2:00 - 2:45pm


Aaron Thompson
Adrienne Adkins
Adrienne Ray

Ahmar Wazir

Anitha Chintalapatix
Anne McDermott
Antwyn Jackson
Arnie Esparterox
Betina Fletcher
Branon Barrett
Cheri Jerger
Chris Brownx
Curt Phillips
Danita Patel
Deb Wilsonx
Delia Housealx
Dianna Christensenx
Hayley Evansx
Hari Krishna
Heather Moorex
Howard Thomasx
Janet Hutchinsonx
Jason Clemx
Jay Vancil
Jennifer Baileyx
Julie Alvarezx
Justyna Sardin
Kathleen Prewittx
Kelly Llewellynx
Lakshmi Erigineni
Leah Skienx
Lisa Rees
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Tasel
Pandu Muddana
Porsche Dorseyx
Preston Brownx
Revathy Ramakrishnax
Sarah Fillingx
Scott Laughlinx
Seema Sreenivas
Shalon Quinnx
Shamim Almamun
Steve Goodman
Timothy Jacksonx
Todd Johnson
Vladimir Ladikx
Yvette Brownx
Zac Cohen


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: C4FrJwd*  

2021 Data Submission ExtensionScottJanuary 2021 through December 2021 Data Submission deadline has been extended to March 31, 2022 at 11:59pm (Pacific Time). 

This data submission deadline applies to:

  • EQRS Clinical Data
  • Clinical Depression Screening and Follow Up
  • In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Attestations

Additionally, CMS has extended the EQRS Clinical Data submission deadline for January 2022-February 2022, to May 31, 2022, at 11:59 PM PT. Beginning March 2022, clinical months will resume for data submission on the first of the month and close approximately two months after the end of the reporting month.

  • CMS/EQRS has updated all of the dates and deadlines in the EQRS Facility Dashboard
  • Question from Nathan - Since the deadline is 11:50 Pacific time will EQRS sat the deadline is April 1st
    • Per Michael, Yes it will, 4/1/22 2:59am eastern time
PI Feature UpdateHayley/Yvette

Vaccination Updates (Haley)

Recording for this discussion: 9:07 - 39:20 (listen to recording for the different UI vaccination module scenarios and feedback discussion and online screens displayed)

  • Hayley presented an overview of the design of the vaccinations UI with feedback from the CMS program, EDI Submitters, networks  and users on the frontline
  • Concerns and why the module is changing will not be addressed at this meeting, they can be addressed at the Program Working Group meeting where the CMS program team will be able to answer those concerns, etc
  • Vaccinations module is moving out from under the manager clinical to under manage patient
    • First reason - This will allow for better continuity of care for patients
    • Right now instead of it being attached to a facility, it is being attached to a patient record
    • Second reason -  We are moving from a monthly submission of the same data over and over again to unique event based data
    • So when an actual event occurs that gets logged
  •  Haley presented the EQRS Vaccination Data Submission Requirements and F&Q document (recording starting at 12:24)

Implementation Discussion (Yvette)

Recording for this discussion: 39:24 - 59:42

  • There are no dates determined for the implementation of this module at this time
  • EDIs will get a chance to test this module at the end of this PI in prod preview environment
  • Expectation is that the EDIs would be working on creating the new vaccinations file as well as updating the clinical file to remove vaccinations
  • Similar to the handling of phases 1, 2 and 3, we will be coordinating schedules and go live for the vaccination implementation so there is no interruption in data collection and that EDI Submitters are ready to make this change across the board
  •  When the date comes for the cutover, the old xml that has some vaccination information in the clinical file will no longer accept that from anybody and you would be expected to send in a separate chunk of xml for the vaccinations module at that same time
  • Question for the EDIs - How much time is required?
  • The document that Hayley presented earlier on the screen, Yvette will share a link to the document that will show all the UI elements that would be needed
  • Since development has not started, Yvette does not have a sample xml right now
  • Howard did request a firm date on when the EDIs will receive the sample xml or final xml
  • Questions from Nathan
    • The day that this transition happens, can the EDIs have clarity on if the old xml file is not updated and if they send a file with vaccination data in it, is it going to just error the vaccination records and accept other data or is it that the whole record will be rejected b/c those are two different experiences?
      • Per Yvette, the entire record would be rejected; not the entire file
      • NRAA file will be rejected because they only send one record per file
    • Can the EDIs get the requirements documentation (business) that provide how to report different patient scenarios?
      • Hayley would like to share with the EDIs the documentation she currently has for their feedback
      • Howard would need about 2 weeks after the final documentation is in final form in order to provide feedback when the NRAA technical team will be ready to start development, not to complete testing
  • Question from Kathleen regarding the migration of the data
    • CMS plans to migrate only the latest vaccination data for patients 
    • The existing data will still be there, NCC will still have access to the database
    • Per Janet H. when the network works with the facility, the facility looks in that vaccination module won't be able to see that the patient has had all 3 in the series of PPSV23, so while NCC is able to report that to the network, the facility won't be able to see that information if it's not migrated to the vaccination module since that is one of the ones that has a series required
      • Per Yvette, that is correct and that was the plan.  CMS program can review and let the ADO know if there are any changes
  • When does CMS/EQRS ADO believe they will be ready to test, etc?
    • Per Yvette, they are hoping to get to the EDIs in prod preview by the end of this PI (end of March, beginning of April)
    • CMS/EQRS ADO would be in a position to test with the EDIs in about a month from now
EDI Submitter's Progress (upcoming feature development)EDIs


Nathan submitted a ticket a few hours before the meeting - they have had examples were clinicians have done manual entry and then the data isn't there when they go back in the next week to do the next month of data

      • The data is blanked out like it was never entered
      • Michael is researching it at this time; he will look to see if has to do with the clean up of duplicate records
        • Michael did respond to Nathan's ticket and sent him an email with the details
        • The data was not erased or missing
        • Nathan is good with the feedback from Michael



DCI received the transplant waitlist report and compared to previous months, they have 200 extra records on the report

      • Vlad will send Michael some examples from the clinics
      • Michael is still researching
      • Looks like there is a transplant OPO (PA HR H) where they did not report some things in their transactional data
      • Even though the records  previously matched maybe the didn't; Michael will do further research
      • All of the patients are still matching; much better match rate now
    • Regarding a discussion Vlad and Michael had earlier,
      • Michael  and Nancy Carlson did find the missing patients and they are mapped for Vlad and looks fine
      • Michael will send Vlad the UPI list back to him


    • Per Howard, they heard a report inside EQRS in the UI, people were not able to use the clinical reporting. Was EQRS down this week?
      • Per Michael the facility dashboard may have indicated unavailable, not an EQRS report
      • Michael has people looking into it

Action Items:

  • DaVita and FKC would like Scott to send examples of CMS role requests so they can reach out to their communities and determine the root cause of the request Scott Laughlin  
  • Kathleen request an update on the ICH CAHPS Attestation report.  Todd will follow up with Dianna and get back to the group (Todd Johnson)
  • Request from Chris - display/capture EQRS rule updates or "hot-fix"/non major release dates that can be shared with the EDI Submitters that may impact their ability to correct/update patient data
    • Scott will research a way to be able to identify a feature that a rule update or "hot-fix" impacts, so the EDI Submitters are aware of the change Scott Laughlin
  • Scott will discuss revisiting the DaVita effective date and date of death issue with Lisa Scott Laughlin
    • Scott will provide a response to Nathan (1/14/22) 

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