[Intl_DxMedPhys] CMS image quality eCQM measure

[Olav Christianson]

Dear Colleagues,

I wanted to take a moment to address the recent CMS clarification regarding
the Excessive Radiation eCQM. Over the past year, I’ve been in regular
communication with CMS, and they have been consistent in their stance that
any vendor may perform the calculations required for this eCQM.

Unfortunately, misinformation has caused unnecessary confusion within the
medical community, with one of the most common misunderstandings being the
false belief that vendors must be “certified” to perform the calculations.
The recent clarification should eliminate any remaining doubts. It clearly
states that “hospitals and clinicians are not required to use the Alara
Imaging Software” and that “any software vendor capable of calculating and
reporting this eCQM in accordance with the measure’s specifications” can be
used. To further clear up any ambiguity, CMS also confirmed that “hospitals
and clinicians are not required to demonstrate to CMS that the software
they or their vendors use can generate and transform the radiology data
into the necessary format.” In other words, there is no certification
requirement.

In response to Isaac, CMS seems to understand your concerns over lack of
transparency. Their clarification also states, “Nothing would prevent a
hospital or clinician seeking assurance about the ability of specific
software to perform these tasks from requesting that information from a
vendor.” Transparency in compliance reporting is essential, yet some
vendors withhold key details under the guise of "proprietary information,"
raising concerns about what they might be hiding.

I encourage everyone to request transparency from their vendors. For
example, Imalogix provides full transparency. Every formula and value used
in calculations is clearly documented, allowing providers to verify metrics
with confidence. In an industry where trust and accuracy matter,
transparency should be the standard—not the exception.

Best,

Olav

On Thu, Jan 30, 2025 at 6:34 PM Rutel, Isaac B. (HSC) via
Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> While I find this announcement reassuring from a policy sense, (even
> though it was already mentioned in the initial publication) from the
> practical aspect, has ANYONE been able to wrangle the actual calculations
> for these metrics from Alara
>
> While I find this announcement reassuring from a policy sense, (even
> though it was already mentioned in the initial publication) from the
> practical aspect, has ANYONE been able to wrangle the actual calculations
> for these metrics from Alara Inc or any other contributor?  I have had no
> luck.  While I imagine that other vendors will eventually be able to
> provide this . . . how is that possible if there are no published
> calculations/specifics for these metrics.  I don’t even want to carve out
> business, I just want the opportunity to spot check the calcs to see if the
> metrics from Alara (or other non-specific manufacturer) are calculating
> correctly.
>
>
>
> *Isaac Rutel, Ph.D., DABR*
>
> *Associate Professor*
>
> *Dept. Radiological Sciences*
>
> *OUHSC*
>
> *405-596-2623*
>
>
>
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> *From:* Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu> *On Behalf Of *William
> Sensakovic via Intl_dxmedphys_wd_osu_list
> *Sent:* Thursday, January 30, 2025 2:49 PM
> *To:* Wunderle, Kevin via Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Subject:* [EXTERNAL] [Intl_DxMedPhys] CMS image quality eCQM measure
>
>
>
> FYI, from cms about 10 minutes ago Excessive Radiation Dose or Inadequate
> Image Quality for Diagnostic Computed Tomography in Adults eCQM- Measure
> Clarification The Centers for Medicare & Medicaid Services (CMS) is
> providing clarification
>
> FYI, from cms about 10 minutes ago
>
>
> Excessive Radiation Dose or Inadequate Image Quality for Diagnostic
> Computed Tomography in Adults eCQM- Measure Clarification
>
> The Centers for Medicare & Medicaid Services (CMS) is providing
> clarification regarding the reporting requirements for the *Excessive
> Radiation Dose or Inadequate Image Quality for Diagnostic Computed
> Tomography in Adults* electronic clinical quality measure (eCQM)
> beginning with the Calendar Year 2025 performance period.
>
> Hospitals and clinicians who choose to report this eCQM may use any
> vendor’s software that meets the necessary requirements to generate the
> standardized data elements required to calculate the measure, consistent
> with the measure’s specifications. Hospitals and clinicians are not
> required to use the Alara Imaging Software for CMS measure compliance. Any
> software vendor capable of calculating and reporting this eCQM in
> accordance with the measure’s specifications, including transforming
> radiology data into a format compatible with eCQM reporting, may report
> this measure on behalf of hospitals and clinicians. Hospitals and
> clinicians are not required to demonstrate to CMS that the software they or
> their vendors use can generate and transform the radiology data into the
> necessary format.  However, nothing would prevent a hospital or clinician
> seeking assurance about the ability of specific software to perform these
> tasks from requesting that information from a vendor.
>
> As with all eCQMs, CMS will monitor measure results to ensure that all
> reported data for the *Excessive Radiation Dose or Inadequate Image
> Quality for Diagnostic Computed Tomography in Adults* eCQM are both
> reliable and valid. This may include analyzing data to identify outliers
> and common characteristics of outlier submissions.
>
>
>
>
>
> William F. Sensakovic, PhD, MRSC(MRSE), FAAPM
>
> Chair and Assoc. Prof., Mayo Clinic (Arizona)
>
> Founder, Telerad Physics Teaching, LLC
>
>
>
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