Ex-Rad eCQM inquiry

XMLWordPrintable

    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Hide
      Thank you for your inquiry regarding the Excessive Radiation Dose or Inadequate Image Quality Measures in the MIPS (CMS1056v2), IQR (CMS1074v2), and OQR (CMS1206v2) programs.

      Vendors are not required to use the Alara Imaging software for CMS measure compliance. As documented in the in the CY 2024 Hospital Outpatient Prospective Payment System Final Rule:

      In regard to the use of Alara Imaging software and other vendor software, hospitals are not required to use the Alara Imaging software for CMS Measure Compliance. They may choose to use any software(s) that performs the necessary functions to generate the same standardized data elements necessary to calculate the measure consistent with the measure’s specifications. At this time, the Alara Imaging software is the only vendor to offer translation software that specifically performs all the necessary functions, in one software package, to generate the data elements necessary for the measure specifications.

      The pre-processing software requires CPT and ICD-10 codes for each study. Most sites choose HL7 v2.x for this purpose, though HL7 FHIR queries can also be used to retrieve indications. HL7 FHIR is the preferred method to send intermediate variables from pre-processing to an EHR or Radiation Dose Management system. Additional details regarding integration can be found here: https://www.alaragateway.com/documentation
      For measure calculation purposes, PHI does not leave the health provider / system network, whether that exists on premise or in the cloud.

      Supplemental demographic data (e.g. race, ethnicity, sex, and payor information) is not used in the eCQM logic, however it is included in the QRDA reports sent to CMS.
      As the eCQM Issue Tracker responds to questions about the measure specifications, please refer your questions regarding benchmarking to the QPP Service Now website: https://cmsqualitysupport.servicenowservices.com/ccsq_support_central and select "QPP" as the topic.

      Please note that the Alara software is HIPPA, HITRUST, and SOC2 compliant with 3rd party audits. The measures steward is happy to complete security assessment requests by health systems and welcome conversations.
      Show
      Thank you for your inquiry regarding the Excessive Radiation Dose or Inadequate Image Quality Measures in the MIPS (CMS1056v2), IQR (CMS1074v2), and OQR (CMS1206v2) programs. Vendors are not required to use the Alara Imaging software for CMS measure compliance. As documented in the in the CY 2024 Hospital Outpatient Prospective Payment System Final Rule: In regard to the use of Alara Imaging software and other vendor software, hospitals are not required to use the Alara Imaging software for CMS Measure Compliance. They may choose to use any software(s) that performs the necessary functions to generate the same standardized data elements necessary to calculate the measure consistent with the measure’s specifications. At this time, the Alara Imaging software is the only vendor to offer translation software that specifically performs all the necessary functions, in one software package, to generate the data elements necessary for the measure specifications. The pre-processing software requires CPT and ICD-10 codes for each study. Most sites choose HL7 v2.x for this purpose, though HL7 FHIR queries can also be used to retrieve indications. HL7 FHIR is the preferred method to send intermediate variables from pre-processing to an EHR or Radiation Dose Management system. Additional details regarding integration can be found here: https://www.alaragateway.com/documentation For measure calculation purposes, PHI does not leave the health provider / system network, whether that exists on premise or in the cloud. Supplemental demographic data (e.g. race, ethnicity, sex, and payor information) is not used in the eCQM logic, however it is included in the QRDA reports sent to CMS. As the eCQM Issue Tracker responds to questions about the measure specifications, please refer your questions regarding benchmarking to the QPP Service Now website: https://cmsqualitysupport.servicenowservices.com/ccsq_support_central and select "QPP" as the topic. Please note that the Alara software is HIPPA, HITRUST, and SOC2 compliant with 3rd party audits. The measures steward is happy to complete security assessment requests by health systems and welcome conversations.
    • Not measure related
    • Not measure related

      Our radiology physicists have a number of questions about the MIPS eCQM Excessive Radiation Measure for MIPS (CMS1056v2), IQR (CMS 1074v2), & OQR (CMS1206v2).  First, they wanted CMS to clarify whether the use of Alara is required, and if the use of alternate products is allowed, how CMS will ensure best practices for exclusions and calculations are respected?  If an alternate product is allowed or developed, is there a certification process where CMS or ONC will approve product use for this measure to ensure integrity is present with computational variables?  Is an HL7 connection to the EHR required for compliance with the rule?  If supplemental data elements including patient race, ethnicity, sex, and/or payor information is not available, should those patients be reported without the supplemental demographic data?  Is PHI sent to the cloud by the translational software?   When will benchmarks for this measure be available?  Our radiology physicists will likely have additional questions and would like a CMS or measure steward contact to address further technical questions.  Despite this being planned as a required OQR measure in 2027, this will need to undergo a security risk assessment at our organization where detailed information about security and architecture is obtained.  Thank you for your consideration of these questions. 

            Assignee:
            Augustine Weber
            Reporter:
            Amanda Fredricksen
            Votes:
            0 Vote for this issue
            Watchers:
            0 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: