The healthcare industry has rapidly adopted digital tools to improve health outcomes and plan operability over the past few years, in part due to the impact of the COVID-19 pandemic. From February 2020 to 2021, telehealth grew 38 times what it was pre-pandemic and has now become an everyday component of the industry. In 2020 alone, more than 90,000 digital health applications were launched to help patients with everything from chronic disease management to health literacy.
But digital adoption goes far beyond member-facing tools. Digital engagement tools like automated emails and interactive text messages have empowered health plans to deliver more personalized and cost-effective outreach to members. Packaging healthcare data into downloadable files and electronic health records (EHR) enables providers and health plans to provide more coordinated, effective care and improve plan performance.
While digital health management has grown rapidly, new regulatory standards are pushing for even higher adoption rates, especially when it comes to quality measures.
The Road to Digital Quality Management
The Centers for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) has outlined a roadmap to transition all Healthcare Effectiveness Data and Information Set (HEDIS®) quality measures to digital formats over the next five years. Current reporting methods for HEDIS rely on manually processing claims data and importing supplemental data, often through medical record reviews. These digital quality measures are designed to streamline this process by improving data aggregation, standardizing reporting methods for quality scores and maximizing system operability between providers and health plans.
Several HEDIS measures have already adopted digital reporting standards. In measurement year 2021, Medicaid and Commercial plans were required to report the Prenatal Immunization Status measure based on the Electronic Clinical Data Systems (ECDS) reporting standards. Starting in 2023, Breast Cancer Screenings will be fully digital, with Colorectal Cancer Screenings following in 2024. The NCQA has also declared that Adult Immunization Status, an ECDS-reported measure, will replace two immunization measures in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
In addition to transitioning current HEDIS measures to ECDS reporting standards, new measures will immediately require digital reporting. This will put additional requirements on health plans and providers to establish new coding methods.
This shift to digital reporting standards will require health plans to optimize their technical infrastructures to process HEDIS performance. To ensure a smooth transition to digital quality reporting, it is important to understand the key technical terms that will shape quality and IT conversations.
What are Digital Quality Measures?
Digital quality measures (dQMs) are a method of reporting HEDIS® measures in a digital format. Published as a self-contained downloadable package, dQMs use the Clinical Quality Language (CQL) standard for representing a clinical quality measure as an electronic document.
Standardizing dQMs in this format allows both humans and computer systems to easily read and process performance metrics without the need to convert between file formats. These measures require less interpretation and recoding, minimizing human error and improving interoperability when reporting plan performance.
What is an ECDS?
ECDS is a method of reporting dQMs by packing a health plan member’s personal health information and healthcare experiences in a standard data file. Healthcare systems already use ECDS-reported measures in a variety of formats, including:
- Electronic health records
- Electronic health information exchanges
- Clinical registries
- Case management systems
- Administrative claims processing systems
The more healthcare systems that use ECDS reporting, the more easily member data can be shared within health plans and between plans and providers. Essentially, the right people will always have the right information, improving the ability of providers, care management teams and customer service teams to deliver high quality care.
The Impact of dQMs on Health Outcomes
The journey to digital reporting requires a significant change in how quality teams collaborate with IT teams and provider networks to measure health outcomes. While CMS and NCQA have set a strict timeline for this transition, the benefits to a digital-first approach are well worth the investment.
Perks of dQMs:
- Operational efficiency: Reducing manual HEDIS measure calculations and expanding interoperability between healthcare systems improves the ability for plans to deliver.
- Sunsetting of medical record reviews: Transitioning to dQMs will eliminate the need for medical record reviews for quality reporting.
- Greater insights: Accessing member records in a digital format enables plans to review member-level data and stratify populations based on social risk factors, barriers to care and health outcomes more easily.
- Better quality of care: Based on these insights, plans can implement more member-centric tactics to improve care.
The goal of dQMs is to enable regulators and health plans to develop more efficient methods of improving health outcomes for members and eliminate health disparities for underprivileged populations. With the ability to seamlessly share member health records between plans and providers, quality teams can more actively monitor care gaps, identify social determinants of health and track improvements in health outcomes.
How to Transition to dQMs
Capturing, processing and reporting health outcomes through dQMs requires a strong digital foundation and infrastructure. Some measures will convert easily, others will need to have significant methodological updates, and several measures will be entirely redesigned. To meet the proposed deadlines from CMS, health plans will need to immediately begin working with IT and quality teams to ensure a smooth transition to dQMs.
Just as CMS and NCQA have established a roadmap to dQMs, health plans can develop their own transition plan by:
- Assessing organizational and technical infrastructure: Aligning interoperability projects with transitioning to digital measures will require a several year runway to develop the tools and platforms for reporting.
- Improving access to electronic clinical data: There is a wide variation on the amount of supplemental data captured currently in various databases and public records. Plans should begin accessing this information while developing strategies to pursue data elements currently not captured.
- Monitoring the conversion to ECDS-reported measures: ECDS-reported measures are contingent on health plans having complete access to robust electronic clinical record data. The loss of medical record reviews will need to be addressed in the planning for additional Data pursuit.
- Prepare providers for ECDS reporting: New measures will require capturing services that may not currently be in claims data. Plans will need to address new coding needs and the importance of additional clinical documentation in structured fields.
- Modernizing member engagement: The availability of more clinical data will provide health plans with an opportunity to better tailer communications and member programs to better address everyone's specific needs and risk factors.
While the journey to digital quality management includes several twists and turns, health plans are not in this alone. Healthmine’s Expert Advisory Services team has decades of experience providing guidance to health plans as they begin to transition to dQMs and ECDS reporting. Reach out to us for industry insights into these new regulatory requirements and to explore strategies for transitioning to digital HEDIS measures.