2021.07.28 EQRS Program Working Group Meeting

• Slide presentation - PI15 Plans and roadmap

EQRS Program Working Group PI 15_072821.pptx

• • EQRS Product Roadmap showed what was scheduled for PI14 and then what is planned for PI15 - PI17
  • Ongoing include Quality Incentive Program, Routine O&M and Reporting Functionality
  • Dates shown at the top of the roadmap and where projects start and end in different PI's.  Keep in mind we are working in an agile space with our ADO 
  • There may be shift in projects if we find something of more importance
  • Agile environment allows the flexibility to react and reprioritize as needed
  • Be mindful and do not take the dates on the roadmap as gospel
  • Daily Quality Initiatives
    • Enhance Form 2728
    • ESRD Patient Repository within the ESRD Patient Registry
  • Upcoming Data Collections
    • PPSV23 Pneumococcal Vaccination Data
    • Telemedicine Usage
    • Nursing Home Identifier
    • Identify & Visually Display Depressed Patients
    • Additional Kt/V Methods for Clinical Adequacy Values
      • Question from Vlad - Define "Standard" method for measuring Kt/V to support the UFR measure
      • Per Nathan, it's the difference between standard and single pull.  It is what EQRS accepts today and it's the primary calculation for patients that treat 3 times a week,
      • Standard is a more appropriate calculation for patients that are treated 4 or more times a week
      • Need guidance on what numbers are acceptable for QIP.  Ahmar will get back to Vlad with his question.

Questions Received: See slide #6 and #7 in the slide presentation for more detailed information on questions

• Comments from the EDIs (DaVita)
  
  • Seems like a wasted effort for the networks to go directly to the clinics b/c the data is pulled electronically from our EMRs and sent to EQRS
  • Comparing what's in EMR to EQRS will most likely be the same unless a timing issue and data has been corrected in one of the systems, since it was originally pulled
  • 90% of the work is not done by the clinic
  • For limitations on medical records, they have policies and procedures. Their clinics are not allowed to share medical records, it has to go through DaVita's medical records department
  • Seems like a lot of work that could be handled differently.  They have 4 organizations that submit 90% plus of data.  Instead of 18 networks going to "x" thousand clinics, there could be 1 entity go to 4 people and try to work together to solve the concerns CMS may have. Seems more efficient
  • Through the Social Security Act, the networks are required to maintain the registry and the Social Security Act sets up at least 17 networks right now. They are the ones that have to do the work, not one single entity
  • DaVita is supportive of data quality, they are questioning the mechanism with which it's being done.  It seems the least efficient mechanism possible chosen
• DCI (Vlad)
  • How will the audit be done and who will it the audit is important?
  • Instead of being asked to see everything, all information, it would be nice to limit certain things (for example they want to audit just lab results and depression screening),  The allows a limited data set
  • The data managers will be the ones performing the audit
  • Data Managers will be working with the EDIs (DCI-Vlad)
  • Regarding Transplants, are there any plans to map patients differently from the way it is done today from  UNIS to EQRS, other than mapping by social security? 
  • UNIS data does not include an MBI, the program needs to revisit this

• DaVita has the mechanism of NHSN to share data, but they stopped reporting it because it takes capacity of people to do the reporting
• DaVita not reporting has not changed the intensity with which they put behind flu vaccinations.  They have been good at reporting and it's been proven for years
• Per Lisa, vaccinations are a priority of this administration across CMS
• CMS will be working on several different aspects of vaccination work in this contract
• Per Rachelle - NHSN reporting requirements and healthcare worker data - when it was dropped as a QIP measure, they no longer report this and it will be a huge lift to go back to recording this when its not a mandatory measure. If CMS could consider other ways they could deliver the data, it would be appreciated. 
• Lisa will go back and have some conversations with CDC 

• Lisa offered to meet again next week to get everyone's thoughts on data quality
• Lisa requests that the EDI's come up with some ideas to share with leadership
• It may not change the contract right away because it would have to go through review and discussed internally
• DaVita (Nathan) will discuss on their side and get back to Lisa this week on how they want to move forward

Additional questions for future communications: 
1. What is MDS? Networks are surveying clinics to ID nursing home patients. Can they use NHSN annual survey and/or MDS rather than surveys?    

2. Definition of nursing home? Is SNF included?    

3. What is definition of Telemedicine and Rural?

4. Can the audit process be discussed? 

• • Lisa does not want to involve the networks at this time 
  • Lisa would like to hear the ideas first and take back to her leadership 

Next meeting scheduled for 11 Aug 2021