Many quality professionals are feeling anxious about the transition to digital quality measures (dQMs).
The old way of doing things is changing, as the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) led the charge for the move to Fast Healthcare Interoperability Resources (FHIR®) and a digital measure transformation for hospitals, providers, and payer programs. For many payers, they have heard a lot about the reason for the changes but still struggle to feel their organization will be ready for the HEDIS® transformation to fully digital by 2030.
Don’t let the change to HEDIS digital adoption date fool you – the clock is already ticking faster than you expect. Now is the time for health plans to assess their programs, prepare for phased measure roll-out, and – most importantly – find a vendor that will be ready for the change.
Not sure where to begin? We have you covered with a strategy and checklist to help you get started and stay on track with your transition to dQMs.
dQMs transition: What you need to know
Traditional quality measurements – such as manual measure coding and chart extractions – are valuable tools for performance improvement and benchmarking; however, they have limitations, including providing results after care delivery or data being fragmented across unaligned initiatives.
According to NCQA,1 transitioning to dQMs will:
- Reduce administrative burdens and costs
- Improve measure alignment across programs
- Enhance data relevance for better patient care
What are dQMs?
dQMs are measures built using FHIR® as the data model. While FHIR measures are already incorporated into NCQA HEDIS measures, widespread adoption for reporting HEDIS remains limited when they aren’t required.
With dQMs, data sources extend beyond traditional claims and medical record review (MRRs) to include:
- Electronic health records (EHRs)
- Registries
- Case management systems
- Health information exchanges (HIEs)
A phased transition will gradually replace traditional hybrid measures with digital alternatives. By 2030, all HEDIS measures will be fully digital, and hybrid measures will be retired.
Your ‘getting started’ dQMs checklist
To prepare for this transition, follow these key steps:
- Create an inventory
Identify the interoperability and data format options your large providers use and their EHRs. - Prioritize high-volume vendors
Start a pilot program to integrate data from one vendor and slowly add data from others. - Partner with an intermediary data aggregator
Scale with better access to data from multiple providers and EHR vendors. - Confirm file format
Avoid delays by ensuring you get usable digital files (JSON FHIR, not PDFs). - Assess the impact by measure and hybrid lift
Review your hybrid measures to understand the lift between your administrative and hybrid rates. - Prioritize impacted measures
Determine what strategies may make sense in this multi-year transition based on current-day performance (i.e., off-cycle MRR, clinical data partners, interventions). - Plan with your IT partners
Consider the additional scale of data in addition to your claims and supplemental data sources. - Consider the mix of HEDIS and non-HEDIS measures
Check if your state programs have indicated they will move to a digital approach. Some traditional measurements will continue.
Formulating your digital measure strategy and finding the right partner
During this dQM transition, it’s essential to understand how your internal quality operations will be affected and identify areas for improvement.
You need a clear plan for reducing the impact of measures transitioning from the hybrid to the electronic clinical data systems (ECDS) methodology, and how you will close the “hybrid lift gap.” For measures where there is a significant gap between your administrative rate and your sample or hybrid rate, you will want to plan for additional quality improvement activities to occur. Those activities may involve targeting campaigns for member engagement or performing them.
One of the best ways to be prepared now and for what’s ahead is by partnering with a trusted expert in digital measurement. Inovalon provides a scalable, future-ready solution to support your quality initiatives and ensure digital compliance.
With Inovalon’s Converged Solutions Suite, you can:
Leverage FHIR data
Native ingestion of your FHIR data into the Converged Solution Suite is supported. You’ll be able to maintain your existing feeds while minimizing disruptions to your current processes. Supporting a mix of FHIR and non-FHIR-based feeds may be necessary, as not all supplemental data sources are available in FHIR formats.
Calculate digital measures
Utilize measurement rate outputs based on FHIR standards while not losing the enriched measure output you come to expect from Inovalon. Meanwhile, support for scoring and reporting of traditional quality measures will continue.
Close the hybrid measure gap
Inovalon supports prospective MRR with abstraction forms to fill any gaps that may exist in your clinical data coverage. A web-based MRR application with artificial intelligence and natural language processing features will roll out in 2026, designed to handle the processing of large medical record volumes.
Inovalon’s Converged Outreach intervention planning tool can also be used to target campaigns for member and provider engagements to help close performance gaps due to the methodology changes.
Fill your clinical data needs
Source and retrieve EHR data for members not covered through other clinical data feeds with Inovalon’s Electronic Record On Demand™ solution.
Get Expert Insights on dQMs
Want to dive deeper into the transition to digital quality measures? Watch our webinar, where you’ll learn about Inovalon’s roadmap for digital measure readiness and discover everything you need to know to stay ahead of the curve with your health plan.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
1 Digital Quality Transition Hub, https://www.ncqa.org/digital-quality-transition/
Inovalon and design® and Inovalon® are trademarks of Inovalon, Inc.