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Aaron Thompsonx
Adrienne Adkins
Adrienne Ray

Ahmar Wazir

Anitha Chintalapatix
Arnie Esparterox
Branon Barrettx
Cheri Jerger
Chris Brown
Curt Phillipsx
Danita Patel
Deb Wilsonx
Dianna Christensenx
Hari Krishna
Heather Moore
Howard Thomasx
Janet Hutchinsonx
Jason Clemx
Jay Vancil
Jennifer Baileyx
Julie Alvarezx
Justyna Sardinx
Kathleen Prewittx
Kelly Llewellyn
Lakshmi Eriginenix
Leah Skienx
Lisa Rees
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Tasel
Pandu Muddana
Porsche Dorseyx
Revathy Ramakrishnax
Sarah Fillingx
Scott Laughlinx
Seema Sreenivas
Shalon Quinn
Shamim Almamun
Steve Goodmanx
Timothy Jacksonx
Todd Johnsonx
Vladimir Ladikx
Yvette Brownx
Zac Cohen
Zachary Serlethx


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: uFcEk1=v 

2021 Data Submission InformationDianna/Janet

Where do you stand?

Recording for this discussion: 5:23


  • EDI 2021 Data Submissions - EQRS Communications Hub - HCQIS Confluence (
    • Howard expressed a concern that he does not see how NRAA will be able to get their data in by the end of February
    • Suggest for CMS/Program to continue to think about a month delay at a minimum for completion of the 2021 Data Submissions
    • Looking at FKC numbers, Kathleen is concerned the numbers may reflect last years problem of "ghost" patients; concerned the problem has returned
    • Kathleen will send Michael the UPI for him to investigate
    • FKC is receiving an error for that patient
    • If Michael has the UPIs in the report he can perform a bulk fix
    • Per Janet, they are looking for discharge records at facility X for a patient that has a 21 as a submitted patient
    • If the patient happens to be a hemodialysis patient then it's going to be counted twice
    • If it has neither hemodialysis clinical nor vascular access it will double KFCs numbers for their hemodialysis patients
    • If it happens to have all three in the same month, its going to be in all three groups, theoretically the patient could be counted as many as three times
    • If there is not a 21 submitted on the patient record (PTMT record) they don't get on the list
    • The 6790 (on the chart) is the sum of all of the ones that are missing and save for all three data submission types
    • So if there is one that is saved, it still counted in there b/c until it is submitted, it's not real


EQRS ADO UpdateMichael

News you can use....

Recording for this discussion: 13:42 - 21:30

  • Clinical 2021 Data
    • All duplicate clinical records that would have been attached to patients have been cleaned up
    • Whether it was caused by an outage or by your submissions - they have been cleans up
    • Continue to be cleaned every Sunday going into Monday morning reports for Janet
    • If the same patient data was put in the same file for clinical at the same time and it's processing, the system can't know that and has no record to say it is a duplicate yet - Michael has logic to find those every week and logic to clean those every week
  • Patient Data
    • County
      • For all of the things that are being stripped away due to the data ingestion, and the EDIs are not sending 100% in each patient demographic xml - the system thinks you don't want that piece of data there
      • Until that code can be fixed by Yvette's team in his PI, Michael is cleaning them up every Sunday night before Janet's job kicks off at 3am every Monday morning 
    • Date of Death
      • Any patient records that had a missing date of death and cause of death and had to submit a 2728 and an end date of death, all the data has been cleaned up
    • Death Discharge
      • If there was a discharge prior, we don't want to override discharges that were already there with a death discharge, we look to see if they were discontinued and what that date was and if there was no discharge already present we would put a discontinued discharged with that date so they were not at your facility longer than they should have been
      • If there was already a discharge like transfer out to hospice or something, we didn't change anything that was already present as the final discharge
      • For all the ones that didn't have one, we updated with either a discontinue or a death based on the 2746 data discontinued present at that day; no discontinued, put the death date
    • SSN
      • Updated all the missing SSNs where if the patient record didn't have an SSN; but had an EDB SSN and we matched the EDB, we went ahead and put those back to help with patient matching being an exact match for when you are submitting patients as well as patching to UNOS
    • MBI
      • Script has been finished this week
      • MBIs will be put back in place this Sunday night
    • Medicare Status
      • Michael worked with data managers and performed a global clean up
      • Every patient that had a duplicate Medicare status with the effective date of patient ID Medicare status and the date that was causing people to have validation problems on 46s and 44s all have been globally cleaned up (226,000 patients)
      • Facilities will be able to go forward with 2744s and add deaths without it being a problem
      • These will be clean up every Sunday night
    • Feedback from Howard - Thanks to Michael for the data clean up effort
      • Some of the data that has now been cleaned up were blockers on getting data in and even made people have to stop submitting data
      • This will help for the push for the EDIs request for an extension on the February deadline date
  • 2021 Data Submission Error trends (patient demographic files and clinical files)

Recording for this discussion: 22:08 - 48:36 (Recommended to listen Listen to recording for detailed information and discussion)

    • Planning to have error reporting as something available on demand by the EDI submitter community
    • Due to the volume of content, recommended that all the trending information be sent via email to certain recipients.  Michael will with Scott
EDI Submitter's Progress (upcoming feature development)EDIs

Recording for this discussion: 48:53 - 1:02:42


  • Per Steve Goodman - Will CMS plan to cut off the information from being submitted in the clinical file or will they run in parallel with the standalone vaccination file and will there be any data coming in on that clinical file as well?
      • The new vaccination module will not run in parallel with Clinical vaccinations submissions.  Per the request of EDIs, once all current vaccines (flu, pneumo, hep b) work is complete and ready for prod the vaccination section will be removed from clinical submissions
      • This is being worked on by Yvette's team in this PI (PI17), but there is not a timeline in terms of production
      • If Yvette get's dates from the Program, she will share with the group
      • As soon as CMS/ADO's can get preliminary files like XSDs, data dictionary, they will be shared with the EDIs
      • Development is just being started on this feature and clarifying questions with the Program (Porsche Dorsey)
      • There is HCD work going on as well which will change the way the screens look
      • Updated files for vaccinations may not be shared with EDIs until iteration 4 (3/3 - 3/15); demo will be 4/5
      • Recommendation from Howard - it would be helpful to layout, similar to the SDLC, an approach with the estimated dates for specs, testing cycle, etc so the EDIs can start planning for their own development
      • Per Scott, we will use the Friday EDI call to start tracking some dates and milestones
      • Per Kathleen
        • There is a path were the result is the new module's live, the clinical module has changed but we're still submitting the old XML.  Is there any work or consideration going on in this PI that if that happens, the clinical module won't just reject our entire records.  It will at least accept the data that it can accept and ignore the data that it can't accept particularly with vaccinations
        • Pointing out this is a risk. They will still be submitting the former XML format into a module that no longer accepts it and then the possibility of the majority of our clinical data just being rejected
        • Per Scott, we understand the EDIs need time to develop and update their systems; also time to train their staff, etc
        • CMS/Program will work with EDIs to coordinate the timeline when the vaccination functionality is turned on
      • When the transition happens, what's going to be the system behavior of the lab files?
        • Haley from the HCD team will work with the EDIs to get their thoughts and perspective on the workflow, the questions and then working with Porsche in parallel to develop that
        • The idea is to get the EDIs feedback, involvement so there are no surprises at the demo
        • Per Kathleen there are two different groups of work for FKC to build new code and modify the clinical XML; there is a chance it just doesn't happen simultaneously
        • Scott has asked Haley (HCD team) to present a summary of her findings at one of the Friday EDI calls





Action Items:

  •  Request from Chris - display/capture EQRS rule updates or "hot-fix"/non major release dates that can be shared with the EDI Submitters that may impact their ability to correct/update patient data
    • Scott will research a way to be able to identify a feature that a rule update or "hot-fix" impacts, so the EDI Submitters are aware of the change Scott Laughlin
  •  Question from Nathan - With the turn of year, it's also time for annual attestations
    • As part of the process the EDIs usually gets a weekly report of the status of the ICHCAPS attestations
    • This report has come from different contracting groups
    • Per Janet Lea Hutchinson - this is not something the NCC has provided
    • Per Scott - we will need to get back to Nathan on this Scott Laughlin
    • Kathleen will send requirements to Shalon (1/14/22)
  •  Scott will discuss revisiting the DaVita effective date and date of death issue with Lisa Scott Laughlin
    • Scott will provide a response to Nathan (1/14/22)