2024.5.29 EQRS Program Working Group Meeting

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 05292024.mp4

•  Porsche shared that they are collaborating with QIP on streamlining the SDOH questions between the 2728 and the QIP reporting beginning in January 2025 (Jump to recording 00:44 ~ 11:10)
  • They are reducing the duplication of effort as much as possible pertaining to that section questions 22-29 on the 2728
  • Some of them are redundant
  • These are not required anyways; however strongly encouraged to complete on both the 2728 and the QIP tool
  • Porsche can't speak for QIP but they may or may not be required for QIP
  • Communications will be set out, but it takes some time to go through the approval process
  • The fields on the 2728 we are keeping between 22 - 29 for the SDOH questions are 22, 24, and 26
  • 22 = Does the Patient have a living will or medical physician order for life sustaining treatment?
  • 24 = Do you have caregiver support to assist with your daily care; follow up questions - for home dialysis, kidney transplant - Does the caregiver live with you?
  • 26 = Do you understand health literature English; two follow up questions: Do you need a different way other than written documents to learn about your health? Do you need a translator to understand health information?
  • 23, 25, 27, 28 and 29 - you do not need to build in or develop capacity to collect.
    • Those will get recorded using the QIP screening tool   
  • Kathleen -
    • The form in EQRS will retain all of the questions 22-29, but CMS will be glad to receive questions 22, 24, 26?
      • Per Porsche, that is correct
    • For questions 23, 25, 27, 28, 29, it is only an attestation of whether or not the screenings were done. So answers to these questions are not going to be recorded anywhere.  Is this everybody's understanding on the CMS side, both EQRS and QIP?
      • Kathleen is talking about the 2025 screening tool
      • Per Porsche, QIP felt that information would be collected in their screening tool
      • Per Nathan, not that the screen will collect the exact same questions, but there's a second part of the rule that we have to report for those who screened positive
  • Questions 23, 25, 27, 28 and 29 will eventually "fall off" at the next 2728 refresh happening in 2026

• CMS guidance around nephrologist signature on the 2728 within 75 days of patient transfer (Jump to recording 11:15 ~ 18:38)
  •  When a patient transfers to a different facility prior to the 2728 being signed by the nephrologist, there is an exception now that allows a 75 day.  It extends the 45 to 75 days for the form to be signed and submitted on behalf of the patient
    • The form is due in 45 days across the board
    • The 75-day exception is only when a patient transfers prior to the form being signed and it they have up to 75 days to submit the signed form BUT the goal is to have it close to the 45 days as possible
  • If there is any confusion, this can be incorporated in the FAQs
  • If there are any other FAQ questions the EDIs think will be beneficial, feel free to share with Porsche
  • Leah - If it's past the 45-day due date and a patient has transferred to another facility and then the nephrologist signs it on the 60th day and the form is submitted will it be counted as late for the facility in EQRS?
    • Because it's under the exception, it should not be counted as late
    • Per Michael Kennedy, it's not in the system that would show as late so people can mail back and forth
    • Need to work with the NCC 
  • Geraldine - Because there was an extension of the 2728 they were going to make some additional changes to fix up some of the issues on the back of the form.  Are they going to repost the new version of the 2728 because right now what is posted is the original.  
    • Per Porsche, yes, it is still with editing.  When it is final, it will be reposted
  • Kathleen - Is it that they only get an extension to 75 days if the patient transfers within the first 45 days? Isn't the form past due if they transfer on day 60?
    • The nephrologist gets 45 days to sign the form, and it's only if the patient transfers within that 45 days do they get an extra 30 days
    • Is there going to be a control in EQRS that changes that due date based on a transfer? 
      • When the NCC goes through their late forms, they will be able to separate out the late ones that involve the transfer before 45 days
      • If Kathleen is talking about the due date that shows on the form management screen, Michael Kennedy will take it to Anitha's team and discuss a possible backlog item for that logic

DaVita -

• Nathan - Regarding the SDOH for 2025 
  • When will it be on CMS's radar?
    
  • When will the EDIs start to learn what they are expected to report?
  • Does CMS/ADO know what is going to be built in EQRS or is there a roadmap for it?
    • Adrienne will take it back to research
  • 2728 and Prod Preview 
    • When can the EDIs expect it to be fully functional and ready for testing?
      • Per Anitha, except the tribe and race changes, everything else should be available in prod preview
      • Michael suggested to allow the new race and tribe values via EDSM for the 2018 version of the form 2728
      • Currently working on these changes so the EDIs can upload the new tribe values before the 2728 can go live 
      • Right now, in the Quality Assurance stage and can't provide a date but should be completed in the next 2 weeks and then have it deployed to prod preview
      • This is not a new list of tribes, it is the existing list of tribes
      • There is no date when a new tribe list will be available
      • The tribe list that is on confluence is dated November 2022
        • Michael/Anitha will get that updated

FMC -

• Kathleen - For native Hawaiian or other Pacific Islanders, what's going to enable, country of origin or enrolled tribe?
  • Anitha will provide an answer via the email that Porsche has sent out with Kathleen's other questions
  • Is the Sub Race document with a date of February 2024 the current document?
    • Per Anitha, no.  Once all the race and tribe mappings are complete, a new document will be uploaded to confluence
  • Is the master list of primary causes of renal failure still in the queue to be distributed?
    • It should already be in the data dictionary
    • Anitha will get back to Kathleen on this
  • There was mention the 2746 is going through some changes
    • Is it possible if an updated form or master list of the causes of death (2023 version) could be provided before the October 1 launch?
    • Per Adrienne, she will get the updated master list and share it with this group
  • For the new Care Compare reports that are being built to be in EQRS, there's patient lists and facility reports. Is the facility report going to be both the annual DFC/DFR and the quarterly DFC/DFR available in EQRS?
    • At this time the ADO has only been asked to work on the annual, not the quarterly

DCI

RHA 

US Renal 

Innovative Renal Care

Administrative Reminders

• If any Production issues are encountered, please submit a Helpdesk ticket.  This will allow the EQRS team to better track the issue and progress.
  • Service Center: 866-288-8912 or qnetsupport-esrd@cms.hhs.gov. 
• CMS will refresh data in the EQRS Prod Preview environment on the first Sunday of every month. The planned schedule is below.

• • Sun, 03 Dec 2023
  • Sun, 07 Jan 2024
  • Sun, 04 Feb 2024
  • Sun, 03 Mar 2024
  • Sun, 07 Apr 2024
  • Sun, 05 May 2024
  • Sun, 02 Jun 2024
  • Sun, 07 Jul 2024
  • Sun, 04 Aug 2024
  • Sun, 01 Sep 2024

• • If there are any issues with the scheduled date(s) please notify the team by the Friday before that Sunday when the refresh of data is scheduled to take place
  • If there are any issues encountered with the refresh on Sunday, it will be moved to Monday (next day)

• Next meeting scheduled for: 12 Jun 2024