Aaron Thompsonx
Adrienne Adkins
Adrienne Rayx

Ahmar Wazir

Anitha Chintalapati
Arnie Esparterox
Betina Fletcher
Branon Barrettx
Carol Olsenx
Cheri Jergerx
Chris Brown
Curtis Phillipsx
Deb Wilson
Dianna Christensen
Greg Eccleston
Hayley Evansx
Hari Krishna Pemmasani
Heather Dubendris
Heather Moore
Howard Thomas
Janet Lea Hutchinson
Jason Clemx
Jennifer Baileyx
Justyna Sardinx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Lakshmi Erigineni
Leah Skrienx
Lisa Reesx
Malik Arsalan
Matt McDonoughx
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Rachelle DuBose Caruthersx
Revathy Ramakrishna
Sarah Fillingx
Seema Sreenivasx
Scott Laughlinx
Shalon Quinnx
Steve Goodman
Todd Johnson x
Vladimir Ladikx
Yvette Brownx
Zach Serleth


Meeting RecordingArnie

This session will be recorded for the purpose of documenting the meeting minutes and action items. If there are any objections to the recording of this session, please make it known now. Absence of an objection to the meeting being recorded will count as consent to recording this meeting

Passcode: 0yE?aL#1 

Features (upcoming)Lisa

Adding Parathyroid Hormone and Vitamin D measures to EQRS

  • Request to add submission of the Parathyroid hormone to the clinical lab
  • Is this something the EDIs collect?
    • Per FKC, Kathleen has to look into
    • DCI collects it. It is called PTH
      • Problem #1 - different labs do it slightly different; use different SA, as a result, you will get different results which can or cannot be comparable
      • Problem #2 - it is a very unstable parameter; you could measure it on a patient now then in 2 hours you may get two different numbers
    • Per DaVita, Nathan would need to check what they run and what is collected, labs, etc.
    • NRAA representatives were not on today's call
  • Lisa suggest further discussion takes place with a smaller group
    • Lisa will work with the NCC and their availability the week of 1/3/22 to schedule a meeting to discuss further
    • Nathan will reach out to NRAA (Howard) and provide the information that a meeting will be scheduled the week of 1/3/22
  • There was a question on whether Lisa could provide more context as to why PTH would be added?
    • Per Lisa, there is an interest in seeing how well this element is being controlled in patients with the medications that are available
Identify Depressed PatientsLisa/Yvette/Scott

Discuss question and suggestions captured at the 11/30 PI16 System Demo

Nov 30 2021 EQRS System Demo Questions_Suggestions 121421.docx

  • Complete list of questions and suggestions can be reviewed in the above link
    • (Recording discussion begins: 17:05) - There are two questions here. One is for depression screening and the other is for cognitive decline. If the patient is screened for cognitive decline, there is a place to enter a score. No score is required for depression screening.

      If the score is only for cognitive decline, then

      1. Clarify that the score is only for cognitive decline and,
      2. Clarify that the question “Has the patient been referred for treatment” refers only to cognitive decline and,

      Disable the options to indicate if the patient has been referred for treatment, to indicate a decline, and enter a score when cognitive decline screening is No.

    • Per Lisa, not sure that we want a score for the cognitive decline.  She believes the question is "Does the patient have cognitive decline? Yes or No. If there was cognitive decline, the user could not proceed to the screening for depression
    • It supposed to be a way to rule out people with cognitive decline so that you can move on to the depression screening
    • Per Yvette - the way it is set up is that if the patient didn't have depression screening, that is when the questions about cognitive decline are asked
      • One of the questions is a Yes or No question and the other is asking about the cognitive decline score
      • In one of the demos, it was suggested to add "What is the cognitive decline score?" so the user would know this is about cognitive decline 
      • Another related question was how that score is obtained and that it may not be able to be compared because people do it differently
    • Per Nathan - not every organization is using the same screeners for either depression screening score or cognitive decline score. Therefore, the scores being compared to each other are not apples to apples, etc.
    • Per Vlad - you should be asking for cognitive decline question first then proceed to depression screening questions but currently it is backwards, depression screening is first, then ask about cognitive decline
    • Per Kathleen - it makes sense to ask first if screening has been done, if not, then why? then one of the reasons is cognitive decline
    • Lisa and Yvette will discuss this scenario in the afternoon and get back to EDIs
  • Per Nathan - for this new module, there is a lot verbiage around the term depressed patient and the assessments that are out there do not indicate if the patient is depressed or not, they are just assessments for if the patient should have more follow up.  This may cause confusion if the language in there today continue to say "these are depressed patients or defines a patient as depressed when clinically they may not be just because they got a high score on an assessment
    • Lisa and Yvette will discuss the wording/verbiage; how the language can be different and less confusing
    • Per Kathleen - suggest to make them similar to the QIP questions, positive indicators of depression
  • Per Nathan - still confusion around if it's every patient before reporting on all patients, all the time, or only those who screen positive.  Nathan encourages integrating this with current depression reporting.  Some of the data set that exists today answers some of the questions that are in the new module
    • Per Lisa - this cannot happen. They are two different  things
    • All patients need to be screened every quarter because they could change
    • For the quality improvement project for the networks, its not just the development of a system.  The system is being developed to provide the data to the networks for the projects they are working on
    • Per Vlad - that is not how other CMS programs treated that requirement
  • Per Lisa - we are not discussing changing the project activity, we can discuss how it is collected.  The project has already been approved through senior leadership and this is what the networks are doing
  • The project is to identify patients who are depressed and connect them with services
  • Per Todd Johnson - Lisa is on target.  This call is to discuss how the data is being collected as related to EQRS and the programs position is that the project is in the contract and that is something that won't change
  • The dialysis community never comments on the network contract; CMS/Program went out to the dialysis community and asked before they wrote the contract; there were discussions prior to the contract and everyone said depression was something that needed to be worked on
  • The patient even said depression was something to be worked on
  • Lisa will discuss with Yvette the verbiage/language surrounding the questions for depressed patients and cognitive decline.  In addition, review the EDIs feedback and suggestions (action item)

Discuss better ways to communicate about transplants.

  • The Program (Lisa) would like to work with the EDIs and the facilities, not just independent facilities but also the EDI facilities
  • To understand their patients that are trying to start a transplant journey or who are on a transplant journey
  • It would be valuable to see information and see the information from transplant centers
  • Also to work with the transplant centers to see what CMS can offer them about their patients
  • Overall to further the communication and improve the coordination of care across the two entities
  • Per Nathan, a big limitation they have found is data sharing; it would be good to improve the data sharing and quality of the data.
  • Another area of interest to improve is how to make the user interface within EQRS usable
  • Right now there is no way in EQRS to see the status of their patients on a waitlist
  • From the transplant side, they would like to be able to see all of the patients on their waitlist and which dialysis center they are treating at
  • Per Lisa, they are looking to start exploration possibly in the next PI; explore what would be good to the facilities, transplant centers and what CMS already has that they can display

Next meeting scheduled for  

Action Items:

  • Lisa will discuss with Yvette the verbiage/language surrounding the questions for depressed patients and cognitive decline.  In addition, review the EDIs feedback and suggestions Lisa Rees 
  • 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 a 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





  • No labels
Write a comment...