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The healthcare industry is undergoing a significant transformation, and the transition to digital measurement is becoming increasingly important. In our "Digital Quality Measures – The Future is Now" blog and "Digital Quality Measures – Transformation in Quality Reporting" blog we discussed the importance of preparing for the digital HEDIS transition and the challenges that come with it. In this third installment, we explore the specifics of the transition and explore the impact on health plan performance.

As NCQA accelerates the rollout of Electronic Clinical Data Systems (ECDS) measures and public reporting, early results give us a clearer picture of both the challenges and potential of this new model. Some health plans already see measurable gains. Others are uncovering gaps in clinical data access that have serious implications for performance scores. See how we helped one health plan with Commercial, Marketplace and Medicare members, and with seven different submissions to NCQA, streamline their complex HEDIS solution.

Early Evidence: ECDS transition

According to NCQA's State of Healthcare Quality Report^[1], the 2022 transition from Breast Cancer Screening (BCS) to its ECDS counterpart, BCS-E, was relatively smooth, with minimal changes in reporting across all lines of business. However, health plans never reported Breast Cancer Screening using the hybrid methodology, so the specifications for BCS-E were largely similar to the traditional Breast Cancer Screening measure.

The data shows minimal changes in reporting rates between the traditional Breast Cancer Screening measure and its ECDS counterpart. The following table illustrates the similarity in reporting rates:

In contrast, the transition from Colorectal Cancer Screening to its ECDS counterpart, COL-E, presented some challenges. The removal of the hybrid methodology resulted in a gap in reporting between 3% and 6%. The use of medical record review supports the long look-back period for colonoscopies, which may not have been performed under eligibility with the current health plan.

The following table highlights the difference in reporting rates between the traditional Colorectal Cancer Screening measure and its ECDS counterpart:

Closing the Gap

In monitoring industry readiness for ECDS, NCQA has performed annual assessments of ECDS measurement^[3]. Among the questions NCQA seeks to answer is the percentage of submissions that used non-claims sources, and whether health plan performance varied when non-claims sources were utilized.

The table shows non-claims data for three measures: breast cancer screening, colorectal cancer screening and cervical cancer screening.

Not surprisingly, a lower percentage of plans submitted BCS-E utilizing non-claims data. Colorectal cancer screening and cervical cancer screening, which historically relied on medical record review, have a higher percentage of plans submitting non-claims data in the ECDS versions of these measures.

The table also shows the gap in rates between plans submitting solely based on administrative sources, and plans including non-claims, or clinical sources. For both measures, multiple-year look-backs might drive the difference in rate. This represents an opportunity to leverage provider history to fill the gaps.

NCQA concluded that “generally, plans that used electronic non-claims data sources had better performance than plans that used claims data alone".^[4] As each measure transitions, evaluation of the key drivers is necessary to inform your data acquisition strategy.

The Impact of Medical Record Review

Controlling High Blood Pressure is a traditional measure that relies on non-claim sources. This measure is typically calculated using the hybrid methodology and medical record review (MRR). NCQA looked at the performance gap between the average plan performance, including medical record review, and the average plan performance, excluding medical record review^[5]. In 2021, this performance gap was over 31%. This gap has improved significantly, and in 2023, the performance gap was just over 24%.

The new Blood Pressure Control for Patients with Hypertension measure (BPC-E) is intended to replace the traditional measure for Controlling High Blood Pressure (CBP). While claims data with CPT category II codes are still supported in this measure, high performance requires clinical data, represented with LOINC codes and values for diastolic and systolic blood pressure readings. With a significant performance gap between plans including medical record review and those excluding it, it is essential to prioritize and take stock of data acquisition strategies.

Why Are Some Plans Doing Better?

Plans that saw improvements in their ECDS performance typically had certain key elements in place. For instance, they often had established Electronic Health Record (EHR) data pipelines, which allowed them to access and use high-quality clinical data. Some plans also participated in regional Health Information Exchanges (HIEs), which enabled them to share and access patient data across different healthcare providers. Additionally, the use of clinical registries and tight integration with provider networks and care management systems were also common characteristics of plans that saw improvements. These elements combined to provide better access to high-quality clinical data, which in turn translated into better performance scores. Better access to high-quality clinical data leads to better performance scores.

On the other hand, plans that struggled with ECDS performance often lacked some of these foundational elements. For example, they may not have had the legal agreements to access EHR or HIE data, which limited their ability to collect and utilize clinical data. Some plans also lacked standardized formats for data exchange, such as HL7 or FHIR, which made it difficult to share and integrate data from different sources. Furthermore, plans that struggled with ECDS performance often had weak data governance practices, which made it challenging to ensure audit readiness and data quality. Without these essential elements, clinical events such as immunizations, screenings or behavioral health assessments can go unrecorded, even when the care was delivered, leading to artificially lower performance rates.

The Hybrid Method Is Going Away

NCQA has stated its intention to fully retire the hybrid reporting method by MY2029^[6]. For many plans, this safety net is still crucial, particularly for measures like:

• Colorectal and Cervical Cancer Screening
• Childhood and Adolescent Immunizations
• Lead Screening in Children
• Prenatal and Postpartum Care
• Blood Pressure Control

As hybrid phases out, health plans must prepare to rely solely on clinical data, and that will require changes in provider contracts, data governance and workflows.

Closing Thoughts

Early results from ECDS reporting suggest that digital measurement can enhance performance, improve accuracy and reduce manual burden when clinical data is accessible. Without strong data infrastructure, plans may find themselves vulnerable.

Now is the time to assess your readiness and build the partnerships and pipelines needed to succeed in a digital HEDIS environment. If you are wondering how your HEDIS solutions stack up, download our "Checklist for Choosing a HEDIS Vendor" for an easy comparison tool.

Coming Up Next

In our next post, we’ll connect the dots between digital HEDIS and federal interoperability policies. How do TEFCA, FHIR and the 21^st Century Cures Act play into this transformation?

Stay tuned as we explore how national policy is shaping quality measurement.

^[1] https://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality-report/

^[2] 2023 was the first year of reporting Colorectal Cancer Screening for Medicaid.

^[3] https://wpcdn.ncqa.org/www-prod/wp-content/uploads/Special-Report-Nov-2024-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf

^[4] https://wpcdn.ncqa.org/www-prod/wp-content/uploads/Special-Report-Nov-2024-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf

^[5] https://wpcdn.ncqa.org/www-prod/wp-content/uploads/Special-Report-Nov-2024-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf

^[6] https://wpcdn.ncqa.org/www-prod/wp-content/uploads/Digital-Transition-Webinar-12_2024.pdf