When it comes to measuring health plan efficacy, the gold standard is HEDIS, or the Healthcare Effectiveness Data and Information Set. HEDIS is used by more than 90% of health plans to report on health data for 190 million Americans. Like everything in healthcare, HEDIS measures change, and it’s crucial to stay on top of those changes so your organization can meet all the necessary reporting requirements and timelines.

Here’s everything you need to know about HEDIS in 2020.

HEDIS is going digital

The National Committee for Quality Assurance (NCQA) is digitizing HEDIS measures. Digitized measures will automatically absorb data that clinicians enter into electronic health records (EHR) when providing care, decreasing the amount of separate data entry that must be done. 

The goals of digitization are to:

  • Align quality measures across the healthcare system
  • Reduce the burden and cost of measurement and reporting 
  • Improve the accuracy of reporting
  • Increase flexibility in the use of HEDIS measures 
  • Enhance value for health plans


While digitization will ultimately streamline and speed reporting, it may cause difficulty for large payers that are slower to adopt change at first. Experts predict some plans will continue to collect data as they have in years past, which may put them at a competitive disadvantage, though NCQA will continue to accept traditional reporting for the time being.

Digital measures are rolling out incrementally

In 2018, NCQA released 6 digital or machine-readable measures and launched the HEDIS Electronic Clinical Data System (ECDS) Reporting. Each year for the next 3 years, HEDIS will convert 20-25 additional measures.

In 2019, NCQA provided 8 digital measures for traditional reporting and 11 digital measures for ECDS reporting. Those include:

  • Adult immunization status
  • Prenatal immunization status (PRS)
  • Depression screening and follow-up for adolescents and adults
  • Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults
  • Depression remission or response for adolescents and adults
  • Unhealthy alcohol use screening and follow-up


While digitization will streamline less complex measures, the accuracy of digitization is still in question for clinical data. There remains a need for humans with clinical expertise to assure the quality of automated tools. The most impactful HEDIS measures still require clinical expertise. Those include:

  • Care for older adults (COA)
  • Controlling high blood pressure (CBP)
  • Transitions of care (TRC)
  • Medication reconciliation post-discharge (MRP)


“In my opinion, digitization should start with the least impactful measures,” says Kristen Nicholson, SVP of Account Management at Shearwater Health. “We’ve found, for example, that one automation tool we use with a client is only 60% accurate. That’s why we offer quality as a service, because there’s still a need for an actual human with clinical expertise to achieve the desired 100% accuracy.”

Clinical data will play a bigger role

While health plans have relied on claims data to assess quality in the past, organizations will need to incorporate clinical data into HEDIS reporting moving forward. The NCQA encourages the use of multiple data sources to get a holistic picture of quality, which will happen automatically under the ECDS

ECDS measures are calculated using data collected from:

  • Electronic health records (EHRs)
  • Health information exchanges (HIEs)
  • Clinical research and disease registries
  • Lab reports
  • Pharmacy systems


As these changes take hold, experts say payers may need to report better scores just to stay in the same position, and that organizations can expect to see clinical data playing a larger part in risk adjustment, care coordination and advanced analytics. Organizations can also expect increased communication between payers and providers. 

CMS and NCQA are working toward alignment

In 2017, the Centers for Medicare & Medicaid Service (CMS) launched the Meaningful Measures Initiative, a framework focused on connecting measurement to strategic goals. When the NCQA released its Digital Measures Roadmap (DMR), it touted similar goals, specifically reducing the burden on health plans and providers by identifying priority areas for quality measurement. The organizations plan to continue their tandem efforts in the coming years.

Improving HEDIS scores

There are several things every payer can do to improve HEDIS measures:

  • Submit data in an accurate, timely manner for every service 
  • Ensure charts reflect all services billed
  • Bill for all services, regardless of contract status
  • Consider including CPT II codes to reduce record requests
  • Stay up to date with all things HEDIS using the NCQA website


Here at Shearwater, we offer several services to help improve HEDIS measures including:

  • Chart abstraction
  • Quality assurance 
  • Provider and member data reconciliation
  • Provider and member engagement initiatives
  • HEDIS hybrid measure review
  • HEDIS supplemental measure review


Contact us today to learn more.