QualityNet Jira and QualityNet Confluence will be briefly unavailable on Wednesday, June 26, 2024, between 8:00 PM ET and 9:00 PM ET while the team performs required system updates.  If you have questions or concerns, please reach out to us in Slack at #help-atlassian.



Aaron Thompsonx
Adrienne Adkins
Adrienne Ray

Ahmar Wazir

Anitha Chintalapati
Arnie Esparterox
Betina Fletcherx
Branon Barrettx
Carol Olsen
Cheri Jerger
Chris Brown
Curtis Phillipsx
Deb Wilson
Dianna Christensen
Greg Eccleston
Hayley Evans
Hari Krishna Pemmasani
Heather Dubendris
Heather Moorex
Howard Thomas
Janet Lea Hutchinson
Jason Clemx
Jason Simmingtonx
Jennifer Baileyx
Justyna Sardinx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelly Mayo
Lakshmi Erigineni
Leah Skrienx
Lisa Rees
Malik Arsalan
Matt McDonoughx
Melissa Fieldhouse
Michael Kennedyx
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Porsche Dorseyx
Rachelle DuBose Caruthersx
Revathy Ramakrishna
Sarah Filling
Seema Sreenivas
Scott Laughlinx
Shalon Quinn
Steve Goodmanx
Todd Johnson x
Vladimir Ladikx
Yvette Brown
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

https://us06web.zoom.us/rec/share/dUNJSmNV6FhjsrJl8f5EY67jruCf7HtXXogv4pNUcc2BHaE_vC6JieNJPbcC6E89.2onlYbP9Hl_3l6Pf Passcode: $4cyQKq8  

2021 Data Submissions Porsche/Todd

2021 Data Submissions Extension update

  • The program does not have an update at the time of this meeting
  • The decision is still our of the programs hands and with leadership and going through the proper channels to get a decision
  • As soon as the program knows something, they will share it as soon as possible
Feature(s) UpdatePorsche/Todd

HCP Flu Reporting to NHSN

  • Right now the CDC is looking at some training and Todd is working on getting firm dates for the training
  • When Todd gets the dates for training, he will send out to the group
  • Questions from Nathan
    • The facilities received the communications with the March 26 deadline.  How was the deadline picked if training is still not decided and when it will happen?
    • The CDC has not given the electronic submitters the technical documentation needed
    • Flu season ends March 31st, so any data the EDIs report for this flu season is not actionable by the networks
    • Todd requested that Nathan send the concerns surrounding the HCP Flu reporting to NHSN to him; Todd will be meeting with the CDC on Friday, 2/25 (Action Item)
    • Nathan confirmed the deadline of March 26 is a CMS deadline

Parathyroid Hormone (PTH) and Vitamin D

  • Michael will be meeting with CM (Abby and Nick) tomorrow to talk to their contractor to see exactly which fields they have
  • Michael and Nancy Carlson have done the environmental clinical and system research to see what we have, what they used to collect and currently don't collect
  • Michael will then set up a series of meetings with the EDIs - Vlad, Nathan, Kathleen, Howard and Kelly, etc so it can be determined by April what is needed or not needed and try to standardize, etc
    • The goal is to determine how we can get both CM and CCSQ what they need to answer the Congressional inquiry and show what our program is doing
  • Question from Nathan - Is there a timeline when EDIs will get expectations of what is to be reported or is it dependent on the conversation Michael will have with the contractor?
    • It is dependent on Michael's meeting with the contractor
  • Question from Vlad - Can the EDIs just give a comma delimited file with results for a whole year?
    • Per Michael, maybe but we can discuss at the meeting the details


  • Nathan sent an email to CMS/Program last month around the implementation of the new vaccination module
    • Todd has the vaccination questions and will review with Porsche.  Feedback will be provided at the next Program Working Group meeting, 3/9 (Action item)
    • Per Nathan - he was following up on the outstanding questions that the EDIs have for vaccinations
      • How will certain things be handled?
      • What the expectation is for implementation: Would there be any data movement from the data that's in the system today to the new module?
      • Would the EDIs only report moving forward or report a full historical set of data and then everything new going forward? What are the reporting expectations?
      • In general, there are a bunch of questions out there the program has not been able to answer.  The EDIs cannot move forward with an of their development planning type work until they have answers from the program
    • Per Steve Goodman - he is requesting for an updated data dictionary that will include Flu and Hep B (type and subtypes) and how to handle boosters
      • Per Scott, a new data dictionary has not been prepared yet.  As soon as it has been updated, it will be sent out to the EDI submitters
      • Steve mentioned that not only the data dictionary but any information on subtype mappings and any decisions on how the EDIs are expected to handle certain information would be great

Open Forum



  • Nathan asked where do we stand with the Identify Depressed Patients (IDP)
    • There are a number of outstanding questions and concerns
    • EDIs need the final expectations and requirements
    • Per Porsche the program is working internally to finalize a few more details and nearing completion
    • The program is finalizing answers to the questions and concerns to provide back to the EDIs
    • Not finalizing to get it functional in the system
  • Follow up question to the information provided earlier regarding the 2021 Data Submission Extension -
    • Why is it taking so long to get an answer and when the EDIs may get answer?
      • It's been 5 weeks since the formal request was put in
      • The informal request was raised in December, 2021
    • Per Porsche, she does understand the concerns for the EDIs.  She has been out of the loop of the leadership conversations so she does not have a definitive response; the decision is pending
    • As soon as the program hears something, she will share with the group


  • Per Kathleen, no updates for KFC


  • Per Vlad, no updates for DCI


  • Not able to attend today's meeting

Next meeting scheduled for  

Action Items:

  • Todd requested that Nathan send the concerns surrounding the HCP Flu reporting to NHSN to him; Todd will be meeting with the CDC on Friday, 2/25 (Nathan)
  • Todd has the vaccination questions and will review with Porsche.  Feedback will be provided at the next Program Working Group meeting, 3/9 (Porsche/Todd)
  • 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 CMS.gov 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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