2022.11.16 EQRS Program Working Group Meeting

Date

16 Nov 2022

Name
Aaron Thompson	x
Abigail Viall (CDC)
Adrienne Adkins
Adrienne Ray	x
Ahmar Wazir
Amy Nestler	x
Arnie Espartero	x
Ashley W
Austin Woods
Betina Fletcher
Branon Barrett
Carol Olsen
Cheri Jerger
Chris Brown	x
Curtis Phillips
Dan Kayhart
Deb Wilson
Dianna Christensen	x
Dinesh Chatoth (FKC)	x
Emily Kenlaw	x
Geraldine Bojarski (DCI)
Greg Eccleston
Heather Dubendris
Heather Moore	x
Heather O'Neal
Henrietta Smith
Howard Thomas
Janet Lea Hutchinson	x
Jason Clem	x
Jason Dong
Jason Simmington
Jennifer Bailey	x
Justyna Sardin	x
Karena S
Kathleen Prewitt	x
Kelly Llewellyn
Kelsey Okland	x
Kr Van Allen
Leah Skrien	x
Lisa Rees	x
Lizzie Suh
Lyndsay Crowson
Mahesh (DaVita)
Matt McDonough	x
Martha Bean	x
Melissa
Melissa Fieldhouse	x
Meredith Zywno
Michael Kennedy
Michelle Cassin (DaVita)
Mihran Naljayan (DaVita)
Mitzi Christ	x
Nance
Nathan Muzos	x
Ozlem Tasel
Pandu Muddana	x
Pani Palanichamy	x
Porsche Dorsey	x
Rachael Lazar
Rachelle DuBose Caruthers	x
Revathy Ramakrishna	x
Sarah Filling	x
Seema Sreenivas
Steve Goodman	x
Vladimir Ladik	x
Yvette Brown
Malik Arsalan

Agenda

Items	Who	Topics
Meeting Recording	Arnie	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. https://us06web.zoom.us/rec/share/idOe5Qgz1_KqqQR5FsaP8v4-LLUO4bDUhKF3GDBxQFqArMYKXCactkWeNsAe7aUH.2sT5M52sKqp5kP0H Passcode: 4@DZb8Dg
Feature Updates/Discussions	Lisa/EDIs	Redshift updates routinely failing and what can be done The Program is aware of the issue with Redshift They have discovered that each time it has failed it has been for a different reason making it difficult to track down a definitive reason causing the issue The team will watch it this weekend to make sure it doesn't fail, so they will have data next week The Program is aware of how critical the data is to the networks Status of updated documentation on Confluence page and how this can be built into the process instead of after the fact Nathan is looking for the impact of vaccinations; they have documentation specific for vaccinations but other things where vaccinations used to be, they have never received updated versions of those (lab stuff) In general, documentation on new things coming out Need updated documentation on tribes list; new country list for the new country option coming out Overall documentation seems to be overlooked and it is critical to the EDIs and their teams as they look to make changes/enhancements to their system/logic Adrienne will go back to the EQRS team and ask about the documentation (Action Item Adrienne) Chris Brown suggested having in the documentation a running log of the changes/enhancements made to EQRS and a link to the specific documentation Adrienne pointed out they are doing some HCD work now on notifications and announcements that would be helpful to the community The HCD group is doing research on this and may reach out to this group (EDIs) for feedback/input; this is something for next year Status of deleting Attestations via EDSM submissions Nathan's opinion is for it to go away because it is confusing to the clinics Clinics have inadvertently said a patient is ineligible, they are excluded from the measure In CrownWeb you had the ability to delete those inappropriate attestations electronically; with EQRS that delete function was left out; this was brought up last year around January/February Per Adrienne, Yvette had discussed this with Sarah Filling in a meeting last Friday It was confirmed the functionality was implemented and will be able to be used in the next set of attestations The delete function is live and can be used late January, mid-February Nathan would still like to see it go away Lisa will see if there is a place to share Nathan's concern Question from Kathleen In order to use this functionality is it under the assumption they will get a report of submitted attestations? Per Nathan, yes, they have received a report the past few years Kathleen asked if one of the groups would be providing them this report (instead of having to ask for it) during the submission period; Vintech and softdev have provided this report in the past Lisa will research and find out who the entity was that provided the attestation report to them in the past (Action Item Lisa) CDR status for EQRS data The EQRS data is in the CDR now In a reply from 5 Start data, "Yes, this is an issue. We are hopeful that by getting the data out of the CDR in the future this will be resolved" People are being onboarded to CDR at this time They are getting their feet wet in using the data and finding out where all the data is There are still others still not completely onboarded Will CDR is something that the NCC will switch to instead of using Redshift? Per Lisa, No There should be no delays in reporting during this transition CDR is not a public use file repository It is meant for CMS contractors to access and analyze data It could possibly include networks who are CMS contractors Nathan suggests an overview/demo of CDR and see what is available and understand how the data us being used, where it is going, etc Lisa mentioned there is a confluence page that may help to understand the CDR Peritonitis Feedback on recommendations from EDIs Recommendations were reviewed with CDC yesterday Biggest change is that there were a few places where the choices were - Yes, No or Unknown; since an Unknown option was provided, it will be required There were fairly minor changes over all Lisa will speak to the development team today about the changes and will be working on wireframes Wireframes will be run past the CDC and the EDIs The EDI suggested demographic stuff not to include in the XML, Lisa and the CDC agreed to all if the suggestions Lisa made it clear this is an event-based report The Risk Factors are ONLY for the event You do not have to report risk factors on every single patient Will Peritonitis be its own XML file when it gets implemented? Per Adrienne it will be in a new infection's module Needs to confirm but Adrienne is thinking it will be its own XML file Timing of technical documentation, Prod Preview release, testing Since the Program/CDC had to go back to the drawing board on requirements, there is not forecast when documentation, Prod Preview release and testing will be available Lisa envisions this rolling into the next PI (PI21); sometime in March 2023 All of the documentation, prod preview release and testing will come out in that timeframe Any impact to Clinical Labs XML since they include Infections today Lisa cannot answer if there is any impact to the clinical labs XML This would be a question for the ADO (Yvette) Update on Transplant work, what is coming and when is it expected Transplant work is coming along nicely In this PI20, the role is being developed for transplant centers to submit information; should be ready to go by 12/20 at the latest There has also been research into what would be helpful to put on a dashboard for dialysis facilities to see as well as a dashboard for transplant centers to see Determined the dialysis facility dashboard is more important to develop first before the transplant center dashboard
		Question from Chris Brown Can anyone categorically say one way or the other whether Medicare Compare, especially dialysis facility compare is being updated with EQRS data regularly as it had been? On the web page it says the last update is October 2020 which is when CrownWeb went down and EQRS came up It doesn't seem like it's reflecting the current facilities There are closed facilities that are still on there Per Nathan, an email was just sent mentioning it has been updated with new measure data but not sure if that included the facility data Nathan will forward Chris the email If the email does not answer his question Chris will reach out to Lisa to investigate further List of all updated data sets can be found here https://data.cms.gov/provider-data/search?theme=Dialysis%20facilities Chris reviewed the list, and it is not updated with the new facilities and those that were closed Lisa will follow up on the updated list of Dialysis Facilities for Chris Brown (Action Item Lisa) Question from Vlad They are seeing an unusual number of errors regarding race, ethnicity and other data related errors Per Lisa there was a data clean up in the system that might have been causing those errors Race and Ethnicity data was being stripped during a migration so there was work done in putting that data back into the system Suggested to submit a helpdesk ticket Per Nathan a lot of those values were restored for DaVita and also suggest submitting a ticket and include Yvette Per Ravathy, they are also seeing error related to when ethnicity is in the EQRS system, but they don't even send ethnicity or race the error indicates race is needed. They will continue to observe and if it continues, they will create a ticket to get it looked at Question from Kathleen Follow up to the following question: Does CMS have any timelines they could share for both peritonitis and 2728/2746 updates in EQRS. Per Lisa - We’re finalizing requirements with CDC regarding the peritonitis module so work on it will be extended a least another PI. As for the 2728 and 2746, we’re working on getting them through PRA. PRA = Paperwork Reduction Act OMB has to sign off on any form Work on the forms can be done but need to keep in mind if OMB has changes, those changes will have to be made If everyone agrees then it can be considered for a PI Per Kathleen (FKC) would prefer to wait to start the work until OMM approves the forms Per Nathan (DaVita) would prefer to wait to start the work until OMM approves the forms Lisa will check with her leadership to see if she can share a draft of the forms (Action Item Lisa)
Next meeting scheduled for 30 Nov 2022

Action Items:

Adrienne and ADO will do more research on why Hep B Antibody tests are being overwritten (Action Item Adrienne)
- 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 30^th. The existing codes will be valid up until November 30^th.
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)
Lisa will follow up on the updated list of Dialysis Facilities for Chris Brown (Action Item Lisa)
Lisa will check with her leadership to see if she can share a draft of the 2728 and 2746 forms (Action Item Lisa)