Aaron Thompsonx
Adrienne Adkinsx
Adrienne Rayx

Ahmar Wazir

Anitha Chintalapati
Arnie Esparterox
Betina Fletcherx
Branon Barrettx
Bridget Calvert
Cheri Jergerx
Chris Brownx
Christopher King
Curtis Phillips
Deb Wilsonx
Dianna Christensen
Greg Eccleston
Hari Krishna Pemmasani
Heather Dubendris
Heather Moorex
Howard Thomasx
Janet Lea Hutchinson
Jason Clemx
Jason Simmington
Jeneita Bell
Jennifer Baileyx
Justyna Sardinx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Leah Skrienx
Letty Lamping
Lindsey Clemente
Lisa Reesx
Malik Arsalan
Martha Bean
Mary New
Matt McDonough
Melissa Fieldhousex
Michael Kennedy
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Rachelle DuBose Caruthersx
Revathy Ramakrishnax
Sarah Fillingx
Seema Sreenivas
Scott Laughlinx
Shalon Quinn
Steve Goodmanx
Susan Cali
Todd Johnson
Tracey Coleman
Vladimir Ladikx
Yvette Brown
Zach Serlethx


Meeting RecordingArnie
Slide PresentationScott/Lisa

PI16 Feature Review

Slide Deck: PI16 Feature Review 110321_rev2.pptx

(Please view slide deck for further feature details)

  • CMS/Program will be working on developing slides to show upcoming/future plans for features that may be of interest or impact the EDIs
  • Asking for the EDIs to be patient as the CMS/Program needs some time to pull all the information together to share with the group

Sides #2-5: Admission in Support of a Transplant

    • Question from Vlad - What is CMS' expectation in terms of EDIs reporting the admissions?
      • Per Vlad, some admissions when in support of transplant are very short (1-2 treatments)
      • Do these types of admissions need to be reported?
        • Lisa will discuss with CMS what is the expectation in terms of EDIs reporting the admissions, especially for short admissions in support of transplants (Action Item)

Slides #6-8: Establish a Performance Baseline for Portal Components

    • Question from Chris Brown - Is it possible to look retrospectively at what has happened since EQRS was released to see where the issues were? Are we starting fresh from now?
      • Per Lisa, she does not think there can be a retrospective look back at what has happened since EQRS was released but will take it back to CMS to find out (Action Item)
    • Question from Nathan - Is that both EDSM performance and all of the UI components?
      • Per Scott, he thinks it is a "yes" based on the acceptance criteria that mentions established performance baseline for portal microservices
      • Our goal is for Prod Preview and Prod environments to be in sync
      • If CMS is asking the EDIs to submit any special submissions to perform stress testing of the system, give the EDIs as much advanced notice as possible
      • What goes into the processing of 2744 (reports run for the entire year; running queries) is very resource heavy and when everybody's doing it at the same time it's probably spiking
      • Per Branon, there are measures that can be taken; we have production operational databases and then we have a redshift instance that can be used for reporting and offloading some of the more intensive queries

Slides #9-11: 2744 Reports

    • Question from Nathan -  Are the proposed reports being built from scratch?
      • Per Lisa, they will be built from scratch
      • These reports will be built within the application as opposed to getting them from the network coordinating center
      • Will the reports be in the reports module or under the 2744 module?
        • Lisa will need to ask the team where they plan to have the 2744 reports reside (Action Item)
      • Nathan will send report ideas to Lisa and then she will share with Michael
    • Question from Nathan - Why limited to only the 6 fields? Needs more clarification on the following Acceptance Criteria.
      • "Fields 1, 2, 3, 20, 25, and 26 - need to be displayed on the UI for 2744 A forms from Survey Year 2020 in Finalized Status"

      • Lisa will need to ask Michael why the acceptance criteria is limited to only the 6 fields listed in the Acceptance Criteria? (Action Item)
    • Per Leah Skrien - The 2744 reports are very important
      • There are a couple of things still happening that are impacting the survey
      • Will these things still be happening in PI16?
      • They are the duplicate  Medicare statuses are still not allowing people to update Medicare statuses, therefore the existing report is not working
      • Wanted to keep the potential bugs on everyone's radar for the upcoming year

Slide #12: Prevent Overwrite of Key Patient Identifiers in EQRS from EDSM

    • Per Lisa - Once the patient has been identified, we are going to be pulling the information into EQRS from EDB and once the information on these items is pulled from EDB that's going to be our source of truth
    • The information cannot be changed so that should prevent the overriding process on these items and keep everything where it matches EDB for the patient
    • Per Howard, if there is a need to tweak a patients information for some reason, there needs to be a support process in place and provided for the EDIs
    • Question from Leah - Does this include the effective date? Is there any logic, preventing overriding based on the effective date?
      • Per Lisa, she does not think the effective date is included but will ask Michael for clarification (Action Item)
    • Question from Chris - Now that we're linked to EDB or will be once this does into effect, can we stop the electronic submission of Medicare status and leave it at whatever EDB says the Medicare status is?
      • Per Lisa this idea will have to be a future version (version 2) capability
      • We are trying to create a patient repository where we take more information in from other systems.  This is going to be an epic where we add stuff in different PIs
    • Question from Nathan - If we can't update a record through EDSM submission but can we update it through the UI?
      • Per Lisa, she will need to check with Michael on whether an record can be updated through the UI (Action Item)
      • If an EDI continues to submit the wrong information will they get an error, will there be a new error created, will they have the opportunity to get in their response file the accurate data back?
        • Per Lisa, she does not think and error will be created at this time and there may not be away to notify an EDI
        • The first step is to get the correct data in and get it locked
        • Then next step would be to let the EDIs know 
        • Nathans concern is the gap between those two things; understands the locking down the data; concerned they will be creating a gap between systems were EQRS has the accurate record and we don't have a mechanism to know our data is wrong

Slides #13-18: Patient - Identify & Visually Display Depressed Patients

    • The ability to report monthly is in the system
    • It does not mean that you have to report the screening on every single patient every single month, it was done that way to report screenings every month
    • When we pull the report we will look and see how many were done quarterly b/c that's what is in the network contract
    • Question from Vlad - Will the report be locked? Can they report for a certain month during the whole year?  
      • Per Lisa they had planned to close one month afterwards.  For example, if you have March, you would have April to report it
      • Per Vlad that could be a problem not with the depression screen itself, but with post activity if patient identified as potentially depressed.  It takes time, maybe months to get an appointment with a psychiatrists so the information (actual documentation) may not be available to respond to screening for several months
      • Howard and Kathleen recommend walking through the requirements for depressed patients with the group for a better understanding
    • Due to time, this can be a topic to continue discussions at the NCC call next Wednesday, 11/10
    • Howard request a sort of overview on this topic?
      • Nathan suggests the latest version of the technical feature page
      • Lisa will try to find out if there is anything she can provide Howard regarding this depressed patient topic/feature (latest version of the technical feature page) 
      • Per Scott the most current copy has been posted on the public page under the Resources & References section

Next meeting scheduled for  

Action Items:

  • Lisa will discuss with CMS what is the expectation in terms of EDIs reporting the admissions, especially for short admissions in support of transplants Lisa Rees  
  • Per Lisa, she does not think there can be a retrospective look back at what has happened since EQRS was released but will take it back to CMS to find out Lisa Rees  
  • Lisa will need to ask the team where they plan to have the 2744 reports reside Lisa Rees  
  • Lisa will need to ask Michael why the acceptance criteria is limited to only the 6 fields listed in the Acceptance Criteria?  Lisa Rees 
  • Per Lisa, she does not think the effective date is included but will ask Michael for clarification Lisa Rees 
  • Per Lisa, she will need to check with Michael on whether an record can be updated through the UI Lisa Rees 
  • 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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