June 2024 EQRS News
In This Issue:
New Vascular Access Clinical Dashboard
Register for the June EOCT Town Hall
New Application Names in EQRS Preview
New “Change Applications or Organizations” Preview
Commitment to Health Equity Attestation Reminder
Dialysis Facility Transplant Waitlist – New Inactive Reason
ESRD Data Submission Deadlines
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Upcoming Events:
New User Training
- June 27, 2024 • 2:00-3:30 PM ET
Web Resources:
Conditions for Coverage for ESRD Facilities
CMS Releases New Vascular
Access Clinical Dashboard Feature
On May 3, 2024, The Centers for Medicare & Medicaid Services (CMS) released a new Vascular Access Clinical Dashboard in the End Stage Renal Disease (ESRD) Quality Reporting System (EQRS). The new Vascular Access Clinical Dashboard supports quality improvement initiatives across the ESRD Networks.
The new Vascular Access Clinical Dashboard in EQRS provides dialysis facility users and dialysis organizations with up-to-date information and visualization on ESRD patient vascular access data in-use at an individual facility or, when applicable, throughout the dialysis organization. Using an easy-to-use, intuitive dashboard interface, users can view vascular access data on an individual or aggregate basis for any individual month.
The clinical information on vascular access that displays in this dashboard is not a substitute for the Quality Incentive Program (QIP) analysis, which includes additional data points not included on this dashboard. However, the dashboard can provide users with a snapshot of their patient vascular access data through intuitive graphs with tooltips (Figure 1) and detailed data tables.
Figure 1 – Sample of “Speedometer” Vascular Access graphs in the Dashboard
An easy-to-use Clinical Period drop-down selector (Figure 2) allows users to repopulate the dashboard with data for any selected individual month. The dashboard will be able to display vascular access data for up to the past five years (60 months). However, only one month of data at a time may be viewed in the Vascular Access Clinical Dashboard.
For more detail on using the New Vascular Access Clinical Dashboard in EQRS, read the EQRS News Flash: New Vascular Access Clinical Dashboard post on https://www.MyCROWNWeb.org.
Figure 2 – Clinical Period drop-down list selector
Register for the June EOCT Town Hall
Join the ESRD Outreach, Communication, and Training (EOCT) Team for the June Town Hall event detailing data submission deadlines, user interface updates, planned system enhancements, and more!
Date: June 27, 2024
Time: 2:00 p.m. – 3:30 p.m. Eastern Time
Presenters will discuss the following topics:
- ESRD Data Submission Deadlines
- EQRS user interface updates including the new Vascular Access Clinical Dashboard, the new Top Navigation Bar and Organizational Search features, the peritoneal dialysis (PD) Fluid Cell Count Limit Increase, and more.
- Revisiting the 2025 Social Drivers of Health Measures (SDOH)
- October 2024 Form CMS-2728 and CMS-2746 Modifications
- Frequently Asked Questions
Attendees can view the Town Hall event directly in their Internet browser and listen to audio via Internet streaming – no telephone line is required, but we do recommend headphones for the clearest sound.
From the Chat Box
Question: I keep hearing about the ESRD QIP Preview Period. When will the 2025 ESRD QIP Preview Period open, and how will we find out about our preview scores and how to view them?
Answer: The ESRD QIP preview period is a 30-day period once a year when dialysis facilities can preview their scores, Performance Score Report (PSR), and resulting payment reductions before the public release. The preview period usually begins in mid-July and ends in mid-August. The specific dates of the Preview Period will be announced once available.
During the 2025 ESRD QIP Preview Period, facilities will have the opportunity to preview their scores and any resulting payment reductions prior to public release. Additionally, during the Preview Period, facilities can submit inquiries about how the system calculates their ESRD QIP measure result and request clarification on measure data, as well as submit inquiries to investigate potential errors in measure calculations and scores.
CMS will communicate specific information about the launch date of the 2025 ESRD QIP Preview Period via multiple emails that will be distributed approximately two weeks before the start of the Preview Period and continue through the launch of Preview Period data availability.
Facilities are encouraged to ensure that required personnel have access to the ESRD QIP Application prior to the start of the Preview Period. General EQRS and ESRD QIP questions can be submitted online to the ESRD QIP Team via the QualityNet Q&A Tool. Under Program, select ESRD QIP – End-Stage Renal Disease – Quality Incentive Program.
New Application Names in EQRS Preview
On June 24, 2024, The Centers for Medicare & Medicaid Services (CMS) will rename the applications inside the former End Stage Renal Disease (ESRD) Quality Reporting System (EQRS) to the EQRS Patient Registry and EQRS Quality Incentive Program (QIP). The new names will reflect the role and importance of the system in supporting not only national data reporting for ESRD quality measurements, but also in documenting the care and treatment of the entire ESRD population.
Figure 3 – Preview of new EQRS Patient Registry branding in the new top navigation bar of EQRS
New Change Applications or Organizations Preview
The new CMS update to the top navigation bar (Top Nav bar) will allow users to move between the Patient Registry and QIP applications quicker and easier. Additionally, users with access to multiple facilities will be able to change more easily between facilities.
Changing Organizations
Users with access to multiple facilities will be able to switch between facilities using the Change Organization feature. This will be done through a simple drop-down search feature, which will provide quick access to all facilities that a user has access to.
Figure 4 – Preview of Change Organization drop-down button
Figure 5 – Preview of Organization search box
Changing Applications
Users will be able to quickly switch between the Patient Registry application in EQRS and the Quality Incentive Program (QIP) application. Beginning June 24, users will be able to switch applications using a simple Switch Application button on the left side of the new Top Nav bar.
Figure 6 – Preview of Switch Application button location
Note: If you do not have access to multiple applications or facilities, these features will not be applicable to you.
CMS will distribute detailed instructions on using these new features via an EQRS News Flash release on June 24, 2024.
Commitment to Health Equity Attestation Reminder
Beginning in CY 2024, facilities are now required to submit data annually via an attestation submission in EQRS for the Facility Commitment to Health Equity measure. Facilities will be required to attest to five domains, each representing a Social Drivers of Health (SDOH) competency aimed at achieving health equity. Each domain is worth two points, with a total of 10 possible points. To receive a full 10 points for this measure, facilities must complete and attest to engaging in all activities in each domain.
Dialysis facilities are required to submit the Commitment to Health Equity Attestation annually by the EQRS December data reporting deadline, or approximately two months after December. Since January 1, 2024, facilities have been able to submit, view, and edit their CY 2024 Commitment to Health Equity attestation data. Facilities have until March 3, 2025, at 11:59 p.m. Pacific Time to complete CY 2024 attestation data submission in EQRS.
CMS allows facilities flexibility to select their own screening tool or method to screen patients for SDOH (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety). Multiple screening tools exist and are publicly available. Facilities can refer to the Social Interventions Research and Evaluation Network (SIREN) website.
For additional information on the Facility Commitment to Health Equity measure, including facility and patient exclusions, please refer to the CY 2024 Technical Measure Specifications.
Dialysis Facility Transplant Waitlist Dashboard Update: New Inactive Reason Column Added
In March 2024, CMS released an enhancement to the Dialysis Facility Transplant Waitlist dashboard in EQRS which provides an additional column displaying an “Inactive Reason” for transplant waitlist entries that have a status of “Temporarily Inactive”. The inactive reason is derived from waitlist data provided for EQRS by the Organ Procurement and Transplantation Network (OPTN) contractor. 
For additional information on the Dialysis Facility Transplant Waitlist dashboard, please refer to the June 2023 ESRD Outreach Communication and Training (EOCT) Town Hall event materials (slides and recording) available on the Events page on www.MyCROWNWeb.org.
How to Route Questions
Please do NOT include patients’ Protected Health Information (PHI) and Personally Identifiable Information (PII) (such as patient name, date of birth, social security number, Medicare Beneficiary Identifier, and Health Insurance Claim Number) when submitting a ticket and/or inquiry to the QualityNet Q&A Tool, CCSQ Service Center, or ESRD Network. Any disclosure of PHI or PII should only be in accordance with, and to the extent permitted by, the Health Information Portability and Accountability Act (HIPAA), the HIPAA Privacy and Security Rules, and other applicable laws.
Please note: The EQRS identification number is the ONLY acceptable patient identifier when contacting the QualityNet Q&A Tool, CCSQ Service Center or ESRD Network.
The table below contains contact information organized by question type:
| Question or Issue Type | Contact Information |
|
EQRS & ESRD QIP Questions:
|
QualityNet Question & Answer (Q&A) Tool Note: Access EQRS training and/or educational materials on the Education page on MyCROWNWeb.org. |
EQRS System-related Questions or Issues:
|
The Center for Clinical Standards and Quality (CCSQ) Service Center can be reached Monday-Friday 8 a.m.-8p.m. ET via:
|
ESRD Network Assistance with:
|
ESRD Network Directory:
Contact your ESRD Network directly. Use the link below if you need assistance finding your ESRD Network’s contact information. |
ESRD Data Submission Deadlines for CY 2024 Data
Dialysis facilities must submit ESRD data by the deadlines listed below. Not submitting the required data by these deadlines puts your facility at risk for an ESRD QIP payment reduction. Please note that if the last day of the month falls on a Saturday, Sunday, or federal holiday, the deadline will occur on the next federal business day. The data submission deadlines apply to all collection types (Hemodialysis and Peritoneal Dialysis) and to all submission methods. CMS strongly recommends that facilities complete large data submissions and audit batch submitted data prior to data submission deadlines.
| EQRS Submission Schedule for: EQRS Clinical Data |
|
| Reporting Month | Data Submission Deadline |
| April 2024 | July 1, 2024, at 11:59 p.m. PT |
| May 2024 | July 31, 2024, at 11:59 p.m. PT |
| June 2024 | September 3, 2024, at 11:59 p.m. PT |
| July 2024 | September 30, 2024, at 11:59 p.m. PT |
| August 2024 | October 31, 2024, at 11:59 p.m. PT |
| September 2024 | December 2, 2024, at 11:59 p.m. PT |
| October 2024 | December 31, 2024, at 11:59 p.m. PT |
| November 2024 | February 3, 2025, at 11:59 p.m. PT |
| December 2024 | March 3, 2025, at 11:59 p.m. PT |
| EQRS Submission Schedule for: Clinical Depression Screening and Follow Up Assessments |
|
| Assessment Period | Data Submission Deadline |
| January 2024 – December 2024 | March 3, 2025, at 11:59 PM PT |
| EQRS Submission Schedule for: ICH CAHPS Facility Attestation |
|
| Attestation Period | Submission Deadline |
| January 2024 – December 2024 | March 3, 2025, at 11:59 PM PT |
| EQRS Submission Schedule for: Commitment to Health Equity Attestation |
|
| Attestation Period | Submission Deadline |
| January 2024 – December 2024 | March 3, 2025, at 11:59 PM PT |
| NHSN Data Submission Deadlines for 2024 ESRD Data (BSI in Hemodialysis Patients, Dialysis Event Reporting, and COVID-19 Vaccination Coverage Among HCP) |
||
| Quarter | 2024 Reporting Months | Data Submission Deadline |
| 1 | January-March | July 1, 2024, at 11:59 p.m. PT |
| 2 | April-June | September 30, 2024, at 11:59 p.m. PT |
| 3 | July-September | December 31, 2024, at 11:59 p.m. PT |
| 4 | October-December | March 31, 2025, at 11:59 p.m. PT |
The information included as part of this newsletter is current as of the date of release.