Aaron Thompson
Abigail Viall (CDC)
Adrienne Adkinsx
Adrienne Rayx

Ahmar Wazir

Amy Nestler
Arnie Esparterox
Ashley Wx
Austin Woods
Betina Fletcherx
Branon Barrett
Carol Olsen
Cheri Jerger
Chris Brownx
Dan Kayhart
Deb Wilson
Dianna Christensenx
Dinesh Chatoth (FKC)
Emily Kenlaw
Geraldine Bojarski (DCI)
Greg Eccleston
Heather Dubendris
Heather Moore
Heather O'Neal
Henrietta Smith
Howard Thomasx
Janet Lea Hutchinsonx
Jason Clemx
Jason Dong
Jason Simmington
Jennifer Bailey
Justyna Sardin
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelsey Oklandx
Kr Van Allen
Leah Skrienx
Lisa Reesx
Lizzie Suh
Lyndsay Crowson
Mahesh (DaVita)
Matt McDonoughx
Martha Beanx
Melissa Fieldhousex
Meredith Zywno
Michael Kennedy
Michelle Cassin (DaVita)
Mihran Naljayan (DaVita)
Mitzi Christ
Nathan Muzosx
Ozlem Taselx
Pandu Muddanax
Pani Palanichamyx
Porsche Dorseyx
Rachael Lazar
Rachelle DuBose Caruthersx
Revathy Ramakrishnax
Sarah Filling
Seema Sreenivasx
Steve Goodmanx
Vladimir Ladikx
Yvette Brown
Malik Arsalan


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: 1aLV?dQe 

Program Working Group_20230111-155605_Recording_1920x1080 (1).mp4

Feature Updates/DiscussionsLisa/EDIs

Status updates:

Hep B Antibody only keeping most recent record

    • Per Adrienne, a fix has been deployed into production
    • Should see multiple Hep B Antibody records

Sample 2728 XML status

    • A sample 2728 XML is not ready at this time
    • Once the work is prioritized the ADO will start working on the XML
    • ADO will provide the EDIs with whatever information is available as the XML is being developed
    • The batching of 2728 has been around for years so there hasn't been a need to work on it - there has never been a sample XML provided for that submission
    • The EDIs do have sample clinical data for depression, vaccinations, etc.  They do not have one for 2728 XML
    • EDIs are working on 2728 on their side
    • What are the EDIs looking for in a "sample"?
      • An XML file that will be used to upload 2728 data
    • Per Adrienne, when they have the updated work for the 2728 and the forms go through clearance, the ADO can add this into the feature
    • EQRS ADO will work on the sample documentation when available and get to the EDIs

Depression Screening 2021 Closure Date

CAHPS Attestation Report

    • Historically, for the months of January and now February (since it has been pushed out), the EDIs have received the status of their attestations
    • A list of their clinics and whether or not they have attested or not
    • The report shows the attestations that are successful, or they have clinics that do it inadvertently and they will have to undo it for them b/c they shouldn't have done it
    • It is needed for a 6-week window
    • This report has been provided to the EDIs in the past by a variety of contractors - Ventech, Michael Kennedy (this past year)
    • Lisa will ask the NCC if they can provide the attestation report to the EDIs (Action Item - Lisa)
    • Adrienne request that Nathan/Kathleen send an email to Adrienne and Lisa describing in detail what is listed on the report, what data is normally provided and for what timeframe they need this (Action Item - Nathan/Kathleen)
    • The EDIs were getting this report weekly and up through the end of February; would be helpful to also get it on 2/27 and 2/28
    • What is the deadline for attestations?  Need to confirm the correct date. (Action Item - Jason Clem)
    • The dashboard in EQRS says 6pm Central standard time on the 27th - need to take into consideration time zones
    • Need to look in the actual system to make sure it is right and the backend of the system
    • Per Adrienne they have talked to the ADO about confirming the date and a ticket has been created

2728 Comment Period

    • Nathan expressed a thank you to the team for the work done to get them to post sample forms, crosswalk, and documentation - it has been very helpful
    • Since we know the comment period ends 2/13; does EQRS ADO have a timeline when EDIs should expect it in EQRS?
    • The team has been given the form to start getting familiar with it and some work may be done later in PI21, but don't anticipate the real work starting until PI22
    • EQRS ADO will work with the EDIs; Lisa does not want the EDIs to feel they are going to be pressured
    • This would be a good opportunity to have it released in prod preview for a 2–4-week testing window
    • Chris Brown - Has anything changed on the new form as far as the SSA going to allow electronic signatures when it is released?
      • Lisa had a conversation with SSA and they are working on updating their language
      • SSA is aware of it and has signed off on accepting electronic signature
      • What is the form of the electronic signature going to be? How will it be authenticated?
        • The provider will need to have a system to authenticate the signature
        • A pdf with the appropriate data on it will be acceptable
        • Nathan requested that when SSA releases a memo on this, that the EDIs get a copy or a reference number so they can use it to show that changes were made for 2023 (Action item - Lisa)
        • Is there a future goal were the EDIs do not have to give the field office a paper copy; it's sent electronically to SSA through EQRS?
          • SSA systems are older and right now 2728 is not a priority for them
          • Lisa will check with SSA in about 6 months to see if they are making any movement on this becoming a reality
      • The electronic signature does not apply to the 2746 form because there is no signature required; just the name of the person that filled out the form
      • The 2746 should be coming out soon for review
    • Chris Brown - They received a memo from CDC and NHSN on Monday that suspended the use of sex at birth and gender identity fields in their system.  Will this be an issue with those fields being on the new 2728 form
      • Lisa mentioned that no one has brought this as being an issue to her attention. It has gone up through her leadership and PRA without any concerns
      • Chris will forward the memo he received to Lisa as a future reference
    • NHSN - speaking for several of the networks to the organizations that are batching data into NHSN - they are seeing really Low numbers
      • Are the EDIs having batching issues with NHSN or having difficulty with staff flu vaccinations?
        • Per Adrienne (FKC) the staff flu vaccinations are low; they have several different campaigns going on
        • Per Vlad (DCI) it's likely a data entry issue b/c historically it was never mandatory; some clinics were entering them, and some clinics were not
        • Lisa requested for the EDIs to send something out to make sure it is put into their system; the Program does have measures on it in their contract for the networks
        • Per Nathan - it is similar reason as FKC and DCI.  It's a combination of hesitancy and documentation
    • Regarding 2744 - Per Lisa, staffing has become an issue across the country.  People are burned out and also due to the pandemic.  Is there any bandwidth that the EDIs could report staffing more frequently than annually by facility?
      • How it could be reported can be discussed later
      • What are the questions that need to be answered with the data?
Open Forum

DaVita - Do we know where the holistic corporate role stands? When those who have thousands of roles will have the ability to get rid of the many roles and just have a few?

    • Per Adrienne, they are taking an iterative approach and the corporate roles is definitely on their radar
    • It will not be completed in PI21 but high on the list to be completed


DCI - There seems to be some kind of loopholes clinics have to go through to document 2746, death form; it' happening when a patient withdraws from dialysis then a week or two later the patient dies.  DCI reports this discharge as a withdraw from dialysis, having problem entering 2746 in EQRS. You have to go to admission, change admission to death instead of discontinued dialysis then change the date to the actual data of death then the 2746 can be entered

    • Vlad has submitted helpdesk tickets for this scenario in the past; if he submits a new ticket he needs to send/include the ticket number to Lisa and Adrienne


US Renal


The overview of PI21 Features were captured in the 12/21/22 Program Working Group meeting minutes: 2022.12.21 EQRS Program Working Group Meeting - EQRS Communications Hub - QualityNet Confluence (

FYI - The EQRS ADO will have the HCD team in attendance at the next meeting (1/25/23) to get feedback about the Unauthenticated Portal (EQRS Home Page). Please be prepared to provide input.

Next meeting scheduled for  

Action Items:

  • Adrienne and ADO will do more research on why Hep B Antibody tests are being overwritten (Action Item Adrienne) If issue continues, submit a ticket through Service Center
    • 10/17 - Adrienne request Nathan/Sarah so send her an example file for the issue
  • Adrienne will ask the ADO for a sample 2728 xml (Action Item Adrienne)
    • 10/17 - The ADO does not have a sample 2728 xml file that they can provide
  • Question from Nathan: since we are past that October 1st transition to vaccinations (structure of the labs has been changed). New error codes for the change were updated.  Can we expect new versions of the labs XSDs, data dictionary and other documentation to show this change? Adrienne will get this information and share with the group (Action Item Adrienne)
    • 10/17 - The new XSDs and data dictionary for Vaccinations will be available after November 30th. The existing codes will be valid up until November 30th.
  • Nathan submitted tickets for other enhancements for errors and warning changes (mostly verbiage).  Any update? Nathan will send the ticket numbers to Adrienne and Lisa (Action Item Nathan Complete 10/5)
  • Lisa will look into why and how to resolve the error 20002 (Action Item Lisa) 
  • Create a Service Center ticket for the NA issue for Country of Origin? Once Adrienne has the ticket, she will work on getting that corrected during this PI. (Action Item Nathan/Sarah - Completed demo'd 11/15)
  • Lisa asked if Nathan was able to organize for the EDIs to get together a list of minimal data set and what they currently track? The plan is for Nathan to compile all the spreadsheets and get to Lisa and Abigail (CDC) (Action Item Nathan - Completed 11/8)
  • Need to ask CDC how many pathogens they want identified for a single event? Do they want every organism that was related? (Action Item Lisa)
    • CDC request for the 3 highest count pathogens
  • "Select all that apply within 50 days from the date from peritonitis event" - We need to determine if we wait until you have all of the information.  Theoretically, if we're looking at the outcome 50 days out, you should be able to report that at the 60th day.  So, they would look at reporting 60 days after the event (Action Item Lisa)
    • Lisa will need to ask the CDC about this for clarification 
  • Wanted to talk through the clinical updates (redshift, etc). There were some system issues with clinical data that may have impacted the data that the NCC gets in redshift.  In addition, this past weekend and maybe 2-3 weeks ago, redshift wasn't updated. Per Lisa, she will be meeting with that team (ADO and NCC) this afternoon and will discuss it with them (Action Item Lisa)
  • Peritonitis: how do we let clinics/EDIs/ORGs know what's missing from the peritonitis data from the beginning as opposed to just collecting all data? Nathan will circle back with his clinics/reps to determine what important information they'd like to see in the reports prepopulated. (Action Item Nathan)
  • Status of updated documentation on Confluence page and how this can be built into the process instead of after the fact.  Adrienne will go back to the EQRS team and ask about the documentation (Action Item Adrienne)
  • Lisa will research and find out who the entity was that provided the attestation report to the EDIs in the past (Action Item Lisa) The NCC provides the attestation report.
  • Lisa will follow up on the updated list of Dialysis Facilities for Chris Brown (Action Item Lisa) Chris indicated this was no longer needed.
  • Lisa will check with her leadership to see if she can share a draft of the 2728 and 2746 forms (Action Item Lisa) As of 1/24 waiting response
  • Creating EQRS Documentation that is what is in Production vs Work in Progress

    • The request is to show documentation for what is actually in production right now and documentation of what the ADO is working on in the lower environments
    • Adrienne will work with PM3 on what is needed to update the public confluence page (Action Item Adrienne Ray)
  • Update/ETA on when ESRD Networks might be able to find patients dialyzing outside their Network scope in EQRS once again? It has not been working for 2 weeks

    • When will this be resolved? Need a timeframe when this will be fixed. Is there a work around? (Action item Aaron)

  • Adrienne and Melissa (PM3) understand the request and will go back to see if a form of versioning can be implemented on the EQRS Communications Hub Documentation Repository confluence page (Action Item Adrienne/Melissa) Melissa and Adrienne did meet to review feedback about Comms Hub. There will not be versioning but instead a dedicated place for testing-related documentation. We will review with meeting participants on an upcoming meeting.  
  • Leah Skrien asked about the MBI Lockdown - once it matches up with the EDB the status cannot be changed by the networks anymore, but they have some patients that have Medicare that is effective, and it shows in the Medicare tab in EQRS.  Is it part of the process to go back, if there is somebody in there with a blank Medicare status to match up with EDB and go back and add a status if it wasn't there when the MBI matched up with what was in EQRS?
    • This is a question for the ADO team.  Leah Skrien will write it up and send to Adrienne.  Adrienne will take it back and get an answer (Action Item Adrienne)
  • The 2728 review or comment period is posted on the Federal Register and seemed vague
    • Lisa will try to get hold of someone today to get this handled but may not get finished until next week (Action Item Lisa) Lisa contacted OEDA and believes this was updated
  • Lisa will ask the NCC if they can provide the attestation report to the EDIs (Action Item - Lisa) Provided 1/23
  • Adrienne request that Nathan/Kathleen send an email to Adrienne and Lisa describing in detail what is listed on the report, what data is normally provided and for what timeframe they need this (Action Item - Nathan/Kathleen)
  • What is the deadline for attestations?  Need to confirm the correct date. (Action Item - Jason Clem) Deadline date for Attestations is Feb 28th.
  • Nathan requested that when SSA releases a memo on this, that the EDIs get a copy or a reference number so they can use it to show that changes were made for 2023 (Action item - Lisa) still pending as of 1/23

  • No labels
Write a comment...