[Intl_DxMedPhys] [External] Re: EXT MSG Fwd: The New CMS Measure: Methods for Size-Adjusted Dose and Their Variabilities

Thu Mar 13 12:12:06 EDT 2025

Dear All,

I hope this message finds you well. There continues to be misinformation
circulating within the medical community regarding the CMS eCQM on
excessive radiation dose. While I want to make it clear that the medical
physics community is not the source of this misinformation, it is important
that we work together to stop the spread of inaccuracies and ensure that
the correct information is shared.

First, I’d like to clear up the misconception that CMS requires all vendors
to produce exactly the same output as Alara. This claim is factually
incorrect. The idea that all vendors must replicate Alara’s results is not
only impractical but also inconsistent with CMS requirements. It is
important to recognize that even minor differences, such as the use of
different libraries or programming languages (e.g., Matlab vs. Python), can
result in small differences in output. CMS does not, and has never
required, that vendors achieve identical outputs. In fact, the only direct
mention of Alara in the recent clarification from CMS was to explicitly
state that "hospitals and clinicians are not required to use the Alara
Imaging Software for CMS measure compliance." Rather, CMS mandates that
software be consistent with the measure specifications, which is the sole
standard to be adhered to.

Additionally, I would like to share that Imalogix has held several
discussions with CMS to seek clarification on some of the issues raised in
this thread. While Alara was unwilling to share certain proprietary
information, our discussions with CMS focused on how vendors could proceed
using the data already available in the measure specifications. This
culminated in a demonstration of the Imalogix product in December, where
CMS was impressed with our capabilities. Following this demonstration, CMS
issued the official clarification statement confirming that any vendor
could calculate the three required data elements, provided they adhere to
the measure specifications.

For reference, here is the official CMS clarification:
CMS eCQM Clarification on Excessive Radiation Dose
<https://urldefense.com/v3/__https://ecqi.healthit.gov/excessive-radiation-dose-or-inadequate-image-quality-diagnostic-computed-tomography-adults-ecqm-measure-clarification__;!!KGKeukY!1DviNQ-2Vo0Wr4AOsFWhiA-Wlm33papPl7CIlwGLYXVEBHmHRMAQmvYTofxyie6iUlZ1lXBGSMQzk7oph0I_EjF1pkLwvscYq9aIP6E5_LVBQlqe$ >

Additionally, for those who would like to review the full measure
specifications, here is the link:
Measure Specifications – CMS
<https://urldefense.com/v3/__https://www.qualityforum.org/ProjectMeasures.aspx?projectID=86057&cycleNo=2&cycleYear=2021__;!!KGKeukY!1DviNQ-2Vo0Wr4AOsFWhiA-Wlm33papPl7CIlwGLYXVEBHmHRMAQmvYTofxyie6iUlZ1lXBGSMQzk7oph0I_EjF1pkLwvscYq9aIP6E5_JJ4SK6S$ >

Finally, I want to emphasize that Imalogix places a strong focus on
transparency in the eCQM process. We take a different approach compared to
other vendors in this space, and we provide comprehensive documentation of
the formulas, values, and methods used for CMS calculations on every CT
examination.

I hope this helps to address some of the confusion that has been
circulating. Please feel free to reach out to me directly if you have any
questions or if you'd like to discuss further. I’m happy to help clarify
any points.

Thank you all for your time and collaboration.

Best regards,

Olav

On Wed, Mar 12, 2025 at 1:40 PM Matt Wait via Intl_dxmedphys_wd_osu_list <
intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> I spoke with ALARA yesterday and while they still would not disclose their
> “proprietary” patient size adjusted dose calculation or global noise, they
> did mention working with Tim Stick and Tony Siebert so I would guess this
> 2017 paper is closer
>
> I spoke with ALARA yesterday and while they still would not disclose their
> “proprietary” patient size adjusted dose calculation or global noise, they
> did mention working with Tim Stick and Tony Siebert so I would guess this
> 2017 paper is closer to what they do. To hear them tell it, what CMS
> authorized was any vendor could take the same input and provide the exact
> same output as their method, which is of course functionally impossible
> given the proprietary nature of their calculations.
>
>
>
> *Matt Wait, MS, DABR, DABSNM, MRSE*
> Senior Diagnostic Physicist
>
> Assistant Radiation Safety Officer
>
> Assistant Residency Director
>
> *Kaiser Permanente*
>
> *Southern Permanente Medical Group*
> Medical Imaging Technology and Informatics
> 4867 Sunset Blvd
>
> Los Angeles, CA 90027
>
> x5347 (office)
>
> (818) 232-2427 (mobile phone)
>
>
>
> *From:* Intl_dxmedphys_wd_osu_list
> <intl_dxmedphys_wd_osu_list-bounces+matt.wait=kp.org at lists.osu.edu> *On
> Behalf Of *Zhou, Yifang (Jimmy), Ph.D. via Intl_dxmedphys_wd_osu_list
> *Sent:* Tuesday, March 11, 2025 2:45 PM
> *To:* Justin Solomon <justin.solomon at duke.edu>; Jie Zhang <
> jzctjmn at gmail.com>
> *Cc:* DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Subject:* Re: [Intl_DxMedPhys] [External] Re: EXT MSG Fwd: The New CMS
> Measure: Methods for Size-Adjusted Dose and Their Variabilities
>
>
>
> Another reference for global noise is from a study of Malkus and
> Szczykutowicz, entitled “A method to extract image noise level from patient
> images in CT. ”, Med Phys. 2017 Jun;44(6): 2173-2184. I second to Justin
> in that protocol mis-mapping
>
> *Caution: *This email came from outside Kaiser Permanente. Do not open
> attachments or click on links if you do not recognize the sender.
> ------------------------------
>
> Another reference for global noise is from a study of Malkus  and
> Szczykutowicz, entitled “A method to extract image noise level from patient
> images in CT.”, Med Phys. 2017 Jun;44(6):2173-2184.
>
> I second to Justin in that protocol mis-mapping due to naming convention
> or other inaccurate protocol description may be a bigger concern, not only
> from the global noise perspective, but also from the size adjusted DLP
> perspective.
>
>
>
> Jimmy Zhou
>
> Cedars-Sinai Medical Center
>
>
>
> *From:* Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list-bounces+yifang.zhou=cshs.org at lists.osu.edu> *On
> Behalf Of *Justin Solomon via Intl_dxmedphys_wd_osu_list
> *Sent:* Tuesday, March 11, 2025 11:43 AM
> *To:* Jie Zhang <jzctjmn at gmail.com>
> *Cc:* DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Subject:* [External] Re: [Intl_DxMedPhys] EXT MSG Fwd: The New CMS
> Measure: Methods for Size-Adjusted Dose and Their Variabilities
>
>
>
> I believe most commercial offerings that do CT global noise measurements
> follow some variant of this method: https: //pubmed. ncbi. nlm. nih.
> gov/26102424/ There are some details/parameters that could vary between
> implementations. Would be an
>
>
>
> I believe most commercial offerings that do CT global noise measurements
> follow some variant of this method: https: //pubmed. ncbi. nlm. nih. gov/26102424/
> There are some details/parameters that could vary between implementations.
> Would be an interesting
>
> I believe most commercial offerings that do CT global noise measurements
> follow some variant of this method:
> https://urldefense.com/v3/__https://pubmed.ncbi.nlm.nih.gov/26102424/__;!!KGKeukY!1DviNQ-2Vo0Wr4AOsFWhiA-Wlm33papPl7CIlwGLYXVEBHmHRMAQmvYTofxyie6iUlZ1lXBGSMQzk7oph0I_EjF1pkLwvscYq9aIP6E5_JasGUv5$ 
> <https://urldefense.com/v3/__https:/pubmed.ncbi.nlm.nih.gov/26102424/__;!!KGKeukY!wo8RkvE8k7a3feJqhXalDEECDyEqcOCuOM5YS3bSVdbt6V2c0_wMGKXkI8zHDRIfHlhWeWhQghkXUqkFtYXfDNv2RvQQ8WUZ5K9mSIUFlXtfu4CI$>
>
>
>
> There are some details/parameters that could vary between implementations.
> Would be an interesting study to compare vendors with a common dataset.
>
>
>
> That’s said we’ve had an in house built system making these measurements
> for many years now. In my experience the challenging part of using those
> data is sorting through meta data / protocol / series naming
> inconsistencies when doing aggregated analysis. I’m guessing those sources
> of variability and uncertainty dwarf the variability due to global noise
> measurement implementation.
>
>
>
> Cheers,
>
> Justin
>
> ————————
>
> Justin Solomon, PhD DABR
>
> Radiation Physicist
>
> Duke Health
>
> 919-684-1441
>
>
>
> On Mar 11, 2025, at 9:51 AM, Jie Zhang via Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:
>
> 
>
> Yes. We have also investigated global noise metrics and their potential
> limitations in clinical applications. We are wrapping up our writing and
> hope to share our results soon. Thanks! Jie On Tue, Mar 11, 2025 at 11: 32
> AM Gauntt, David <davidgauntt@ uabmc. edu>
>
> Yes. We have also investigated global noise metrics and their potential
> limitations in clinical applications. We are wrapping up our writing and
> hope to share our results soon.
>
>
>
> Thanks!
>
>
>
> Jie
>
>
>
> On Tue, Mar 11, 2025 at 11:32 AM Gauntt, David <davidgauntt at uabmc.edu>
> wrote:
>
> Jie,
>
>
>
> Does your paper  address the issue of image quality?
>
>
>
> The new CMS measure addresses both dose and image quality, using "global
> noise" as a measure of image quality.  However, as near as I can tell the
> measure does not address how you measure "global noise" in a clinical
> image, and have not found any papers from the measure's stewards addressing
> this issue.
>
>
>
> Does anyone have any references to anything addressing how you calculate
> global noise?
>
>
>
> ---
>
> David M. Gauntt, Ph.D.
>
> Associate Professor
>
> Division of Physics and Engineering
>
> Department of Radiology
>
> (205)975-3777
>
>
>
> <OutlookEmoji-1647458080270d7f02ca5-59f0-4d92-8fab-6fcda46b3f08.png>
>
>
>
>
>
>
> ------------------------------
>
> *From:* Intl_dxmedphys_wd_osu_list
> <intl_dxmedphys_wd_osu_list-bounces+davidgauntt=uabmc.edu at lists.osu.edu>
> on behalf of Jie Zhang via Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Sent:* Tuesday, March 11, 2025 10:04 AM
> *To:* intl_dxmedphys_wd_osu_list at lists.osu.edu
> *Subject:* EXT MSG [Intl_DxMedPhys] Fwd: The New CMS Measure: Methods for
> Size-Adjusted Dose and Their Variabilities
>
>
>
> Thanks to Dr. Wunderle! I originally posted this to the old listserver and
> am now forwarding it to the new Dx list. I am sorry if you receive it
> twice. Jie ---------- Forwarded message --------- From: Jie Zhang <jzctjmn@
> gmail. com> Date:
>
> Thanks to Dr. Wunderle! I originally posted this to the old listserver and
> am now forwarding it to the new Dx list.  I am sorry if you receive it
> twice.
>
> Jie
>
> ---------- Forwarded message ---------
> From: *Jie Zhang* <jzctjmn at gmail.com>
> Date: Tue, Mar 11, 2025 at 9:15 AM
> Subject: The New CMS Measure: Methods for Size-Adjusted Dose and Their
> Variabilities
> To: DXIMGMEDPHYS at HERMES.GWU.EDU <dximgmedphys at hermes.gwu.edu>
>
>
>
> Dear Colleagues,
>
> The new CMS guidance on excessive radiation measurement allows flexibility
> in software selection, but this may lead to inconsistencies and undermine
> its goal.
>
> We recently evaluated five methods for estimating effective diameter and
> their impact on Size-Specific Dose Estimate (SAD) in thoracic and abdominal
> CT. A retrospective analysis of 719 exams revealed inconsistencies in SAD
> methods, dose thresholds, and application across patient populations and
> institutions. Addressing these issues is critical for accurate dose
> reporting and diagnostic integrity.
>
> Our manuscript is available on arXiv: https://urldefense.com/v3/__https://arxiv.org/abs/2503.06644__;!!KGKeukY!1DviNQ-2Vo0Wr4AOsFWhiA-Wlm33papPl7CIlwGLYXVEBHmHRMAQmvYTofxyie6iUlZ1lXBGSMQzk7oph0I_EjF1pkLwvscYq9aIP6E5_Hi998mV$ 
> <https://urldefense.com/v3/__https:/arxiv.org/abs/2503.06644__;!!KGKeukY!wkvI7i3VRXaaElI73WdyPRf_Zk6qQqZ2CCRW0BoG-aYbTN1bVG_WIFbTeFOBYzuVEpUvax1OJJGkFDM4g68KPmxld3yXDnHKjwB6aQ$>
> .
>
> Our findings reinforce concerns raised by the AAPM Commissioned Panel,
> recently published in *AJR*, and we hope to provide a technical
> perspective on the CMS measure.
>
> Best Regards,
>
> Jie
>
> *Jie Zhang, PhD, DABR (D, N), FAAPM*
>
> Professor of Radiology and Biomedical Engineering
>
> Chief, Division of Diagnostic & Nuclear Medical Physics
>
> Program Director, Diagnostic Imaging Physics Residency
>
> Department of Radiology
>
> University of Kentucky College of Medicine
>
> UK HealthCare
>
> 800 Rose Street, Room HX-307
>
> Lexington, KY 40536-0293
>
> Phone: (859) 323-2954
>
> Email: jnzh222 at uky.edu
>
>
>
>
>
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