HEDIS® in 2025
HEDIS (Healthcare Effectiveness Data and Information Set) is a foundational tool used by NCQA and CMS for evaluating health plan performance. Today, HEDIS enables payers to monitor quality, identify care gaps, and demonstrate value across six domains:
- Effectiveness of Care
- Access to Care
- ECDS-Reported Measures (Electronic Clinical Data Systems)
- Utilization and Risk-Adjusted Utilization
- Plan Descriptive Information
- Experience of Care
With over 90 individual measures, HEDIS drives accountability and performance-based reimbursement. As an increasing number of measures shifts to reporting via ECDS, digital-first quality tracking offers an opportunity to:
✓ Broaden measurable care areas
✓ Enable real-time quality improvement
✓ Elevate cost-efficient, value-based care
Payer Data and HEDIS Scores
Low HEDIS scores signal care shortfalls and expose payers to serious risk, including:
- Low Star Ratings, which impact market share
- Member attrition
- Reduced reimbursements or increased penalties
- Plan closure
Payers need high quality data that is comprehensive, interoperable, and clinically contextual in order to demonstrate quality care. Current collection methods are reactive and admin-heavy, often taking weeks or even months, just to prepare audited submissions for NCQA.
Payers collect three types of data-sets, each with their own limitations and data-biases:
How HEDIS Scores Will Be Determined
Road to Digital HEDIS: FHIR + CQL
Quality data determines quality care. As such, according to the NCQA, the Road to Digital HEDIS requires the collection of data in FHIR® and CQL.
FHIR is the HL7 open standard for clinical data exchange. CQL is a human-readable clinical query language. FHIR is the world’s leading data exchange open standard adopted by Payers and Providers alike. It structures and standardizes data, making exchange faster, more accurate, complete and more meaningful. The use of open standards eliminates the need to repeatedly develop proprietary quality measures and maintain costly certifications.
The combined power of a FHIR-first CQL engine transfers NCQA’s measure guidelines into sharable computable formats that automates quality data reporting. Automating the quality measures process—by reporting on prospective gaps in care, for example—paves the way for significant cost-savings and reduced administrative burden, greater operational efficiencies and enhanced accountability towards providing high-value care.
Smile is the first organization to receive NCQA validation for specific measures with its dQM for HEDIS solution
Digital HEDIS—An Opportunity for Payers
The Council for Affordable Quality Healthcare (CAQH) estimates that shifting from manual to automated quality workflows could save payers and providers ~$20 billion (22%) annually.
For HEDIS and other quality measure reporting (which is a heavily burdensome process), Payers who invest in FHIR-first IT infrastructure will benefit from both retrospective and prospective quality workflows. Using CQL Payers can unlock scalable automation and decision support, allowing quality teams to measure, monitor, and act in near real-time. This creates more holistic collaboration between Payers and Providers, as well as enhances member satisfaction, which is directly linked to STAR Ratings.
How Do Payers Maintain High Scores on the Road to Digitized HEDIS
Adopt FHIR‑first and CQL‑enabled tools for automated measure submission.
Use only NCQA-Validated digital solutions (not just certified), to ensure compliance with Digital HEDIS standards.
Smile for a Good HEDIS Score
Smile Digital Health partnered with NCQA to demonstrate the viability and interoperability of Digital HEDIS, fulfilling our commitment to driving interoperability and opening the market for Digital HEDIS submission
As a user of NCQA’s Digital Content Services (DCS), Smile leverages digitized FHIR CQL HEDIS measures that help minimize programming and validation efforts and make HEDIS more accessible at all levels of healthcare.
Smile is playing a leading role in NCQA’s Digital Quality Implementers Community, a collaborative consensus-based effort, to develop, advance, and standardize tools and platforms, like CQL engines, that optimize digital quality measurement.
Our platform is capable of running digital HEDIS measures, as demonstrated by DQIC. In partnership with NCQA, Smile has already:
Submitted 31 measures to NCQA for official review.
Achieved NCQA validation on 11 measures (ready for parallel testing).
Smile dQM—Measures for HEDIS reduces the burden of manual chart review, data collection and HEDIS reporting. Payers will be able to implement NCQA-aligned quality initiatives, collaborate better with Providers, stay ahead of regulatory mandates, deliver higher quality care, and future-proof their operations as the industry moves toward full digital quality reporting by 2030.