it might be 50 months as pediatrician and 9 months as medical director.)

FULL AND PART TIME STAFF: COLUMN A

Table 5a column A provides information on the number of full and part time staff as defined above who work in selected positions within the scope of the project for all of the programs covered by the UDS. All staff reported on a given line on table 5A will have been reported on the same line on table 5. Because all persons counted on Table 5A are counted as 1, while any one or more of them might be reported as a fractional FTE on table 5, the sum of column A and column C for any line must be greater than or equal to the corresponding line on table 5. Count each staff person working in a given position who qualifies under the definitions above as 1 staff person. For example:

• A full time physician who was employed on the census date is counted as 1 person.

• Two half time physicians who were employed on the census date (regardless of whether or not they actually worked that day) are counted as 2 persons.

• A part time physician who works every summer during the migrant season, but was not present on the census date is counted as 1 person.

• A full time physician who worked for the center for ages, but resigned prior to the census date is not counted at all.

• A physician on pregnancy leave who has been out for 8 weeks but intends to return after the leave is over is counted as 1 person even though she was not present on the census day.

Locums, On-call, etc.: COLUMN c:

Table 5a column C provides information on the number of persons defined above who work in selected positions within the scope of the project for all of the programs covered by the UDS. All staff reported on a given line on table 5A will have been reported on the same line on table 5. Because all persons counted on Table 5A are counted as 1, while any one or more of them might be reported as a fractional FTE on table 5, the sum of column A and column C for any line must be greater than or equal to the corresponding line on table 5. Count each staff person working in a given position who qualifies under the definitions above as 1 staff person.

Months: COLUMNS b and D

Report the total number of continuous months with the health center for those persons identified in column a or c.

ATTACHMENT 2 - TABLE 6A – SELECTED DIAGNOSES AND SERVICES RENDERED (Change is to headings of columns (A) and (B) for lines 1 to 20d)

Diagnostic Category		Applicable ICD-9-CM Code		Visits with diagnosis Regardless of primacy (A)		Total patients with diagnosis Regardless of primacy (B)
Selected Infectious and Parasitic Diseases
1-2.	Symptomatic HIV , Asymptomatic HIV		042 , 079.53, V08
3.	Tuberculosis		010.xx – 018.xx
4.	Syphilis and other sexually transmitted diseases		090.xx – 099.xx
4a.	Hepatitis B		070.20, 070.22, 070.30, 070.32
4b.	Hepatitis C		070.41, 070.44, 070.51, 070.54, 070.70, 070.71
Selected Diseases of the Respiratory System
5.	Asthma		493.xx
6.	Chronic bronchitis and emphysema		490.xx – 492.xx
Selected Other Medical Conditions
7.	Abnormal breast findings, female		174.xx; 198.81; 233.0x; 238.3 793.8x
8.	Abnormal cervical findings		180.xx; 198.82; 233.1x; 795.0x
9.	Diabetes mellitus		250.xx; 648.0x; 775.1x
10.	Heart disease (selected)		391.xx – 392.0x 410.xx – 429.xx
11.	Hypertension		401.xx – 405.xx;
12.	Contact dermatitis and other eczema		692.xx
13.	Dehydration		276.5x
14.	Exposure to heat or cold		991.xx – 992.xx
14a.	Overweight and obesity		ICD-9 : 278.0 – 278.02 or V85.xx excluding V85.0, V85.1, V85.51 V85.52
Selected Childhood Conditions
15.	Otitis media and eustachian tube disorders		381.xx – 382.xx
16.	Selected perinatal medical conditions		770.xx; 771.xx; 773.xx; 774.xx – 779.xx (excluding 779.3x)
17.	Lack of expected normal physiological development --does not include sexual or mental development; Nutritional deficiencies		260.xx – 269.xx; 779.3x; 783.3x – 783.4x;

Diagnostic Category			Applicable ICD-9-CM Code	Visits with diagnosis Regardless of primacy (A)	Total patients with diagnosis Regardless of primacy (B)
Selected Mental Health and Substance Abuse Conditions
18.	Alcohol related disorders	291.xx, 303.xx; 305.0x 357.5x
19.	Other substance related disorders (excluding tobacco use disorders)	292.1x – 292.8x 304.xx, 305.2x – 305.9x 357.6x, 648.3x
19a.	Tobacco use disorder	305.1
20a.	Depression and other mood disorders	296.xx, 300.4 301.13, 311.xx
20b.	Anxiety disorders including PTSD	300.0x, 300.2x, 300.3, 308.3, 309.81
20c.	Attention deficit and disruptive behavior disorders	312.8x, 312.9x, 313.81, 314.xx
20d.	Other mental disorders, excluding drug or alcohol dependence (includes mental retardation)	290.xx; 293.xx – 302.xx (excluding 296.xx, 300.0x, 300.2x, 300.3, 300.4, 301.13);  306.xx - 319.xx (excluding 308.3, 309.81, 311.xx, 312.8x, 312.9x,313.81,314.xx)

TABLE 6A – SELECTED SERVICES RENDERED

Service Category		Applicable ICD-9-CM or CPT-4 Code	Number of Visits (A)	Number of Patients (B)
Selected Diagnostic Tests/Screening/Preventive Services
21.	HIV test	CPT-4: 86689; 86701-86703; 87390-87391
21a.	Hepatitis B test	CPT-4: 86704, 86706, 87515-17
21b.	Hepatitis C test	CPT-4: 86803-04, 87520-22
22.	Mammogram	CPT-4: 77052, 77057 OR ICD-9: V76.11; V76.12
23.	Pap test	CPT-4: 88141-88155; 88164-88167, 88174-88175 OR ICD-9: V72.3; V72.31; V76.2
24.	Selected Immunizations: Hepatitis A, Hemophilus Influenza B (HiB), Pneumococcal, Diptheria, Tetanus, Pertussis (DTaP) (DTP) (DT), Mumps, Measles, Rubella, Poliovirus, Varicella, Hepatitis B Child)	CPT-4: 90633-90634, 90645 – 90648; 90670; 90696 – 90702; 90704 – 90716; 90718 - 90723; 90743 – 90744; 90748
24a.	Seasonal Flu vaccine	CPT-4: 90655 - 90662
24b.	H1N1 Flu vaccine	CPT-4: 90663; 90470
25.	Contraceptive management	ICD-9: V25.xx
26.	Health supervision of infant or child (ages 0 through 11)	CPT-4: 99391-99393; 99381-99383;
26a.	Childhood lead test screening (9 to 72 months)	CPT-4: 83655
26b.	Screening, Brief Intervention, and Referral to Treatment (SBIRT)	CPT-4: 99408-99409
26c.	Smoke and tobacco use cessation counseling	CPT-4:  99406 and 99407; S9075
26d.	Comprehensive and intermediate eye exams	CPT-4: 92002, 92004, 92012, 92014
Service Category		Applicable ADA Code	Number of Visits (A)	Number of Patients (B)
Selected Dental Services
27.	I. Emergency Services	ADA : D9110
28.	II. Oral Exams	ADA : D0120, D0140, DO145, D0150, D0160, D0170, D0180
29.	Prophylaxis – adult or child	ADA : D1110, D1120,
30.	Sealants	ADA : D1351
31.	Fluoride treatment – adult or child	ADA : D1203, D1204, D1206
32.	III. Restorative Services	ADA : D21xx – D29xx
33.	IV. Oral Surgery (extractions and other surgical procedures)	ADA : D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7260, D7261, D7270, D7272, D7280
34.	V. Rehabilitative services (Endo, Perio, Prostho, Ortho)	ADA : D3xxx, D4xxx, D5xxx , D6xxx, D8xxx

Sources of codes:

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volumes 1 and 2, 2010 / 2011. American Medical Association.

Current Procedural Terminology, (CPT) 2010 / 2011. American Medical Association.

Current Dental Terminology, (CDT) 2010 / 2011. American Dental Association.

Note: x in a code denotes any number including the absence of a number in that place.

The three new clinical indicators for 2012 will be added to the Table below on lines 17, 18, and 19:

ATTACHMENT 3. TABLE 6B – QUALITY OF CARE INDICATORS

(No prenatal care provided? Check here: )

Section A: Age Categories for Prenatal Patients (GRANTEES WHO PROVIDE PRENATAL CARE ONLY)

DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE PATIENTS

AGE

NUMBER OF PATIENTS ( a )

1

Less than 15 years

2

Ages 15-19

3

Ages 20-24

4

Ages 25-44

5

Ages 45 and Over

6

Total Patients (Sum lines 1 – 5)

Section B – Trimester of Entry Into Prenatal Care

Trimester of First Known Visit for Women Receiving Prenatal Care During Reporting Year

Women Having First Visit with Grantee ( a )

Women Having First Visit with Another Provider ( b )

7

First Trimester

8

Second Trimester

9

Third Trimester

Section C – Childhood Immunization

Childhood Immunization

Total Number patients with 2nd birthday during measurement year ( a )

Number Charts Sampled or EHR total ( b )

Number of Patients Immunized ( c )

10

Children who have received age appropriate vaccines who had their 2nd birthday during measurement year (on or prior to 31 December)

Section D – Cervical cancer screening

Pap Tests

Total number of Female Patients 24-64 years of Age ( a )

Number Charts Sampled or EHR total ( b )

Number of Patients Tested ( c )

11

Female patients aged 24-64 who received one or more Pap tests to screen for cervical cancer

Section E – Weight Assessment and Counseling for Children and Adolescents

Child and Adolescent Weight Assessment and Counseling

Total patients aged 2 – 17 on December 31 ( a )

Charts Sampled or EHR Total ( b )

Number of patients with and counseling and BMI documented ( c )

12

Children and adolescents aged 2 - 17 with a BMI percentile, and counseling on nutrition and physical activity documented for the current year

Section F – Adult weight screening and follow up

Adult Weight Screening and followup

Total patients 18 and over ( a )

Charts sampled or EHR total ( b )

Number of patients with BMI charted and follow-up plan documented as appropriate ( c )

13

Patients aged 18 and over with (1)BMI charted and (2) follow-up plan documented if patients are overweight or underweight

Section G1 – Tobacco use Assessment

Tobacco Assessment

Total patients 18 and over ( a )

Charts sampled or EHR total ( b )

Number of patients assessed for tobacco use ( c )

14

Patients queried about tobacco use one or more times in the measurement year or prior year

Section G2 – Tobacco Cessation Intervention

Tobacco cessation Intervention

Total Patients with diagnosed tobacco dependence ( a )

Charts Sampled or EHR Total ( b )

Number of Patients Advised to quit ( c )

15

Tobacco users aged 18 and above who have received cessation advice or medication

Section H – Asthma pharmacological therapy

Asthma Treatment Plan

Total Patients aged 5 - 40 with persistent asthma ( a )

Charts Sampled or EHR Total ( b )

Number of Patients with Acceptable Plan ( c )

16

Patients aged 5 through 40 diagnosed with persistent asthma who have an acceptable pharmacological treatment plan

Section H – 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 I – ISCHEMIC VASCULAR DISEASE: ASPIRIN OR ANTITHROMBOTIC THERAPY

ASPIRIN OR ANTITHROMBOTIC THERAPY

TOTAL PATIENTS 18 AND OLDER WITH IVD DIAGNOSIS OR AMI, CABG, OR PTCA PROCEDURE

Charts Sampled or EHR Total ( b )

Number of Patients with aspirinor 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 J – COLORECTAL CANCER SCREENING

COLORECTAL CANCER SCREENING

TOTAL PATIENTS 50 TO 75 YEARS OLD

Charts Sampled or EHR Total ( b )

NUMBER OF PATIENTS WITH APPROPRIATE SCREENING FOR COLORECTAL CANCER ( c )

19

Patients age 50 to 75 years with appropriate screening for colorectal cancer

ATTACHMENT 4 – Electronic Health Record (EHR) Capabilities and National Quality Recognition

Appendix D, Grantee Electronic Health Record Capabilities (Revisions highlighted in bold italics)

1. Does your 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

      1. If (c) break out to ask if planned and when (3 months, 6 months, 1 year+, add not planned)

      2. 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:

1. Allscripts

2. athena

3. GE Centricity

4. eClinicalWorks (eCW)

5. e-MDs

6. Epic

7. Greenway

8. CompuGroup (HealthPort)

9. IMS

10. Logician

11. McKesson

12. Medinformatix

13. Medinotes

14. MicroMD

15. NextGen

16. Resource Patient Management System (RPMS)

17. Sage

18. Sevocity

19. SuccessEHS

20. Other

3. Pop-up if (b)

   1. How many sites have the EHR in use?

   2. How many providers use the EHR system?

4. 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

1. 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?

2. 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)?

3. 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?

4. Electronic entry of prescriptions?

If yes, are warnings of drug allergies, interactions or contraindications provided?

If yes, are prescriptions sent electronically to the pharmacy?

5. 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?

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

7. Notifiable diseases sent electronically to state or local health departments?
   
   

8. Reporting to immunization registries done electronically?

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

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

11. Does the system protect electronic health information?

3. 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.

4. Has your health center received national quality recognition, either accreditation or patient centered medical home recognition for 1 or more sites?

1. Yes

2. No

5. If yes, which 3^rd party organization(s) deemed recognition status? (Can identify more than 1)

1. AAAHC

2. The Joint Commission

3. NCQA

4. State Based Initiative

5. Private Payer Initiative

6. Other Recognition Body (Write in name)

ATTACHMENT 5: Additional Edits, Format and Reporting Changes

Certain UDS Tables are revised to clarify data collection requirements and streamline format.

The format of Table 7, Health Outcomes and Disparities, Sections A, B, and C is streamlined in order to simplify and improve data reporting. No changes are made to the data collected in these tables. The revised format is shown below.

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

Section A: Deliveries and Birth Weight by Race and Hispanic/Latino Ethnicity

0	HIV Positive Pregnant Women
2	Deliveries Performed by Grantee’s Providers
	Race and Ethnicity	Prenatal Care Patients Who Delivered During the Year (1a)	Live Births: <1500 grams (1b)	Live Births: 1500-2499 grams (1c)		Live Births: =>2500 grams (1d)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES

Section B: Hypertension By Race and Hispanic/Latino Ethnicity

	Race and Ethnicity	Total Hypertensive Patients (2a)	Charts Sampled or EHR Total (2b)	Patients with HTN Controlled (2c)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

TABLE 7 – HEALTH OUTCOMES AND DISPARITIES Section C: Diabetes by Race and Hispanic/Latino Ethnicity

	Race and Ethnicity	Total Patients with Diabetes (3a)	Charts Sampled or EHR Total (3b)	Patients with Hba1c <7% (3c)	Patients with 7%<= Hba1c <8% (3d)	Patients with 8%<= Hba1c <=9% (3e)	Patients with Hba1c >9% Or No Test During Year (3f)
Hispanic/Latino
1a	Asian
1b1	Native Hawaiian
1b2	Pacific Islander
1c	Black/African American
1d	American Indian/Alaska Native
1e	White
1f	More than One Race
1g	Unreported/Refused to Report Race
	Subtotal Hispanic/Latino
Non-Hispanic/Latino
2a	Asian
2b1	Native Hawaiian
2b2	Pacific Islander
2c	Black/African American
2d	American Indian/Alaska Native
2e	White
2f	More than One Race
2g	Unreported/Refused to Report Race
	Subtotal Non-Hispanic/Latino
Unreported/Refused to Report Ethnicity
h	Unreported/Refused to Report Race and Ethnicity
i	Total

Table 8A, Financial Costs, is revised by adding Line for Vision. This aligns reporting of costs in this table with that of Table 5, where Vision Services was distinguished from the broader Other Professional Services category.

Reporting Period: January 1, 2011 through December 31, 2011

TABLE 8A – FINANCIAL COSTS

		Accrued Cost ( a )	Allocation of Facility and Administration ( b )	Total Cost After Allocation of Facility and Administration ( c )
Financial Costs for Medical Care
1.	Medical Staff
2.	Lab and X-ray
3.	Medical/Other Direct
4.	TOTAL MEDICAL CARE SERVICES (Sum Lines 1 Through 3)
Financial Costs for Other Clinical Services
5.	Dental
6.	Mental Health
7.	Substance Abuse
8a.	Pharmacy not including pharmaceuticals
8b.	Pharmaceuticals
9.	Other Professional (Specify ___________)
9a	Vision
10.	TOTAL OTHER CLINICAL SERVICES (Sum Lines 5 through 9)
Financial Costs of Enabling and Other Program Related Services
11a.	Case Management
11b.	Transportation
11c.	Outreach
11d.	Patient and Community Education
11e.	Eligibility Assistance
11 f.	Interpretation Services
11g.	Other Enabling Services (specify: ___________)
11.	Total Enabling Services Cost (Sum lines 11a through 11g)
12.	Other Related Services (specify:________________)
13.	TOTAL ENABLING AND OTHER SERVICES (Sum Lines 11 and 12)
Overhead and Totals
14.	Facility
15.	Administration
16.	TOTAL OVERHEAD (Sum lines 14 and 15)
17.	TOTAL ACCRUED COSTS (Sum Lines 4 + 10 + 13 + 16)
18.	Value of Donated Facilities, Services and Supplies (specify: _________________________)
19.	TOTAL WITH DONATIONS (Sum Lines 17 and 18)

Table 9E, Other Revenues, is revised by identifying Medicare and Medicaid EHR Incentive Payments for Eligible Providers as a type of other federal grant in line 3A.

TABLE 9E –OTHER REVENUES

Source		Amount
BPHC Grants (Enter Amount Drawn Down - Consistent with PMS-272)
1a.	Migrant Health Center
1b.	Community Health Center
1c.	Health Care for the Homeless
1e.	Public Housing Primary Care
1g.	Total Health Center Cluster (Sum lines 1a through 1e)
1j.	Capital Improvement Program Grants (excluding ARRA and ACA)
1k.	Capital Development Grants
1.	Total BPHC Grants (Sum Lines 1g + 1j + 1k)
Other Federal Grants
2.	Ryan White Part C HIV Early Intervention
3.	Other Federal Grants (specify:________________)
3a	Medicare and Medicaid EHR Incentive Payments for Eligible Providers
4.	American Recovery and Reinvestment Act (ARRA) New Access Point (NAP) and Increased Demand for Services (IDS)
4a	American Recovery and Reinvestment Act (ARRA) Capital Improvement Project (CIP) and Facility Investment Program (FIP)
5.	Total Other Federal Grants (Sum Lines 2 – 4a)
Non-Federal Grants or Contracts
6.	State Government Grants and Contracts (specify:______________)
6a.	State/Local Indigent Care Programs (specify:________________)
7.	Local Government Grants and Contracts (specify:_______________)
8.	Foundation/Private Grants and Contracts(specify:_______________)
9.	Total Non-Federal Grants and Contracts (Sum Lines 6 + 6A+7+8)
10.	Other Revenue (Non-patient related revenue not reported elsewhere) (specify:________________)
11.	Total Revenue (lines 1+5+9+10)

Appendix E, Federally Qualified Health Center Look Alike Reporting in the Electronic Handbook

The forms for FQHC Look Alikes to report in EHB are based on streamlined versions of the UDS Tables reported by grantees. Specific modifications for FQHC Look Alikes are shown below.

Table		Modification (if any)
Service Area
Grantee Profile	Patients by ZIP code	<none>
Patient Profile
Table 3A	Patients by Age and Gender	<none>
Table 3B	Patients by Hispanic/Latino Ethnicity and Race; Patients best served in a language other than English	<none>
Table 4	Selected Patient Characteristics	Lines 13a-c: Managed care member months are not reported. Lines 14 – 15 and 17 – 22: No details are reported on farmworkers or homeless patients
Staffing and Utilization
Table 5	Staffing and Utilization	<none>
Clinical
Table 6B	Quality of Care Indicators	<none>
Table 7	Health Outcomes and Disparities	Disparities data are not reported
Financial
Table 8A	Costs	<none>
Table 9D	Patient Related Revenue	Managed care detail and details of retroactive payments have all been deleted.
Table 9E	Other Revenue	Data on BPHC 330 and ARRA grants are deleted
Other Forms
Appendix D	EHR Capabilities	<none>

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