Digital Quality Measures – Turning Challenges into Opportunity

The shift to digital HEDIS reporting may seem daunting, but it is also an opportunity to modernize how your organization approaches quality measurement. In this final post of our :Digital Quality Measures: series, we explore how to turn today’s interoperability and reporting challenges into tomorrow’s competitive advantage.

Whether you’re preparing for full Electronic Clinical Data Systems (ECDS) adoption or just beginning to engage with clinical data sources, a strategic, phased approach can help you move from compliance to leadership.

Key Challenges Facing Health Plans

As health plans navigate the digital HEDIS landscape, they face multiple challenges. These challenges can be significant, but they also present opportunities for growth and innovation.

Data Acquisition

ECDS relies on clinical data from external sources, such as Electronic Health Records (EHRs), Health Information Exchanges (HIEs), registries, labs and immunization systems. This creates challenges in accessing the data you need to support digital HEDIS reporting. Common obstacles include:

• • Limited data-sharing agreements
  • Provider reluctance or lack of IT maturity
  • Fragmented or siloed data ecosystems

Additionally, accessing these data sources may come with costs, such as fees for data extraction, subscription services or licensing agreements. To overcome these challenges, health plans must develop strategic partnerships with data providers and invest in robust data integration capabilities.

Data Governance

Data governance ensures that data is accurate, reliable and secure. It involves establishing policies, processes and procedures to manage data effectively. In digital HEDIS, data governance is critical to ensure that the data used for reporting is trustworthy and meets regulatory requirements.

A common patient identifier is essential for linking clinical records to health plan enrollment. Without it, health plans must rely on complex matching algorithms. Effective data integration strategies, such as data standardization and validation, are necessary to ensure that patient data is accurately matched and reported, enabling healthcare organizations to make informed decisions and improve patient outcomes.

Data Provenance

One of the biggest challenges in digital HEDIS reporting is ensuring the provenance of the data; understanding where the data comes from, how it was collected and whether it accurately represents the population you are measuring.

For example, consider a measure that uses the PHQ-9 (Patient Health Questionnaire-9), a tool for assessing depression. If the PHQ-9 data is only available in your case management registry, it may represent a biased sample of your membership. Members actively engaged in case management are likely to have different health characteristics compared to the general population. This raises questions about whether the data truly reflects the overall health plan performance, or if it provides a skewed view.

Without proper attention to data provenance, health plans risk using incomplete or biased data, which can lead to inaccurate quality measurements and misinformed decisions.

Audit Standards

Every ECDS data source must be documented, reproducible and traceable to the original system of record (SSOR). Meeting the National Committee for Quality Assurance’s (NCQA) audit standards requires strong data governance, security and version control practices. Health plans must develop a robust audit strategy that ensures the integrity and accuracy of their data and supports transparency and accountability.

Investment

Transitioning to digital HEDIS reporting requires significant investments in technology to support the acquisition, processing and management of clinical data. These investments are critical for ensuring that health plans can access, integrate and report on data effectively, while meeting regulatory requirements. At the most basic level, the volume of data expands quickly when procuring clinical data sources leading to infrastructure investments. The data structures of Health Level Seven (HL7) standards—Fast Healthcare Interoperability Resources (FHIR) and Continuity of Care Documents (CCDs)—are not tabular, so additional IT development might be needed to interpret, validate and map this data. You might need to upskill your teams to learn how to effectively utilize these data sources.

Health plans must assess their current infrastructure and talent gaps and develop a plan to address them. This may involve investing in new technology, hiring new staff, or providing training and development opportunities for existing staff.

Opportunities in Digital Transition

Despite the challenges, organizations that lead the digital HEDIS transition are well-positioned to gain significant benefits. These benefits include:

• Reduce Chart Chase Fatigue: As hybrid measures are phased out, digital submission can dramatically reduce the need for costly, labor-intensive medical record abstraction. This frees up resources for more strategic and high-value activities.
• Gain Timelier Insights: Structured clinical data allows monitoring of quality performance throughout the year. This enables health plans to identify areas for improvement without the lag of claims and medical record review.
• Strengthen Provider Collaboration: Digital reporting depends on access to clinical data, so plans must build deeper relationships with provider networks, IT departments and HIEs. This collaboration can also support value-based payment and care coordination initiatives, driving better outcomes and reduced costs.
• Improve Public Reporting Outcomes: As more digital measures enter NCQA's public reporting, early adopters will be best positioned to demonstrate quality and earn higher star ratings or accreditation tiers. This can drive business growth, improve reputation and support long-term sustainability.

Your Playbook: Steps to Take Now

Here’s a practical roadmap to help your team move forward:

1. Inventory Your Data Sources: Identify all clinical systems you can tap into today. Evaluate the coverage provided by existing clinical sources. Prioritize new sources with the broadest coverage, like registries, HIEs and other data aggregators. Look for overlap across data sources, so that you aren’t paying for the same record multiple times.
2. Establish or Expand Data Sharing Agreements: Up to 70% of the electronic health record is stored in free text or unstructured data. Interoperability alone does not solve that problem. You still need to work with providers with incentives to capture and exchange the data you need in structured form. Begin legal and operational conversations with providers, state registries and HIEs to enable routine data exchange.
3. Review Your MY2025 and MY2026 Measure Mix: Focus on the measures designated for ECDS reporting and those with future ECDS requirements. The schedule for retiring hybrid measures can highlight measures where the removal of medical record review could have a significant impact on rates.
4. Use Medical Record Review to fill data gaps: Medical record review can bridge the gap in the short term, but without the hybrid methodology, the volume of medical record review may increase to achieve the same result.
5. Validate Now: Measures like controlling blood pressure and glycemic status assessment for patients with diabetes are included in multiple quality incentives programs and are highly dependent on clinical results. Utilize parallel reporting of traditional and ECDS measures to ensure comparable results.
6. Create an internal advisory: Evaluate your current ability to support FHIR-based data exchange. Budget for the tools and vendors you may need to support your digital HEDIS strategy. Determine the education strategy for key internal and external stakeholders. Monitor progress against organizational goals.

SS&C Health: Your Digital HEDIS Partner

At SS&C Health, we’ve been supporting HEDIS for over 23 years, and we’re already helping clients successfully transition to digital quality measures. Our experience with FHIR, clinical data integration and NCQA validation allows us to guide your team through every step of the journey. SS&C Health has expertise in integration, automation and artificial intelligence to ensure that you can realize the full potential of all your data sources. We understand the many challenges inherent in meeting HEDIS requirements. Let us partner with you to make the journey smoother and more manageable. Reach out today for a personal conversation; we’re here to help.

Final Thoughts

The digital transformation of HEDIS is well underway, and hybrid methods will be gone before the decade ends. Organizations that act now will not only meet compliance requirements, but also build smarter, more connected measurement systems that align with national priorities and real-world care. By taking a strategic, phased approach to digital HEDIS, you can turn today's challenges into tomorrow's opportunities, and drive long-term success for your organization.