Aaron Thompsonx
Adrienne Adkins
Adreienne Rayx

Ahmar Wazir

Anitha Chintalapatix
Arnie Esparterox
Betina Fletcherx
Bridget Calvert
Cheri Jergerx
Chris Brownx
Christopher King
Curtis Phillipsx
Deb Wilsonx
Dianna Christensen
Greg Eccleston
Hari Krishna Pemmasani
Heather Dubendris
Heather Moorex
Howard Thomasx
Janet Lea Hutchinson
Jason Bullock
Jason Clemx
Jason Simmington
Jeneita Bell
Jennifer Bailey
Justyna Sardinx
Karena Sx
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Leah Skrienx
Letty Lamping
Lindsey Clemente
Lisa Reesx
Malik Arsalanx
Martha Bean
Mary New
Matt McDonoughx
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzos
Ozlem Taselx
Pandu Muddana
Rachelle DuBose Caruthersx
Revathy Ramakrishna
Sarah Fillingx
Seema Sreenivasx
Scott Laughlinx
Shalon Quinnx
Susan Cali
Todd Johnson
Tracey Coleman
Vladimir Ladikx
Yvette Brownx
Zach Serlethx


  • Call will be recorded for the purpose of capturing further meeting notes and action items.  Any objections please inform the host
Opening RemarksLisa
  • We are trying a new process in introducing some of the EQRS development to the EDIs a little earlier
  • We would like to share with EDIs a view of what is in development before the upcoming system demos
Corporate Role(s)Michael
  • In the middle of developing corporate roles at this time
  • There is an enabler for this in PI15 to research all of the user roles in EQRS
  • Will be adding to the corporate role POC for anyone that needs to do things in there as well as the viewer
  • By the end of this iteration hoping to be able to request one in Dev, test and push up to pre prod to get those requests the corporate role in the global app, approve them, view and switch the corporate roles and then make sure they can view all of the facilities, initial work and see how they are coming through
  • Will also be working on all the documentation, authorization logic, savyint and entitlements that have to go through the process
  • Definitely in the thick of the development right now in the backend and building out the frontend and refactoring as necessary so the user will be able to do it from one login
  • Per Howard, what is the definition of corporate role
    • Per Michael it is how they do it in the UI to request that role in the approvals that goes through people that log into the portal
    • It has already been defined
    • There is a primary owner field, secondary owner field, managed by field and the mapping for it to submit the data via EDSM; if you as a corporate entity are in one of those fields, you will have access to that facility
    • You will still need to go through the security official to request the role and approve the role
  • When will this be available?
    • Trying to implement by the end of PI15
    • Need to keep in mind delivery of this feature could slip depending on progress in development, testing, etc
Nursing HomeAnitha
  • For demo, see meeting recording below (00:23:06)
  • Data Dictionary has not been updated at this time
  • This feature is a work in progress
  • Once the changes are implemented and tested in prod preview the Data Dictionary will be updated and sent out with the other related documentation
  • Question from Howard - when will the documentation be sent to the EDIs?
    • Per Anitha, this feature is currently going through internal testing
    • Howard indicated the EDIs should have the documentation when it is in the test phase
    • Development is still needed on the EDI side 
    • EDIs need to get notice of these changes in advance
    • Per Lisa, this process is a work in progress and they want to start bringing in EDIs when shallow dives are taking place
    • This will start in the next PI, bringing in the EDIs earlier in the process
    • Howard recommends a couple of gates that you cannot go through until they are unlocked and gates that the EDIs receive certain types of information regarding development, logic, behavior of EQRS, and xml
    • Lisa will go back to ISG and have internal conversation and see if she can get a meeting scheduled with the EDIs to draw out what the process may be
    • In the meantime lets get with the Product Owner and ISG lead of this feature and get something out to the Howard/EDIs about this nursing home feature for them to review while it is in testing
    • Howard request to get the logic of the four errors that are being contemplated for this feature; a paragraph or two of what's the intent of this and an overview
  • Does any part of this change affect the XML?
    • Yes, there will be some XML changes when it is moved into production
    • Howard would like to see a mock up of the XML at some point
    • Lisa will take it back and try to figure out logistics on Howard's request
  • Question from Vlad - Do we have the ability to tell a patient is in a nursing home?
    • That information may not be in their system at all
    • Suggest that ISG tell the EDIs earlier that in the near future ISG would be interested to know if your patients are in a nursing home
    • Per Lisa, they were in procurement and could not tell the EDIs any sooner
    • Lisa suggest the EDIs come up with a list of things they feel would be important to track in EQRS for quality improvement
    • This feature is for all patients, whether they're receiving in clinic treatment or whether they're receiving home treatment in a nursing home
    • They will be able to use the setting to be able to determine whether they're in center or whether they are at home
  • Question from Kathleen - Regarding the second drop down option (Short Term/Rehabilitation),  If a patient is in a nursing home for a temporary basis, they are not likely going to update the physical address of the patient.  What is the purpose of the Short Term/Rehabilitation option?
    • The FKC will never report a nursing home setting of short term care/rehabilitation
    • Per Lisa, Short Term/Rehabilitation is skilled nursing care that Medicare pays for; it would be 100 days of rehabilitation that Medicare will pay for in a nursing facility
  • Question from Chris Brown - Is this the only checkbox on the screen that identifies a patient as a nursing home resident?
    • Per Anitha, yes, this is the only change
    • Chris' concern is that an SUI user may not encounter this checkbox while it's unchecked and know that this is where they say patient is a nursing home resident and not see this as an address verification type of thing
    • Pointed out because Chris knows how bad the addresses are in EQRS
    • He does not think people will visit this very often and doesn't know that they're going to visit this to designate nursing home residents all that readily
    • Per Lisa, they will go back and have some internal discussion


  • For demo, see meeting recording below (00:52:17)
  • Vaccination has been tied to the patient information
  • When a patient is admitted to one facility from another the vaccination data stays with them
  • Comment from Chris Brown -  The patient isn't the one filling out the information so the question "Is your physical address the same as your nursing home address?" 
    • Need to clarify, making the question clearer. reword the question keeping in mind the patient is not the one entering the information
    • Also need to review the question "Is your physical address the same as your mailing address?"
    • Anitha will take it back to the team to update the questions and their descriptions
  • Comment from Howard - under the Contact Information section, the field "Do not contact" is confusing
    • Need clarity because answering "Yes or No" causes confusion
  • Question from Vlad - Is there verification if entering a second PCB13 shot with a different date? Is there a warning?
    • Per Yvette - When you submit the ID, if you have a different date then we're going to update this record; if it's the same ID, they will update the record; if it's a different ID, they will add a record
    • If it's a different ID but same date, they will add a record
    • The user will see multiple vaccinations displayed, not overwrite the other one
    • Who can delete a record? Any user who can currently delete (for example a facility editor, network patient editor or system administrator)
    • Now that vaccinations are tied to the patient, they go with the patient
      • For example, if a patient leaves FKC  and goes to DCI, DCI with the right role would be able to delete a record
      • The vaccination data is tied to the patient itself and whomever the patient is admitted to, whichever facility is the facility that has scope over them and can make changes to their vaccination data
    • Right now only collecting Pneumococcal
    • COVID-19 was added to the drop down as a Vaccination Type just for testing purposes to make sure what is in the database would display
    • Currently it is based on which vaccine is chosen; for pneumococcal there are two; if you select PCV13 there is only one dose date allowed to be entered; PPSV23 will allow date of second dose
  • Question from Chris Brown - will influenza be included in this release?
    • Per Yvette, it will depend on CMS, right now for this PI, only have information for pneumococcal
  • Suggestion to have just the vaccination type, name, and date
  • That is how the state immunization registries work
  • It would be nice to align our data fields with the state registries; there is a lot of standardization on immunization registries across the country
  • The org ID is what helps the ADO know what the record is
  • Per Rachelle Caruthers - Washington it not a reporting state, but there are 12 states that they report each and every dose of every vaccine given in our clinics, to the registry
    • It is mandatory for every state to report covid19 within 24 hours of administration so every one of their clinics is reporting to the state registries for he covid vaccination
  • Need to have a separate conversation why aren't we developing feeds into EQRS from the immunization registries and getting all of the data there
  • Per Howard, who has been working with the states, has the data centralized somewhere
    • Lisa asked if Howard could work with the states to get permission to put the data in a CMS repository?
    • Howard suggest working with Lisa to request for the data; Kelly Llewellyn has been involved at the state HIE level
      • Howard will gather some information and send to Lisa
Round TableAll

Meeting Recording

Passcode: n&$^YCN2 

Next meeting scheduled for  

Action Items:

  • The definition for "Telemedicine" will be further clarified when Lisa takes the feedback to the team Lisa Rees 
    • 9/8/21 - Lisa is still looking into getting a definition for the EDIs
  • Leah Skrien asked if aside from Telemedicine if there is anything tied to treatment? Lisa will have the other PO's put together something explaining if anything is tied to treatment and bring to the next meeting Lisa Rees
    • 9/8/21 - Per Lisa, her understanding is yes, that Telemedicine was the only thing tied to treatment
  • Anitha will update the "new?" column field with the date the Kt/V "standard" option was moved into production Anitha Chintalapati
  • Nathan request since the Kt/V "standard" option is already in production, can they have the updated data dictionary, XSD, XML examples, error codes and any associated documentation.  Anitha will send the documentation Anitha Chintalapati
  • EDIs would like to understand how, if or when the Kt/V "standard" option will be used as part of the QIP adequacy measures and same for five-star. When will the standard Kt/V be included in QIP and five-star calculations? Need to get something out to the community/EDIs Ahmar Wazir Jason Clem
    • 9/8/21
      • Per Jason, there is no discussion to bring that it
      • On they post a muck list every December of new measures that might be implemented
      • At this time no plans to update the Kt/V measure
      • Per Howard they have a Kt/V with two methods, both are eligible and used in QIPs
      • If not going to use Kt/V, they need to tell people b/c Kt/V is being reported using standard methodology
      • Per Jason, an announcement was sent out on the standard method to all EQRS users - They are still just looking at the UKM two methods for QIP
      • Howard suggest to review the announcement again
      • Per Lisa, they will take this back to the QMVIG team for clarification and to get a definite answer

DateMilestone (M) / Task (T)DescriptionPhaseStatus
2/28/2021MCode deployed to pre-prod for testing.1Complete
3/15/2021 - 3/24/2021TEDIs perform integration testing.1Complete


MEDIs sign-off on integration testing.1Complete

3/24/2021 - 3/25/2021

TADO prepares for coding deployment.1Complete


MProduction deployment.1Complete
3/31/2021MProd-Preview environment contains refreshed prod data 2Complete
2/24/2021 - 3/10/2021 TReview of phase 2 codes and finalize list of codes.  Complete
3/11/2021 - 4/30/2021TADO perform coding updates and regression testing - Phase 2 (Patient Codes) 2Complete


MProd-Preview environment data refresh.2Complete


MRemaining Phase 2 (Patient Codes) deployed to pre-prod for testing.2Complete

5/4/2021 - 6/1/2021


EDIs performs integration testing - Phase 2 (Patient Codes) 
Starting 5/4 - EDIs submit prod file in prod environment and PP2-3.  This should be the SAME file for both environments.  Review discrepancies between the feedback files and validate codes.



MEDIs sign off-on integration testing - Phase 2 (Patient Codes) 2Complete

6/2/2021 - 6/4/2021

TADO prepares for coding deployment - Phase 2 (Patient Codes) 2Complete


MProduction deployment - Phase 2 (Patient Codes) 2Complete
6/4/2021MPhase 2 (Patient Codes) live in production.2Complete
3/10/2021 - 3/17/2021TReview of phase 3 codes and finalize list of codes.  3Complete
5/12/2021 - 06/08/2021TADO perform coding updates and regression testing - Phase 3 Clinical Codes/27283Complete


MProd-Preview environment data refresh.
6/4/2021 - 6/6/2021T

EDIs SHOULD NOT submit any PATIENT files during this time period in production (to ensure same patients are in PP2-3).


EDIs to drop file into PP2-3 to establish a baseline.



MCode deployed to pre-prod for testing - Phase 3 (Clinical Codes/2728).
Reopening September 2020 to March 2021 Clinical months for submission.

6/9/2021 - 7/6/2021

TEDIs performs integration testing.

Starting 6/9 - Re-drop same file from 6/7/2021 into PP2-3.  Review feedback files from PP2-3 and validate codes.



MEDIs sign-off on integration testing - Phase 3 (Clinical Codes/2728).3


7/7/2021 - 7/11/2021

TADO prepares for coding deployment - Phase 3 (Clinical Codes/2728).3Complete
7/12/2021MPhase 3 (Clinical Codes/2728) live in production.3Complete


MEDSM Implementation Complete (Phase 1 - 3).n/aComplete

7/12/2021 - 9/15/2021


Resubmission of Clinical Data Files (September to December). 

Open July 12, 2021 at 5 a.m. Pacific (8 a.m. Eastern) and close September 15, 2021 at 11:59 p.m. Pacific Daylight Time

9/15/2021 is the official closure date for the clinical months of September, October, November, and December 2020.

CMS highly recommends completing large data submissions prior to the official clinical closure date.





Data fully submitted and ready for measure and scoring calculations.

09/20/2021 - 02/28/2022T

Submit January-September 2021 EQRS Clinical Data, ICH CAHPS Attestations, and Clinical Depression Screening and Follow-Up Plan reporting in EQRS. Additionally, all subsequent months in 2021 will open for data submission on the first day of each month (i.e., October opens October 1; November opens November 1; and December opens December 1). 

02/28/2022MThe clinical closure date for all months in 2021 is February 28, 2022 at 11:59 PM PT.n/a

Data Submission (Errors & Warnings) Milestone Dates - By Phase

Phase No.

File Type

Code Bucket Name


ADO Completion Date

LDO Testing Start Date

Testing Completion Date

Production Date



Admit Reasons

11221, 11222, 11223, 11224, 11225







Patient Codes







Clinical Codes







2728 Codes





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