The digital transformation of the Healthcare Effectiveness Data and Information Set (HEDIS) is a significant development in the healthcare industry, driven by the need for high-value measurement and interoperability. This transformation is part of a larger effort to improve the quality and efficiency of healthcare, and to enable better decision-making through the use of data, which is the topic for our "Digital Quality Measures 鈥� The Future is Now" blog.
The Foundation: The 21st Century Cures Act
The 21st Century Cures Act[1], enacted in 2016, is a foundational piece of legislation that has driven the development of interoperability standards in healthcare. The Act defines interoperability as the ability of different healthcare systems to exchange and use electronic health information seamlessly, without requiring special effort from the user. This definition has guided the development of interoperability standards, including the Fast Healthcare Interoperability Resources (FHIR) standard, widely used in the healthcare industry. Additionally, the Act has established the United States Core Data for Interoperability (USCDI) as the standard for data exchange, which provides a clear framework for the standardized exchange of health information. The USCDI standard ensures that healthcare data is standardized and interoperable, enabling seamless exchange of health information between different systems and stakeholders.
The Centers for Medicare and Medicaid Services (CMS) has introduced several regulations that support the development of interoperability in healthcare. These regulations include the requirement that health plans make data available to enrollees through third-party applications, using the FHIR standard. Additionally, CMS has introduced regulations that require health plans to provide prior authorization data to enrollees, and to establish provider access APIs to enable providers to request patient data.
However, despite these regulatory efforts, there is still a missing piece: providers are not obligated to share data with payers according to these standards. Moreover, CMS regulations only impact payers under CMS authority, leaving commercial products outside these regulations. To address this gap, the market can still enable interoperability through initiatives such as the Trusted Exchange Framework and Common Agreement (TEFCA), which operates as a nationwide framework for health information sharing.
TEFCA: Building a National Trust Framework
The Trusted Exchange Framework and Common Agreement (TEFCA)[2] is a nationwide framework that enables the secure and interoperable exchange of health information. TEFCA has created a network of Qualified Health Information Networks (QHINs) that serve as the backbone for network connectivity across the country. These networks must pass rigorous technology and security testing and agree to the same rules of engagement for themselves and their members. In August 2024, the expansion of TEFCA included HEDIS reporting as a level 2 exchange purpose[3], highlighting the industry's dedication to leveraging interoperable health data for digital quality measurement.
Aligning HEDIS with Interoperability Standards
NCQA's digital HEDIS strategy is intentionally designed to align with national interoperability priorities, ensuring that the organization's efforts to promote digital quality measurement are harmonized with broader industry initiatives. This alignment is evident in several key areas, where NCQA's digital HEDIS approach is closely tied to national policy goals and interoperability standards.
Use of FHIR APIs and interoperable data standards: FHIR is the cornerstone of national interoperability efforts. All HEDIS digital measures are specified using FHIR data models and conform to the USCDI standard, enabling seamless exchange of health information between different systems and stakeholders.
Standard logic via Clinical Quality Language (CQL): NCQA ensures consistency in measure interpretation by utilizing CQL, a standardized language for expressing clinical knowledge and logic. This facilitates the accurate and reliable calculation of quality measures across different data sources and systems.
Removal of data silos: NCQA's Electronic Clinical Data Systems (ECDS) reporting supports the use of diverse clinical sources, including electronic health records (EHRs), health information exchanges (HIEs) and registries. This enables the aggregation of data from multiple sources, promoting a more comprehensive understanding of patient care and outcomes.
Transparency and traceability: To ensure the integrity and reliability of digital quality data, NCQA requires each source system to be thoroughly documented and audit-ready. This provides a clear audit trail, enabling stakeholders to track the origin and movement of data and verify the accuracy of quality measures.
By aligning its digital HEDIS strategy with national interoperability priorities, NCQA is helping create a more connected, efficient and effective healthcare system. This alignment enables the organization to leverage industry-standard technologies and approaches, promoting the widespread adoption of digital quality measurement and improving the quality of care.
Data Standards in Practice: What Plans Are Using
When selecting data sources for ECDS reporting, it's essential to prioritize interoperable sources that can facilitate seamless data exchange. FHIR and CCD (Continuity of Care Document) formats are prime examples of such sources, as they enable the standardized exchange of health information between different systems and stakeholders.
NCQA's data aggregator validation program plays a crucial role in ensuring the integrity of these data streams. By validating data for use in HEDIS programs, this program eliminates the need for primary source verification, resulting in significant time and cost savings.
However, opportunities for incorporating structured clinical data into HEDIS reporting extend beyond FHIR and CCD formats. Health plans should explore additional data sources that have been gathered in a standardized form using the coding systems outlined in the USCDI. To ensure the accuracy and reliability of these data sources, health plans must establish proper governance mechanisms to validate, store and trace the data. Furthermore, these data sources should support incremental data loads and updates, enabling health plans to maintain a comprehensive and up-to-date picture of patient care. Read our "ECDS: How One Client Prepared for NCQA Digital Measure Expansion" case study to learn how we helped one health plan solve their clinical data dilemma.
To succeed with ECDS, health plans must tap into a diverse array of clinical data sources, each with unique formats and challenges. The most accessible and commonly used sources include:
- Electronic Health Records (EHRs), which provide a comprehensive record of patient care
- Clinical registries, which collect data on specific conditions or treatments
- Health Information Exchanges (HIEs), which facilitate the exchange of health information between different healthcare providers and organizations
- Public health agencies, which collect data on population health and disease trends
- Immunization and lab reporting systems, which track vaccination rates and laboratory test results
By leveraging these diverse data sources and ensuring their interoperability, health plans can create a robust and accurate picture of patient care, ultimately driving improvements in quality, safety and outcomes.
Closing Thoughts
HEDIS is undergoing a transformative shift, becoming not just digital, but also interoperable, standards-based and connected to the broader health IT ecosystem. This convergence of federal policy, clinical informatics and value-based care is revolutionizing the way we approach healthcare quality measurement. For organizations looking to stay ahead of the curve, now is the time to prioritize interoperability and position themselves for success in a value-based care environment, where the ability to access, manage and validate structured clinical data will be increasingly important.
Coming Up Next
Draft specifications for Measurement Year 2026 have been published. We鈥檒l review the changes and their impact on health plan data strategies in our next blog in the series.
[1] https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification
[2] https://rce.sequoiaproject.org/tefca/
[3] https://rce.sequoiaproject.org/wp-content/uploads/2024/08/SOP-HCO-XP-Implementation1.pdf
Written by Amy Salls
Sr. Director, Revenue and Quality Analytics
