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CMS measure compliance

Ensure precise CT radiation dosing and enhance patient safety with the CMS Measure Compliance software

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About the measure

As part of Alara's commitment to improving radiology quality, Alara Imaging serves as steward for new measures developed by the University of California San Francisco (UCSF) for use in CMS Quality Programs.

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The measures provide a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality.

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The measures are included in three CMS quality programs:

IQR

The Hospital Inpatient Quality Reporting Program (IQR)

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OQR

The Hospital Outpatient Quality Reporting Program (OQR)

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MIPS

The Physician Reporting Program (MIPS)

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These measures are electronic clinical quality measures (eCQMs). As radiology measures, standardized data elements are derived from structured fields within both the electronic health record (EHR) and the radiology electronic clinical data systems.

Because of limitations in eCQM formats, they cannot currently access and consume elements from these radiology sources. Alara translation software was developed to transform primary data into a format that can be ingested by these new eCQMs. This translation software is provided freely to hospitals and physician groups. Hospitals and physician groups can then use their preferred vendor for eCQM calculation and CMS reporting.

Interested in supporting calculation of the measure?

Review the documentation

Interested in learning more about the measures?

Visit the eCQI Resource Center government website.

Frequently
Asked
Questions

What are the “Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults” CMS measures?

Developed by the University of California San Francisco in cooperation with the Centers for Medicare and Medicaid Services (CMS), these measures provide a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer.

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What is Alara's role in these CMS quality measures?

Alara serves as the measure steward for these CMS quality measures and has designed secure measure implementation software to minimize physician and health system reporting burden.

What is the rationale for these quality measures?

Diagnostic imaging using CT occurs in more than a third of acute care hospitalizations in the U.S. (Vance, 2013) and greater than 90 million scans are performed annually in the U.S. (IMV, 2020). There is marked observed variation in the radiation doses used to perform these exams (Smith-Bindman, 2019). The inconsistency in how CT exams are performed represents a significant, unnecessary, and modifiable iatrogenic health risk, as there is extensive epidemiological and biological evidence that suggests exposure to radiation in the same range as that routinely delivered by CT increases a person's risk of developing cancer (Board of Radiation Effects, 2006; Grant, 2017; Hong, 2019; Sakata, 2019; Sadakane, 2019; Bernier, 2019; Meulepas, 2019; Brenner, 2020; Berrington de Gonzalez, 2020; Sugiyama, 2020; Hauptmann, 2020; Huang, 2020; Abalo, 2021; Cao, 2022; Hauptmann, 2023).

What CMS programs include these measures and when do the measures financial incentives take effect?

The measures are included in three CMS programs. The clinician measure is part of the Merit-based Incentive Payment System (MIPS) program beginning with reporting in 2025. The inpatient measure is part of the Inpatient Quality Reporting (IQR) program beginning with reporting in 2025. The outpatient measure is part of the Hospital Outpatient Quality Reporting (OQR) program beginning with voluntary reporting in 2025 and 2026, and reporting in 2027.

What is the Alara Software for CMS Measure Compliance?

New Electronic Clinical Quality Measures use additional software to access primary data elements stored within radiology data systems to translate them into a format that eCQMs can consume.

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Why was this software created?

Because of limitations in their specifications and format, eCQMs cannot currently access and consume elements from radiology sources in their original DICOM formats. Thus, translation software was developed to transform primary data into a format that the eCQM can consume. These eCQMs require the use of additional software (translation software) to access the primary data elements that are needed for measure computation. Primary data elements are translated into data elements that can be ingested by an eCQM. The purpose of the Alara Imaging translation software is to access and link these primary data elements with minimal site burden, assess each CT exam for eligibility based on initial population criteria, and generate the translated data elements necessary for eCQM computation.

How does the software work?

The HIPAA- and SOC II-compliant software securely ingests existing data from the electronic health record (EHR), radiology information system (RIS), and picture archiving and communication system (PACS). The software then translates the ingested data into the standard format needed for measure calculation, performs necessary computations, and generates outputs that can be shared with health systems, sent to preferred EHR and technology partners, or submitted directly on to CMS.

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How is image quality calculated?

The measure was not intended and does not attempt to quantify all aspects of image quality. The measure assesses image noise and is only intended to ensure that radiation dose is not lowered to such a degree that the diagnostic value of the test is compromised.

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Does the measure consider why a CT scan was performed?

Yes, a CT done for a suspected kidney stone is not judged against the same radiation dose and image noise thresholds as a CT done for abdominal pain or a suspected aortic dissection. The relationship between different indications for CT and the CT categories has been published in peer-reviewed medical literature. The Alara Medical Imaging Gateway’s proprietary algorithm ensures consistency in these categories based on anatomy and clinical indication.

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Does the measure consider patient size?

Yes, patient size is an important contributor to dose and is accounted for through normalization of total dose based on patient size. The purpose of the size adjustment is to ensure that heterogeneity of patient size between sites does not unfairly impact measure score. In extensive testing, the size adjustment successfully accounted for the impact of differently sized patients in assessing whether the radiation dose and image noise was within range.

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How were image noise thresholds established and will radiologists be inundated with low image quality CTs?

The measure sets a standard for acceptable image noise and radiation dose within each CT category. These thresholds were established using a rigorous research design in which a broad range of radiologists’ assessments were used as a gold standard. During testing, fewer than 1% of studies were judged to have unacceptable image noise (range of 0.0% - 0.6% across hospitals).

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Why doesn’t the measure include other variables in the calculation such as patient demographics or the type of scanner used to perform the test?

In extensive research, the only patient factor that is a strong predictor of dose is patient size. Other patient factors (e.g., adult age, sex) have little association with radiation dose. Further, the addition of more variables would increase complexity of measure calculation, increasing burden without benefit.

How can I be responsible for radiation dose levels given the hospital pays for and manages the machinery and technologists?

The measure has been adopted for the Hospital Inpatient Quality Reporting Program, the Hospital Outpatient Quality Reporting Program, and the Physician Payment Program (MIPS) expressly to help align physicians, technologists, and hospitals to work together to reduce radiation doses.

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Where can I learn more about the science, methodology, and development of these measures?

Details on the development of these measures can be found on the University of California San Francisco website.

How much does the Alara software when used for CMS measure computation cost?

The Alara software when used for CMS measure computation is available to healthcare systems free of charge.

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How is data security ensured?

Alara's software is HIPAA- and SOC-II compliant and monitored via ongoing third-party audits. For CMS measure computations, all patient health information used stays within the healthcare organization firewall to ensure data security.

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As an integration partner, how can I connect my EHR, RIS, or PACS system?

Please review the Documentation Page of Alara’s website.

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As a technology partner, how can I receive software results to serve my customers?

Please review the Documentation Page of Alara’s website.

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Where can I find additional detail on how to deploy this software?

Please review the Documentation Page of Alara’s website for additional detail.

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Where can I find information from CMS about quality measures?

General resources are available on the eCQI Resource Center website. Additional details related to these measures can be found on the eCQI Resource Center's measure steward page.

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Your gateway to CMS compliance — accurate, secure, free.

About the measure

As part of Alara's commitment to improving radiology quality, Alara Imaging serves as steward for new measures developed by the University of California San Francisco (UCSF) for use in CMS Quality Programs.

The measures provide a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality.

The measures are included in three CMS quality programs:

IQR

OQR

MIPS

Interested in supporting calculation of the measure?

Interested in learning more about the measures?

Frequently Asked Questions

What are the “Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults” CMS measures?

What is Alara's role in these CMS quality measures?

What is the rationale for these quality measures?

What CMS programs include these measures and when do the measures financial incentives take effect?

What is the Alara Software for CMS Measure Compliance?

Why was this software created?

How does the software work?

How is image quality calculated?

Does the measure consider why a CT scan was performed?

Does the measure consider patient size?

How were image noise thresholds established and will radiologists be inundated with low image quality CTs?

Why doesn’t the measure include other variables in the calculation such as patient demographics or the type of scanner used to perform the test?

How can I be responsible for radiation dose levels given the hospital pays for and manages the machinery and technologists?

Where can I learn more about the science, methodology, and development of these measures?

How much does the Alara software when used for CMS measure computation cost?

How is data security ensured?

As an integration partner, how can I connect my EHR, RIS, or PACS system?

As a technology partner, how can I receive software results to serve my customers?

Where can I find additional detail on how to deploy this software?

Where can I find information from CMS about quality measures?

What additional references can I review to learn more?

The modern integration solution for medical imaging workflows.

Frequently
Asked
Questions