2023.01.11 EQRS Program Working Group Meeting

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

• • Depression Screening closure date is 2/28
  • Nathan looked at the MyCrown web site and he didn't see it there
  • Per Jason, it should be combined.  There is one box at the bottom underneath the monthly clinical that has ICAHPS and Depression - 2/28/23
  • If Nathan is not able to find the date as described, he will reach out to EQRS ADO/EOCT
    • https://mycrownweb.org/2022/04/eqrs-data-submission-deadlines-for-the-2022-reporting-months/ (at the bottom)

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?

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

FKC

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

RHAs

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 (cms.gov)

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.