Lessons Learned From Leading Health Plans Implementing Digital Quality

November 22, 2024 · Guest Contributor

By Rebecca Jacobson, MD, CEO & President, Astrata

From my seat as CEO and co-founder of Astrata, I have a unique view into the transformation underway in health care quality measurement—the move from traditional to digital HEDIS. Three forces are driving this transformation: the move to value-based care, the rise of standards-based interoperability and the increasing financial pressures on payers.

I will outline how these forces align to offer payers an extraordinary opportunity if they innovate in digital quality. I’ll also share some of the lessons Astrata learned from working with health plans that are moving to a fully digital HEDIS workflow. But first, let’s quickly review what this transition is, and the value it produces.

The Transition to Digital HEDIS

From the lens of payer quality leadership, the basic elements of digital transformation—outlined in the diagram below—center around the use of clinical data to drive a prospective and improvement-focused approach.

The use of clinical data to measure health care quality in close to real-time creates new value for health plans, including:

• More complete, accurate and generally higher quality rates.
• Improved ability to drive meaningful quality improvement programs with better data.
• Reduced administrative burden on providers.
• Reduced costs of quality measurement.

Digital transformation—a combination of technology, process and culture changes—typically requires a phased adoption aligned with change management. Early on, health plans engage in mapping their data to FHIR, gain trust and confidence in new digital measures, then gradually increase the number of digital measures they can compute and begin to use the new measures for quality improvement activities before moving to a digital-only reporting program. Closely aligned with these changes is the use of ancillary technologies such as Natural Language Processing (NLP), which can help health plans adjust to the loss of the hybrid methodology. NLP is an important bridge in the transition to FHIR—and it will also be a critical success factor in the future as measures become more outcome focused.

Lessons Learned From Leading Health Plans

What lessons have we learned from leading health plans as they transform their HEDIS operations? I’ll give you my top three.

1. Develop a clinical data strategy supported by executive leadership. More than quality measurement is at stake. The use of clinical data with more sophisticated analytics is an important driver of excellence for health plans. Risk adjustment, member engagement, payment integrity and many other activities also benefit from a more complete clinical picture. Strong clinical data strategies are inherently silo-busting, and they blend approaches by sourcing data from multiple entities, in a wide variety of formats, while ensuring unified use of these data across programs.
2. Commit to standards and standards-based technologies. We have seen this conscious choice pay dividends. The use of standards such as FHIR APIs, USCDI and CQL will ensure a common architecture and technical approach to health plan operations that more easily and nimbly adapt as health care and standards evolve. This is as much a culture change as it is a technical advance. Both quality and IT leadership need to upskill staff, but must also insist on standard-based solutions from the vendor community.
3. Remember that small is beautiful. While it may be tempting to engage in a deep study of data quality, or design entirely new IT infrastructures, the best way to start is to remember “small is beautiful.” We advise health plans to immediately begin computing digital measures—starting with just one or two. This typically requires mapping existing data (including claims data) to FHIR using NCQA’s HEDIS Core FHIR Implementation Guide—although intermediate data representations can be more useful for health plans with existing data warehouses. Early on, this can be slow going, and will be highly iterative, but it picks up speed as new measures are added, because you will have mapped the associated FHIR resources before. Start small, but make the complete round trip, from data mapping through result inspection. Once you have confidence in the result, you can focus on comparing the digital measure to the traditional one.

The Opportunity of Digital Transformation

Three powerful forces are aligning to move us to a digital quality ecosystem—creating an unparalleled opportunity for plans that move quickly. Let’s unpack those ideas with a focus on the opportunity for forward-thinking leaders.

Value-Based Care. Payer quality measurement is evolving rapidly from an accountability-based activity, focused on reporting, to an effort that is deeply integrated with value-based care and population health programs. This trend will continue as the number of members in value-based care arrangements grows. Faster, more accurate quality measurement drives faster and better interventions from payers and practitioners. New technologies will also foster changes in the measures themselves to leverage the richer data. As a result, it will be hard to keep up if you aren’t already working with the right tools.

Standards-Based Interoperability. We have probably never been as close to an interoperable health data ecosystem as we are today, and the increasing alignment we see from federal and state organizations to advocate for these standards, and embed them in every program, should be a signal to all leaders. Even bigger changes are afoot, as evidenced by both the data access solutions increasingly offered to payers by EHR vendors and the national interoperability efforts that directly build on these standards. Once access points widen to increase data flow, health plans that are positioned to drink from the firehose will strengthen their competitive position and be able to drive more consistent results among growing segments of their business.

Financial Pressures. Health insurers are facing unprecedented financial pressures, including the Covid 19 public health emergency and response, reduced Medicare payments and increasing medical expense ratios. Current methods for measuring quality are highly manual, repetitive and costly. They don’t scale well to value-based programs, producing financial risk. The next set of changes to quality measurement includes removing the HEDIS hybrid methodology and focusing on electronic clinical data. Without technology innovation, these changes will drive measurement costs up even further. In contrast, health plans that digitally transform their operations will adapt more easily—and with less cost—as the changes keep coming. And these plans will be better positioned to use the insights from clinical data to drive down medical expenses.

The message is clear: Digital HEDIS will be a powerful differentiator for plans that seize the moment. And the moment is now.

This blog is brought to you by Astrata and the views expressed are solely those of the sponsor.