2022.10.19 EQRS Program Working Group Meeting

Issue:

• DaVita did their normal patient demographic submission on Monday, 10/17 6:03am (mountain time) to 8:55am (mountain time).
• Over the weekend DaVita had an internal data issue where they pulled in a lot more records than they normally would have. 
• Most are historical records and a lot of them short term admissions
• Most of the cases are the creation of system discharges; looks like the patient is not in that clinic anymore
  
  • DaVita sent an email to the EDIs about potentially pausing their submissions
  • FKC has paused their patient submissions
  • CMS has had internal discussions this morning and have come up with the two approaches:
    • Approach 1: Find a way to identify all the records that need to be cleaned up; to develop a script to clean up those records may be time consuming and will take a lot of work; there is concern it may also introduce a level of risk that not everything will be caught therefore impact the integrity of the data
    • Approach 2: Perform a rollback to a point in time; this would involve a rollback of the entire EQRS database to a point in time before the erroneous data was submitted; All EDI submitters would need to resubmit up to the current time; CMS believes the rollback is the best solution to get the data back to a higher level of integrity
  • CMS would like to get feedback from the group
  • CMS will be working on a plan
  • Lisa did mention the NCC ran a gap report this morning and they are only seeing .04% (1558 patients) difference from the gap report last week
  • Chris Brown also just saw a handful of records (~30-40 records)
  • Not sure if it is a following open admission; a lot of DaVita's were historical records; they were completed admission and discharge
  • Chris looked at whether they were at a different facility last week compared to today.  There's not a lot of those either that are non-normal
  • Chris ran a system discharge report; network 4 there were only 50-60 which is not out of the norm
  • The NCC (Janet) will run the system discharge report looking at Monday, 10/17
  • These records were not in a specific timeframe per Nathan
  • Geraldine from DCI pointed out an issue that happened last week but per Nathan that issue is different than the one being discussed at this time.  The issue Geraldine is referring to may be confined to a specific set of patients
    • Two patients involved in this issue
    • They were admissions reported from DaVita back from 2014 last week
    • May be a concern if this issue has been going on for a while; the DaVita team is looking into the issue to see if it is a broader issue
    • Per Nathan, DaVita's submissions have been "normal" until this past week
  • The incident that occurred that affected their Monday submissions happened over the weekend 
  • They did not send any other patient demo data that was affected until Monday, 10/17 when they submitted the erroneous data
  • CMS needs the exact time stamp in order to determine what to rollback to
    • Per Sarah the only data affected by this issue was data submitted in a job that started at 6:03am (mountain time) on Monday, 10/17 and completed at 8:55am (mountain time) on Monday, 10/17
    • Everything else before that time was unaffected
    • DaVita has halted all submissions after that time through the present
  • Is there a frequency when with which CMS can roll back?
    • CMS can roll back by day
  • Will need to ask the EDIs what the volume of submissions will be to resubmit again?
  • What would be included in the roll back?
    • patient admission treatments
    • 2728
    • 2746
  • This will not impact compliance rates for data quality project
  • Clinical data will not be rolled back
  • No impact to depression data
  • Vaccinations are not impacted
  • FKC and DCI is receiving 9999... errors which is a separate issue; a notification was sent out the other day regarding that issue
  • CMS will be coming up with an announcement regarding this issue
  • CMS team will put together a plan (approach, timing) and communication
  • The roll back can be done at any time; it will depend on what needs to be done for downtime for incoming submissions; APIs and UI will be shut down for the restores
  • From 6:03am (mountain time) forward any data sent in needs to be refreshed/resubmitted again (patient data) until current
  • What about manual submissions done this week? Do they have to be redone?
    • Yes, CMS is looking at capturing data submitted via the UI and reapplying them after the restore
    • Suggested to redo all manual submissions not just those identified; some users may be fixing something that they believed was an error that should not have really been fixed
    • FKC team is doing August clinical data before it closes
    • If the system is restored to prior, then this will involve more time to redo them and the window to get August data in becomes smaller and smaller
    • Per Dan, they do have the ability to reapply the manually entered data only for patients that are not matching with the list of patients that we know had bad data
    • Is there consideration to extend the clinical data?
      • This is a question for QIP - Ahmar was not on the call to answer
  • When a plan is determined, when will it be implemented?
    • CMS would like to come up with a plan by COB today
    • Need to determine the work involved and timing
  • DaVita is putting together a list of patient IDs affected
  • Instead of reaching out to the facilities to let them know to look at certain patients to reenter, per Chris the delta will be small enough for them to go through 
  • DaVita, FKC and DCI have already stopped or can stop their submissions for now

Note: A meeting will be held next Wednesday, 10/26/22 11-12pm to discuss Peritonitis 

Open Forum

DaVita

FKC 

DCI 

RHA