Aaron Thompsonx
Adrienne Adkins
Adrienne Rayx

Ahmar Wazir

Anitha Chintalapati
Arnie Esparterox
Betina Fletcher
Branon Barrettx
Cheri Jergerx
Chris Brown
Curtis Phillipsx
Deb Wilson
Dianna Christensen
Greg Eccleston
Hari Krishna Pemmasani
Heather Dubendris
Heather Moorex
Howard Thomas
Janet Lea Hutchinson
Jason Clemx
Jennifer Baileyx
Justyna Sardinx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Leah Skrienx
Lisa Reesx
Malik Arsalan
Matt McDonoughx
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Taselx
Pandu Muddanax
Rachelle DuBose Caruthersx
Revathy Ramakrishna
Sarah Filling
Seema Sreenivas
Scott Laughlinx
Shalon Quinn
Steve Goodman
Vladimir Ladikx
Yvette Brown
Zach Serlethx


Meeting RecordingArnie

EQRS Waitlist report


Patient matching algorithm concerns

  • The matching algorithm was doing what it is supposed to do; it was not broken; the team just enhanced it
  • The patient matching algorithm returns 6 specific codes; it was doing it's job
  • There were opportunities to match more patients and send them through that process even for patients that have changed or had done other things
  • Anticipating we can match several thousand more patients

Patients removed from the waitlist continue to show as listed on the report

  • There are instances were UNOS will send the patient more than once, even for the same listing center and listing date
  • Researching, it looks like for people familiar with admission discharges in the way that flows, there are some specific examples that education is a part of it
  • For anything that is duplicative were we are inserting an additional record with a removal date were they did not send the removal code or removal date, we are going to enhance the code to change that and stop that process
  • Also going to add the active status and what the removal code means

Question from Nathan -

    • Will active or inactive status be added? Per Michael, planning on adding an active status and what it means.
      • There are several letters that they send with that also for the removal codes to add the text there too
    • Need to have a conversation with the NCC on the timing of when they actually update the data set that the EDIs get
      • Per Lisa, yes, this can be discussed when they are on a call with the NCC

Patients who are listed before they start dialysis are not showing as waitlisted at all on the report 

  • Until the patient starts some type of treatment (Dialysis or receives a treatment) they won't be in EQRS
  • Once the patient is added into EQRS, if they are in the next submission from UNOS, they should match

Question from Vlad -

    • Is there a process if clinic looks at the UNOS data sent to them and they have their own contacts with the transplant centers and they call the transplant center and the transplant center tells them its not really true.  What is the process to reconcile the data?
      • Per Lisa they don't have control over the UNOS data; If the clinic and transplant center agree something is incorrect with the data, the transplant center will have to update UNET
      • UNOS will only deal with the transplant center
      • Per Vlad - Would it be logical to start the process where UNOS would respond not just to transplant center but also to dialysis clinics? Would it be possible to ask them to change the current process?
        • Lisa said she can try to look into it

HCP Flu data source


NHSN doesn’t allow bulk upload

Question from Nathan -

    • CMS/Lisa is working with the CDC to try to get them to implement a mechanism where the EDIs can bulk upload their data?
      • Per Lisa - CMS has actually asked the EDIs to report it to the NCC and CMS can report it to them
      • That is what is on the table, not guarantee what they will come back with
      • If the NCC is not agreeable to that solution, then yes, CMS will pursue having a bulk upload 
    • Because there is ongoing discussions, have they considered messaging to the networks about pulling back a little on the priority of this one compared to there projects?
      • Per Lisa -  they have not considered this because it is flu season and important that patients get their vaccination
      • Per Nathan - there just seems to be a disconnect that the EDIs know they cannot report fully, yet they are pulling data out of the system that the EDIs know is not complete and saying your rates are low, but they're low because the EDIs are not reporting in bulk
      • Facilities have the option to report and keep the networks from calling them, so there is an alternative
      • Lisa will continue to work on towards a solution/answer

Question from Rachelle -

    • Is the network supposed to be measuring monthly, quarterly, or just at the end of the year?  What is their measurements reporting frequency?
      • Per Lisa - their measurement is monthly, therefore if the EDIs did a file upload it would also be monthly

Only annual summary at end of flu season

  • CMS is in discussions with CDC to get come changes in place
  • At this time there have not been any changes

Identifying Depressed Patients


Data reporting and clinical applicability concerns previously raised

  • This is in the network contract and CMS will continue to move forward with it
  • CMS/ADOs are working on the screen in EQRS and aware there are some concerns
  • Lisa did work with the team to address the concerns
  • Per Kathleen - it is not impossible for FKC to get CMS what they need but there are concerns on what they want; the questions they are asking in this module
  • For example there is a question, Who is providing the mental health treatment? The options given are options the VP of social work said that they are usually reluctant to tell you
  • Therefore, that is information the EDIs will more than likely not have
  • Another question asked is the branding medication that they are taking for mental health treatment. Unless the patient reported it to the EDI, the EDI may not have that information
  • Suggestion from Kathleen to discuss what the data points that CMS really needs so they can report it
  • Lisa will check with Yvette when she can go through the screens related to depressed patients and explain things, what is required, optional, etc (action item)

Vaccinations (Pneumo, HepB, Flu)


EDIs plan to wait until all three are complete to not triplicate work

  • At this time, CMS is not planning to move any other vaccinations soon
  • So the EDIs still need to do the work for the PPSV23 
  • When CMS gets ready to move the other 3 vaccinations, Lisa will commit to moving those all 3 at one time but for now we need the PPSV23 as is delineated in the new collection mechanism
  • There are specific things in the contract that require data to be separated
  • If the EDIs are not able to do it through the EDSM process, they we need to ask the EDI's facilities to report it
  • Per Nathan - there was talk of having an overlap were they could continue to submit in their current format while the new version is there.  Is that still the case and do we know what that overlap time period is going to be?
  • When asked how long it will take the EDIs to fix it, move the reporting
    • Nathan replied - its not fixing it, it is creating brand new reporting, it is it's own file and own structure
    • DaVita is still targeting the first quarter
    • Per Scott - the period of overlap is definitely available; based on past conversations with the EDIs, they have penciled in Q1
  • Per Kathleen - the IT team and Kathleen were reviewing the updated clinical XSD and XML for after the vaccination modules are moved but there were still 3 questions in there about vaccinations (simple Yes, No questions).  Kathleen was not aware there would still be vaccination questions in the clinical model.  She thought they were all coming out all together.  
  • Understanding was that once everything is in production, the vaccination module is there, the clinical module should have zero reference to a vaccination
    • Per Scott - Yvette indicated that what Kathleen is seeing in the files is the development direction that was made before we all agreed to deploying vaccinations all at once, so pneumococcal moved to patient, the other vaccinations are still in clinical because that was the decision at that time
    •  Suggestion is for the EDIs to start working on the patient piece and there will be more to come on clinical as development is picked up for hepatitis and flu moved those to patient
    • Expectation is that at some point CMS will be getting another update on the clinical XSD and XML
    • Vaccinations is becoming its own file, this is not going into the patient demographic file 
  •  Per Nathan - Need clarification on the actual migration. Are we not migrating?
    • Per Lisa - her understanding was that everyone was ok with migrating the data
  • Per Nathan - Is the expectation that EDIs only report new vaccines?
    • Per Lisa - No, if a patient mentions he/she did have a vaccination in the past, the EDIs should submit that information
    • EDIs are not expected to send in the full record every time

Additional technical questions

  • Per Vlad - They agreed that they would receive a periodic report showing them all the vaccination information for their patients 
    • Yes, the NCC will do that
  • The plan is to develop all vaccine types and convert them at the same time?
    • Per Lisa - with the exception of PPSV23 because it is already developed and they need to release it
      • PPSV13 will be in the old system and PPSV23 will be in the new system
      • When CMS gets ready to move the vaccines. Lisa hopes to be able to let the EDIs know a PI ahead; develop it in the PI so the EDIs should be aware about it 24 weeks
      • EDIs should be able to start preparing and planning their systems out

Question from Vlad -

  • What is the release date on PPSV23?
    • Per Lisa - she will have to get back to Vlad on when the release date for PPSV23 (action item)

Prevent Overwrite of Key Patient Identifiers in EQRS from EDSM


How updates are made and EDIs to know when our data is accurate from EQRS “locked” records

  • The EDIs will be given a report back that tells them what's incorrect in their data

How are updates made?

  • Once a patient is matched to the EDB the refresh process is place - in the first half the data is pulled down once the connection is made and they populate EDB fields in EQRS
  • Once the match is made, they will populate the fields and lock the records so the UI nor EDSM can change something that would break an EDB match and negatively impact coverage
  • This is the first step of the patient repository
  • In planning this for when EDSM sends something in a patient demographic file and it is different or we already have a patient mapping, a pat org ID, if we're not going to update those 6 or 7 fields that are key patient identifiers (first name, last name, date of birth, date of death, MBI, SSN); they will not be updating.  They will not reject the patient demographic
  • They are still going to process the record, they will just ignore anything that is different for what EQRS knows that EDB has that allows for code coverage connection between the two
  • A new warning will be created; suggested that the warning messages be distinct for each field
  • The changes will be locked down in the SUI for everybody
  • Once the record is locked, it will be locked for EDSM and the UI
  • This feature is currently being worked on in PI16
  • If it is not completed in PI16, it will be done in the early part of the next PI

Admission in Support of a Transplant


Expectations of reporting short stays (e.g. 1-2 treatments)

  • Lisa is not ready to discuss this at this time
  • She may have more information by the next meeting

Business Requirements documentation


Need for all of the above items

    • CMS should make this become standard practice in each PI for any new EQRS items

Need to create for existing EQRS functionalities

Data Management Guidelines is not a BR document it’s a data reporting expectations guide

  • Lisa asked the EDIs what they mean by Business Requirements?
    • Per Nathan, BR are the rules of reporting the data, not just from a technical EDSM structure
    • BR are more of the rules of reporting of the data points; for example the definition of Telemedicine
    • Looking for an official document that explains the expectations of the data
    • What is the workflow CMS expects for a feature? For example Depression screening, what is the workflow, procedures, exceptions

Next meeting scheduled for  

Action Items:

  • Per Lisa - she will have to get back to Vlad on when the release date for PPSV23 Lisa Rees 
  • Lisa will check with Yvette when she can go through the screens related to depressed patients and explain things, what is required, optional, etc Lisa Rees 
  • 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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