[CQM-7525] Excessive Radiation Dose IQR and OQR Numerator Logic Created: 12/12/24  Updated: 01/10/25  Resolved: 12/26/24

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals Priority: Moderate
Reporter: Becky Crellin Assignee: Mathematica EH eCQM Team
Resolution: Answered Votes: 0
Labels: None

Solution: Thank you for your inquiry regarding CMS1074v2 and CMS1206v2, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR) and Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility OQR). Yes, AlaraCommon.CT Scan Qualifies is calling the function AlaraCommon.Qualifies for each type of scan with the appropriate noise and dose thresholds for the scan type. For your example, Qualifies"(Study, "Abdomen and Pelvis Low Dose", 64, 598), 64 is noiseThreshold Decimal and 598 is sizeDoseThresold Decimal and "Abdomen and Pelvis Low Dose" is the code.

Please let us know if you have any outstanding questions.
Solution Posted On:
2025 Reporting Period EH/CAH eCQMs:
CMS1074v2
Last Commented Date:

 Description   

I have a few questions regarding Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR) (https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS1074v2.html) and Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility OQR) (https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS1206v2.html) numerator logic.

 

Numerator

  • "Qualified Scan with Values" CTScan
      where AlaraCommon."CT Scan Qualifies" ( CTScan )

 

Referencing the following function:

  • AlaraCommon.CT Scan Qualifies(Study "Diagnostic Study, Performed")
  • "Qualifies"(Study, "Abdomen and Pelvis Low Dose", 64, 598)
      or "Qualifies"(Study, "Abdomen and Pelvis Routine Dose", 29, 644)
      or "Qualifies"(Study, "Abdomen and Pelvis High Dose", 29, 1260)
      or "Qualifies"(Study, "Cardiac Low Dose", 55, 93)
      or "Qualifies"(Study, "Cardiac Routine Dose", 32, 576)
      or "Qualifies"(Study, "Chest Low Dose", 55, 377)
      or "Qualifies"(Study, "Chest Routine Dose", 49, 377)
      or "Qualifies"(Study, "Cardiac High Dose or Chest High Dose", 49, 1282)
      or "Qualifies"(Study, "Head Low Dose", 115, 582)
      or "Qualifies"(Study, "Head Routine Dose", 115, 1025)
      or "Qualifies"(Study, "Head High Dose", 115, 1832)
      or "Qualifies"(Study, "Extremity", 73, 320)
      or "Qualifies"(Study, "Neck or Cervical Spine", 25, 1260)
      or "Qualifies"(Study, "Thoracic or Lumbar Spine", 25, 1260)
      or "Qualifies"(Study, "Simultaneous Chest and Abdomen and Pelvis", 29, 1637)
      or "Qualifies"(Study, "Simultaneous Thoracic and Lumbar Spine", 25, 2520)
      or "Qualifies"(Study, "Simultaneous Head and Neck Routine Dose", 25, 2285)
      or "Qualifies"(Study, "Simultaneous Head and Neck High Dose", 25, 3092)

 

However AlaraCommon.CT Scan Qualifies references "Qualifies" and NOT "AlaraCommon.Qualifies(Study "Diagnostic Study, Performed", code System.Code, noiseThreshold Decimal, sizeDoseThreshold Decimal)

 

AlaraCommon.Qualifies(Study "Diagnostic Study, Performed", code System.Code, noiseThreshold Decimal, sizeDoseThreshold Decimal)

  • Study.result ~ code
      and ( "Global Noise Value"(Study) >= noiseThreshold
          or "Size Adjusted Value"(Study) >= sizeDoseThreshold
      )

Questions:

  1. My assumption is in function AlaraCommon.CT Scan Qualifies we should be referencing function AlaraCommon.Qualifies for "Qualifies"? Is this correct? If so, in a future release could this be more clear?
  2. If 1 is true is AlaraCommon.CT Scan Qualifies parameters for "Qualifies" missing a parameter?
  3. For example "Qualifies"(Study, "Abdomen and Pelvis Low Dose", 64, 598).  I assume 64 is noiseThreshold Decimal and 598 is sizeDoseThresold Decimal but there is no parameter for code System.Code. Should there be a value there and there should be an additional parameter in that string?
  4. What was the intent of code System.Code?

 Comments   
Comment by Mathematica EH eCQM Team [ 01/10/25 ]

Thanks for your follow-up inquiry. The Qualifies function, AlaraCommon.Qualifies(Study "Diagnostic Study, Performed", code System.Code, noiseThreshold Decimal, sizeDoseThreshold Decimal) takes 4 parameters.

  • A Diagnostic Study, Performed
  • A code
  • A decimal for noise threshold
  • A decimal for size dose threshold

For the sample call to that function of Qualifies"(Study, "Abdomen and Pelvis Low Dose", 64, 598), Study is the first parameter that is the Diagnostic Study, performed. "Abdomen and Pelvis Low Dose" is the second parameter that is the code for the type of CT scan. 64 is the third parameter which is the noise threshold and 598 is the fourth parameter which is the size dose threshold. The confusion may be that you interpret it as a string, but "Abdomen and Pelvis Low Dose" is a code.

Comment by Mathematica EH eCQM Team [ 01/02/25 ]

Thank you for the follow-up question. We will review your ticket and provide a response as soon as possible.

Comment by Becky Crellin [ 01/02/25 ]

Just wanted to get further clarification to my questions above.

  1. Will the specification be updated to be more clear?
  2. "Qualifies"(Study, <no code System.Code>,"Abdomen and Pelvis Low Dose", 64, 598).  I understand what the last three parameters are as noted above. But from AlaraCommon.Qualifies(Study "Diagnostic Study, Performed", code System.Code, noiseThreshold Decimal, sizeDoseThreshold Decimal) there is the additional code System.Code parameter. What does this represent, how should that be read/used, and should there be that additional parameter in the "Qualifies" string to account for this?
Comment by Mathematica EH eCQM Team [ 12/20/24 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Mathematica EH eCQM Team [ 12/13/24 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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