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Inconsistency with the documentation of UDS Table : Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (CMS164v7) #13

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mshgithub opened this issue Jan 31, 2024 · 2 comments

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@mshgithub
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Documentation feedback.

There’s some inconsistency with the documentation of UDS Table : Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (CMS164v7) (as well as the tables at the bottom of the dataelements page that follow it) as compared with the documentation on other tables. Specifically, naming convention and “packaging” of multiple elements into a single element changes around that point.

Patient Characteristic – Birth Date is referred to as Patient Age in UDS Table : Childhood Immunization Status, but as Patient Characteristic in CMS164v7 and CMS277v0. The Patient Characteristic designation seems better here, as it matches Patient Characteristics for Payer, Ethnicity, etc… I’m treating these as equivalent, as they’re using the same deidentify-birthdate-to-age profile.

Encounter Performed
Discharge Disposition
Encounter Period
Encounter Diagnosis

The three encounter data points and the Encounter Dx are referred to in this one differently than every other UDS Table except for HIV Linkage to Care. All tables up to this point break required Encounter elements into four categories. This measure and HIV Linkage to Care add an additional data point for Encounter.DischargeDisposition, but unless something non-intuitive is going on here, it seems like the documentation should match to the established naming conventions and level of granularity.
Encounter, Performed - Participant
Encounter, Performed - Diagnosis
Encounter, Performed - Diagnosis Rank
Encounter, Performed - Period

Diagnosis data also seems to lose track of the previously established naming convention. CMS164v7 refers to Diagnosis and Diagnosis Time (OnsetTime), while previous tables all use the following:

image

@ljtucker
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ljtucker commented Feb 5, 2024

Hi @mshgithub, we're understanding your question to be: Is Encounter, Performed - Diagnosis Rank required/a necessary element to send? If so, the answer is: it depends on which quality measures are being sent, and what's in your data set. If that does not answer your question, could you clarify?

From above, we also see that you seem to be developing UDS+ data above the requested minimum. For reference, here is the floor/minimum required data points needed for this stage:

For reference, the 'minimum' for voluntary CY23 submission includes:

  1. Submit data for your entire universe of patients (not a subset)
  2. Submit all the demographic tables data
  • Table: Patients by ZIP Code
  • Table 3A: Patients by Age and by Sex Assigned at Birth
  • Table 3B: Demographic Characteristics
  • Table 4: Selected Patient Characteristics
  1. Submit all or part of the clinical tables data
  • Table 6A: Selected Diagnoses and Services Rendered – optional
  • Table 6B: Quality of Care Measures – submit 2 or more eCQMs from this table
  • Table 7: Health Outcomes and Disparities – submit 2 or more eCQMs from this table

The UDS Test Cooperative (UTC) suggests health centers may be the most ready to submit these eCQMs:

  • Table 6B: Quality of Care Measures
    • Cervical Cancer Screening
    • Colorectal Cancer Screening
  • Table 7: Health Outcomes and Disparities
    • Controlling High Blood Pressure
    • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)

Health centers may choose any eCQM from these tables as long as they submit at least two measures from each table
REMEMBER: Submit both demographic and clinical data for the entire patient population, not a subset of patients

@joshua-hiltunen
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joshua-hiltunen commented Feb 15, 2024

Had similar feedback over in #17.

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