This episode explores the challenges and opportunities plans face during the digital transition. The most common challenges are outdated systems, fragmented data sources, and managing data integration effectively. We discuss innovative strategies to reshape HEDIS® reporting and analytics—from integrating diverse digital data into a unified platform to accelerating processing speeds for real-time insights. Plans can leverage these powerful analytical tools, flexible reporting, and actionable data to proactively identify care gaps, deploy intervention campaigns, streamline workflows, and ensure regulatory compliance.

This episode equips health plan leaders with the strategies they need to stay competitive and fully embrace the latest industry strategies for HEDIS success. 

Host: Today we’re talking with Sharon Kurht, Director of Quality. Sharon has 14 years of experience in HEDIS, Medicare Stars, and Medicaid. Sharon is an RN, holds a doctorate in nursing from Northeastern University, where she is also a health informatics professor at the graduate level. Welcome Sharon.

Sharon: Thank you. HEDIS® is such an important topic in health plan operations. I’m excited to talk about it.

Host: Let’s start by defining HEDIS’ purpose. HEDIS, is the Healthcare Effectiveness Data and Information Set. It’s a set of performance measures developed by the NCQA, the National Committee for Quality Assurance. It measures and compares the quality of care and services provided across the health insurance marketplace. HEDIS includes various measures related to the effectiveness of care like preventive services and chronic disease management, it measures access to care like the availability of providers and the ability to schedule appointments in a timely fashion. Member experience and satisfaction is measured. For utilization measures, it tracks usage patterns of healthcare services, and it measures contextual information about the health plan itself, such as enrollment information and the structure of provider networks in a given health plan. Over 90% of health plans in the United States use HEDIS to ensure that patients receive high-quality care.

Sharon, what’s the hot topic in HEDIS right now? What’s the buzz? What are plans talking about? What’s on everyone's mind?  

Sharon: I’d say the big buzz is that HEDIS measures are becoming digital and moving away from the traditional path of digging through medical records. Right now, the industry is transitioning and using a hybrid model. So, every year one or two measures go digital. The NCQA aims to be completely digital by 2030. That’s an estimation, of course. It’s to be determined. But now is the time for plans to move and adopt a robust approach to mining digital data prospectively.  

Host: What does prospective mining look like? Will you provide some detail around that?  

Sharon: It means all of the data has to be compiled into one platform so it can be processed using the NCQA-certified rules. And then, the data has to be linked to each HEDIS measure so an analytics engine can rate each measure. We are no longer going to be relying solely on claims data. This is a holistic approach to data management and analytics, which means we need to tell the whole data story. So, that’ll include data from the Health Information Exchange, state immunization records, EMR data, pharmacy data, claims data, and supplemental data from provider officers. The goal is to link as many data sources as possible.

Host: It seems like having all of this data connected to each HEDIS measure will improve how plans monitor performance.  

Sharon: Yes, monitoring performance is easier with the digital data sources connected to each HEDIS measure. UST HealthProof has optimized its HEDIS engine to process data very quickly, we can process 2 million member records within one business day. This is well above the industry norm, which can take days to run reports. The value in having data that reflects the most current state of HEDIS is that plans can identify areas for opportunity and drive improvement initiatives that target the needs of their member population from moment to moment. We do this especially well. We don’t just process the data. We run prospective monthly reports, analyze it, identify opportunities for improvement, and oversee member outreach initiatives to maximize performance.  

Host: Can you give me some examples of HEDIS improvement initiatives?  

Sharon: Yes, for example, if we see the rate for colorectal cancer screening is low, we can do an outreach campaign to those specific members—you know, email or text them reminders to have their tests done, or we can send them an at-home option like a Cologuard kit. We see a lot of success with these types of campaigns. Members get busy and forget, so those targeted reminders are very effective. Another example, the data might indicate that a low percentage of the plan’s population has gotten an annual mammogram. That’s an example of the Effectiveness of Care domain campaigns.

Maybe, the data indicates low performance in an Access to Care measure. Or maybe, the plan needs to expand their provider network or offer provider incentives.  

If there is a test out of compliance, we can reach out to the provider to close the gap.  

Host: So, there’s an element of provider engagement in HEDIS?  

Sharon: Absolutely. We’re integrated with risk adjustment so we can reach out to providers to close both diagnosis and HEDIS gaps and suggest next-best-actions. All of that data is compiled and connected.

There’s a host of use cases on how we can respond to the data. We’re evaluating the data against the 90 measures in all six domains of HEDIS.

Host: Once the action is taken by the member or the provider to close the HEDIS gap, how is the HEDIS engine updated?  

Sharon: The HEDIS engine is digitally connected to claims. So, once the claim for the action is submitted, it auto-updates the HEDIS engine. So, if the mammogram is completed, the claim is generated and updates HEDIS.

Host: Fantastic. I can see how this is a drastic process improvement from manual abstraction and provides plans with better insights for continual improvement. The benefits are clear. But, I’m sure the transition is not all roses, though. What are the challenges for plans right now as the industry shifts to digital HEDIS?

Sharon: Yes, getting settled into digital HEDIS may initially be challenging for plans. Integrating the different data types and ensuring the file specifications are correct is already a heavy lift for some plans. Digital HEDIS will require a sophisticated team of data analysts and developers to identify and prepare the data for the HEDIS engine. Most health plans aren’t big enough to have a data team, so finding the right HEDIS vendor will become even more important now than ever.  

One of the things we offer in our HEDIS platform is pre-built, self-service reporting dashboards so plans can access their own data as needed. Of course, we support the analytics and strategy but it’s nice for plans to also have their own access to reports. Our abstraction tool also toggles between retrospective and prospective views of the HEDIS data. So, it’s a very transparent platform.

Host: Can you describe the difference between retrospective and prospective HEDIS data?  

Sharon: Yes, so, retrospective is the official HEDIS submission that goes to NCQA and informs CMS for Star measures.  

Prospective is the data that we monitor on a monthly basis and use for improving performance so there are no surprises as to how HEDIS will perform.

Host: I think it’s very important to look at HEDIS holistically and provide that end-to-end support from abstraction to ongoing monitoring and provide actionable ways to improve performance. It’s a very resource-intensive process to collect, analyze, iterate on the tactics, and then report the HEDIS data accurately.  

Sharon: Yes, it most certainly is. This process has a lot of regulatory rules and data governance. Medicare Advantage plans use both Star Ratings and HEDIS measures to ensure high-quality care, drive quality improvement, and meet regulatory requirements. The integration of HEDIS measures into the Star Ratings system means that strong performance on HEDIS metrics can positively impact a plan's overall Star Rating. HEDIS accounts for 17% of the 40 Star measures. So, getting HEDIS performance up is a very worthwhile investment for plans.  

Host: What’s the best way for plans to stay on pace for the digital adoption of HEDIS measures?

Sharon: Plans need to evaluate their infrastructure for their capacity to exchange data from different sources, like using the FHIR standard to exchange data with providers, other health plans, and the Health Information Exchange. Part of this will look like incentivizing clinical data sharing with provider groups and focusing on a few pilot measures at a time. It’s important to start adopting the digital measures now.

Host: Thank you, Sharon. You're right, the NCQA recommends a phased approach, and with any transition this is the best approach. We know where the industry is headed so there’s no sense in waiting. The time to modernize is now.

Sharon: Absolutely.  

Host: Thanks Sharon. It was great talking with you and learning about this next phase of HEDIS and where the industry is headed.

Sharon: I’m happy to share what I know.

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