2021.05.19 EQRS Program Working Group Meeting

• Call will be recorded for the purpose of capturing further meeting notes.  Any objections please speak up

• Hospitalization and Clinical data reporting - how it should be handled; need clarification; impact to future
  • Ahmar from QIPS perspective needs to know if its ok to use those values for our calculation – using the hospital data for that month. Ahmar will get a confirmation for the next meeting, then can get feature page done and prioritized
    • QIP ok with using labs from hospitalizations or lab values from outside of the clinic
    • EQRS has a limitation, if they try to report one thing hospitalization they can not report another thing outside labs
    • Hospitalizations have less impact by not reporting hospitalizations unless concrete impact than not supporting certain labs
    • Original question: Until EQRS is solved, is the program ok with NOT to report a hospitalization when the lab dates fall in that hospitalization date range b/c EQRS does not accept both at the same time? Lisa will take back to get an answer (Action Item)
    • May be a change request to EQRS and will need to put on the backlog
      • Let EQRS accept both of these things at the same time, knowing that it will take some time and get the program to make a decision on how we can fill in the gap until a decision is made on the change request
      • In the interim, can we get the program to make a decision if its ok to not report hospitalization when the lab dates fall in that hospitalization date range because EQRS doesn't accept both?
      • Reasoning - Missing labs have greater impact than a missing hospitalization

• Nothing to update at this time, may be awhile before have anything to share
• Lisa will bring back information on CDR when an update is available

• CDC gets vaccination information
• Lisa has been trying to get hold of the right person at CDC to get more information and do any follow up

NRAA - Has there been any discussion how we are going to open the clinical portal, sequencing, timing, staging of which Clinical Reporting periods will be open? How is it going to happen?

• This is more of a QIP and ISG focused topic.  There have been conversations on going
• Nothing to report at this time

• DUA team has added EQRS in EPI, 
• HSAG - getting DUA prepared and submitted, Lisa waiting to receive for approval
• Need to extend current ones through June? Lisa will look into ability for an extension
• Nathan concerned about things getting done in 10 business days
• Lisa will talk to HSAG - soon as their DUA with CMS is approved they will send DUAs to this group
• HSAG knows the importance of this and there should not be any lag
• Others chimed in and indicated it will take a few (~2-3) business days to get signed
• Lisa can get them approved electronically in less than a day
• Lisa will check if we have ability to extend past end of the contract (5/31) (Action Item)
• What days do the groups usually get files? Thursday's
• Hopefully the 2744 updates will be done by 5/21
• Lisa will do everything she can to get them signed, so that we can try to stay within the 10 day window
• Lisa will do some research and see what would happen if we're unable to get it completed in 10 days and get back to the group (Action Item)

Need to get this meeting back to what it used to be

Suggest to bring back:

• Roadmap - Lisa will look into providing this in the meetings (Action Item)
• PI Planning - Lisa will look into providing this in the meetings (Action Item)
• Need good business rule documentation - capture in a centralized location to shared with the community (Action Item)

Lisa left a meeting not long ago where they were talking about SSN's

Opened up discussion to the group for their pain points around SSN and getting them into EQRS (2728)

• Vlad - problems they see at least paper 2728 does not make people enter SSN
• Basically people enter MBI but not SSN
• Also not mandatory within EQRS so you create 2728 without the SSN 
• Causes two problems
  • Problem with SSA - eligibility not processed properly
  • With transplant - only way to identify patient by SSN, they have info about active patients on the list and use SSN to match to CrownWeb to see who those active patients belong to and If there is no SSN in CrownWeb and you know that attribution is kind of missed. So we see some patients that are active on transplant list but report from UNIS does not have that.  When QIP starts to score clinics on the rate of patients on transplant waiting list cases will be missed because SSN is not available in EQRS for those patients 
• Networks started reporting there was a decrease in adding the SSN even before switched forms. Hearing this around February
• Any thoughts on why the decline in adding SSN?
  • Kathleen - One factor may be the switch to the MBI.  Deriving the SSN is completely a random set of numbers and letters.  It is forcing to sometimes having to actively get the SSN from the patient, which the patient might not be willing to provide
  • Kelly L - CMS has quit using SSN for a long time. Kathleen is correct about the MBI, that's where their population hasn't been gathering SSN's too
• Lisa want to make it clear it is not CMS, it is SSA
• CMS trying to facilitate so people can get paid correctly
• CMS is not requiring it in any of their process; SSA needs it to process things and UNIS needs it
• Nathan - Goes back to the point of MBI implementation
  • Should have been built on a new identifier across the system
• Lisa - Overall need to find away to help the groups to get the SSN
• Patients are reluctant to provide a SSN.  During onboarding patients, can you not explain the importance of having the SSN to ensure appropriate payments?
  • Adrienne - Their admission people and those ground teams that work, social workers and their financial coordinators, they do explain the importance, but at the end of the day if the patient doesn't want to give them their SSN, they can't force them to
• Kathleen P - Is there away FKC can put in an MBI and it give them back the SSN?
  • Lisa -  not sure but can look into it (Action Item)
• Nathan - Would be nice to capture metrics (Action Item)
  • Is there a true issue?
  • Was the issue from 1-2 years ago?
  • Was it a one time weird issue that happened?
  • 15% of new patients from 2021 are still missing SSN's
  • Would be nice to understand the scope of this
  • Is it still occurring? Lisa - it is still happening
• Adrienne - Kathleen has to do a lot of research for their company trying to find SSN's
• Nathan -  Another reason they are limited on what they can do is all the reports that SSN was removed from, they don't have the opportunity to say EQRS is missing this SSN against their internal system
  •  They have some SSN's that EQRS doesn't have yet
• Kathleen - It could be useful to have the last 4 of the SSN but EQRS may also have more SSN's than they do and giving the last 4 of the SSN may do little good if trying to figure out what it is, trying to admit the patient  or if they have the first 5 digits
• Kelly - In the near match report they used to get the SSN, that was helpful to their customers when they were having trouble getting patient data to go through. Generated from CrownWeb.  Something like that is helpful
• Kathleen - It was helpful but around 2020 when MBI went into full force the SSN field was provided but it was X'd out the first 5 and provided the last 4 digits. It told them they have an SSN but CrownWeb doesn't or CrownWeb had a SSN and they didn't know what the SSN was.  They would then have to put effort into finding out what the SSN was.
• Vlad - It's better to have some information than to have nothing
• If you admit a patient in your clinic, you should be able to find the SSN
• Nathan - not asking them for something they should not already have access too.  Not understand by they are not allowed to get it back in their reports
• Lisa -  ISG did look into this last summer.  It was built off the direction of either security or privacy
• CMS is the pass through to SSA.  EQRS can run without the SSN
• Kelly - Why can't SSA go to the MBI locator and go locate those MBI's and do that cross matching?
• Suggest to explore that with Nathan if they are asking for SSN's this program
• Kathleen - stressed how important it is to have the SSN in EQRS
• It's important to figure out how to get SSN in the system
• Lisa - asked the groups to try to solve the problem on their end by making sure that people tried to collect the SSN and explain its importance
• Lisa will go back and see what can be done in the system
• Vlad - they have already taken steps to make sure they have all SSN. On the DCI side they will notify clinics when they are trying to admit patients into CrownWeb, they actually send a notice.  They give them a week to figure out the SSN

• Because of a new contract, hesitant to promise NCC resources at this moment