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Aaron Thompson


Abigail Viall (CDC)
Adrienne Adkinsx
Adrienne Rayx

Ahmar Wazir

Alissa Kapke (Ann Arbor)x
Amy Nestler
Ann Turnerx
Angela Kohlheppx
Arnie Esparterox
Ashley Watersx
Austin Woods
Betina Fletcher
Branon Barrett
Carol Olsen
Cheri Jerger
Chris Brown
Chris Morici
Dan Kayhart
Deb Wilson
Delia Housealx
Dianna Christensenx
Dinesh Chatoth (FKC)
Emily Kenlaw
Ethan Crauwelsx
Geraldine Bojarski (DCI)x
Heather Dubendris
Heather Moore
Heather O'Neal
Henrietta Smith
Howard Thomas
Jaclyn Caudillx
Janet Lea Hutchinsonx
Jason Clemx
Jason Simmington
Jennifer Baileyx
Karena S
Kathleen Prewittx
Kelly Llewellyn
Kelsey Oklandx
Leah Skrienx
Lyndsay Crowson
Mahesh (DaVita)
Matt McDonoughx
Martha Bean
Mary Newx
Melissa Fieldhousex
Meredith Zywno
Michael Kennedy
Michelle Cassin (DaVita)
Mihran Naljayan (DaVita)
Mitzi Christx
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Pani Palanichamyx
Porsche Dorseyx
Rachael Lazar
Rachelle DuBose Caruthersx
Revathy Ramakrishnax
Sarah Fillingx
Scott Riddell
Seema Sreenivasx
Steve Goodmanx
Tricia Phulchand
Vladimir Ladik
Tricia Gorman
Yvette Brownx



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.

Program Working Group Meeting Recording 11012023.mp4  

EQRS Feature Updates/DiscussionPorsche/EDIs

MedRec Required Yes/No Feature changes

  • Currently the Medication Reconciliation is optional data that you would send in your clinicals every month
  • They want to make a change to require a question:
    • "Did you complete the Med Rec this clinical month? Yes/No?"
  • If answer "Yes" - then you would submit the same current data that they have for Med Rec, who did it that day? etc.
  • Is there a reason why a "Yes/No" indicator is needed?
    • Per Jason (EOCT) they worked with Arbor on this.  Arbor brought the initial question up.
    • Arbor mentioned they assumed Med Rec was not completed if they did not respond to anything
      • They wanted to add the question and Yes/No indicator to make sure facilities did report "Yes" if they did and "No" if they didn't
    • What is the benefit/value added of adding a "Yes/No" answer?
      • It is just a confirmation of whether or not they actually did it, instead of assuming it was done or not done.  If data was submitted or not
      • Per Arbor (Alissa Kapke) this was recommended by CMS
      • If nothing is entered for the Med Rec elements, you can assume that it is meant the Med Rec was not performed but it is not known for sure so adding a required "Yes/No" field will bring clarity
      • If choosing "Yes" the 3 items may be required to indicate what you've done for Med Rec
        • Will need to determine what happens when you only have 1 or 2 of the 3 elements
        • It depends on the organization
      • If you answer "No" is the user prevented from answering the next 3 questions?
  • If answering "Yes", is entering the person and date still optional?
    • Has not yet been determined since this change has not been completely built out.  All that is known right now is that the "Yes/No" part would be a required field; currently the information is optional
  • Would the system allow a "Yes" and the other field to remain blank?
    • The scenario's have not been determined yet.  A deep dive is still needed on this change to gather requirements
  • This change is still in the early stages and more work still needs to be done.  
  • The Program wanted to mention it in today's call to bring awareness to
  • For the QIP measure, how will the "Yes/No" field be incorporated?
    • It has not been incorporated yet, but it may not really impact it because they look for the 3 required data elements
    • Right now you have to report 3 fields
    • If a "Yes" is reported does that count in the positive calculation of the QIP measure?
    • Will it still require the other fields?
    • Will you need to have a "Yes" and the 3 other fields?
      • It has not been determined if the 3 fields will be required if you select "Yes" but it does make sense to make them required
    • Per Arbor (Alissa Kapke) If "Yes" is entered the 3 other fields will be required to indicate what you've done for Med Rec
  • What is the timing when this field will be required?
    • Not sure when it is needed in production, but the feature will be refined this week
    • The more information the EDIs can get around the technical details the sooner the EDIs can get started internally
  • Will there be a defined period of time when the EDIs can perform testing in prod preview?
    • Per Adrienne, yes, this will be treated like any other work
    • As soon as the ADO has the data dictionary, the XSDs ready, the ADO will make sure the EDIs get them as early as possible
    • EQRS ADO will be grooming this change for PI25 planning session which is 11/15 and 11/16
EQRS Feature Updates/DiscussionDelia/Yvette

Introduce Social Drivers of Health (SDOH) (Jump to recording 18:51 - 42:37)

  • SDOH UI Screens - Demo
  • Discussing attestations where it assesses a facilities commitment to health equity based on their responses to the 5 questions
  • Kathleen - There is text that said "if not applicable, leave blank". What was the rationale of not having an option that says "none of the above"? 
    • We will need Delia to answer this question
  • Nathan - From a batch perspective, how is this going to be implemented?
    • The EDI confluence page has been updated with the XSD, sample file and data dictionary
      • On the confluence page its under the 2728 health equity
    • For each domain, you would have to indicate whether that option is true or false
    • There is not an option for "all of the above"; you have to choose true or false for each of the individual questions
  • Adrienne Adkins - When is the attestation due?
    • Similar to clinical depression, you would have 1 year and 2 months to submit that data for the attestation period
    • It should align with the close of the December reporting period
  • Nathan - Requested to review the verbiage
    • Per Jason (EOCT) there are some small text changes that Delia will be sharing with the ADOs
  • This is available in prod preview now to submit test files and look at the UI
  • The ADO will update the text/verbiage changes when Delia informs the ADO
  • Nathan - How do you get to the Commitment to Health Equity Attestation screen?
    • At the top navigation go to Facilities > Attestations 
      • On the Facility Attestations screen click on Commitment to Health Equity
      • Attestations under the Facilities menu is new
  • Nathan - Is it possible to get rid of the yellow banner that says "ICH CAHPS attestation period is open" and just have it listed in the Reminders list?
    • Yvette will ask CMS if they are ok with it and add this request to the backlog
Open ForumEDIs

DaVita - no additional questions or updates

FMC - 

  • Several months ago, an email went out from EOCT about facility ownership in EQRS and how it needs to be cleaned up for QIP to ensure accuracy
  • They have been trying to do this at the corporate level, but they hit a barrier with the networks asking for change of ownership letters
  • For a lot of their clinics, there was no change of ownership because they bought not individual clinics but an entire organization, such as Liberty dialysis
  • The regional office never issued a change of ownership therefore they don't have one to give to the networks
  • The networks won't update the primary owner field
  • Kathleen is asking if this can be discussed again and for a resolution for his issue
  • The networks will not accept any other documentation except the change of ownership letter in order to change the Primary Owner field
  • In a wholesale acquisition of a company, the regional office does not give out a change of ownership letter.  Instead, they get a change of information letter
  • Porsche and Mitzi will follow up with the Networks

DCI - no additional questions or updates

RHA - not on today's call

US Renal - no additional questions or updates

Next meeting scheduled for:   

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