The NCQA’s move to fully digital HEDIS measures by 2030 is more than a technical change; it is operational, financial and requires significant internal change management, as it will shape the future of the Quality Lifecycle. This move to digital will generate exponential savings for organizations that embrace it strategically.
It’s time to shed the traditional methods of quality measurement that include hybrid chart reviews, manual data abstraction, data exchange through faxes or emails, and data saved in X12 format. The worthy shift to Digital HEDIS involves modernizing to FHIR®-based, machine-readable digital measures, and yes the road to get there has its challenges. Navigating these challenges with a vendor-partner proactively and strategically supports a smoother transition, not just for the Payers, but for Providers and Members as well.
Here is a list of common challenges faced during the transition to Digital HEDIS, and what successful payers are doing right now with Smile Digital Health to ease these pain points.
| Challenges | What Successful Payers Are Doing with Smile |
| Leadership Buy-In Cross-departmental and cross-organizational coordination requires complete executive support. Since this transition is more than just a technical change, Payers have reported challenges with budget-approvals, operational and strategic plans and resource allocation for ecosystem wide digital transformation. |
#1 Leveraging enterprise experience. Smile solutions power compliance and digital quality solutions for over 27 US Payers, touching over 110 million American lives. Our unparalleled experience in FHIR and CQL implementations ranges from pilots to production, and allows for unique customizations along the way. Our organization-wide roadmaps support leadership buy-in that encourages confidence in the investments. |
| Resource Allocation Payer teams are already overburdened with traditional HEDIS workflows, internal initiatives, and upcoming compliance requirements, in addition to maintaining business operations. Transitioning to digital HEDIS Measures adds new resource requirements. Expertise in data quality, FHIR® and CQL, and the technologies that power usa |
#2 Choose a trusted and proven partner. #3 Training staff for the future. |
| Managing Costs Traditional HEDIS processes are manual and labor-intensive. Payers spend months pulling data from fragmented sources. During the transition to Digital HEDIS, the process of acquiring data from proprietary systems, in a structured and standardized way can get expensive if a cohesive strategy is not in place. This makes the financial investment difficult to justify. |
#4 Reducing long-term costs with a smarter data strategy. #5 Building compliance from the start. |
| Internal Coordination Challenges Siloed departments, systems and fragmented workflows prevent Payers from leveraging their data effectively. Without alignment, both calculations of HEDIS measures and Star Ratings suffer, and provider relationships, including out-of-network providers, are strained. |
#6 Creating a single source of truth. The benefit of a FHIR-first data architecture like Smile’s is that a unified data source exists with real-time data exchange that is accurate and consistent across Payers and Providers. The solution engine is EHR-agnostic, with workflows and integrations for both in and out of network Providers that supports Care Gap Analysis and Risk Management. |
| Dependence on External Entities Gaps in data exchange from HIEs, vendors, or UM delegates can delay or damage NCQA reporting. |
#7 Adopting an integrated, end-to-end platform. Smile has a FHIR and CQL solution engine that is able to ingest data from a variety of sources, in different formats into a single source-of-truth repository, limiting the dependencies on external entitles and their proprietary data formats. |
| Uncertainty Around Non-HEDIS Measures Payers must also meet the needs of states, specialty societies, and other stewards — often across jurisdictions and with non-NCQA specifications. Historically, these were handled in a proprietary manner which was manual and created vendor-lock. |
#8 Choosing flexible architecture. Smile’s FHIR-first platform and CQL engine are based on open standards and easily adapt to changes, without repetitive technical work. This allows Payers to execute new measures with ease with no threat of vendor-lock-in. |
The Takeaway
NCQA is encouraging plans to pilot digital reporting as early as Measurement Year 2025.
Innovative Payers are not waiting for the 2030 deadline to start pilots and parallel testing (if you don’t know what the requirements of parallel testing are learn about it here). They’re securing the right partnerships, aligning internal teams, and building towards a flexible, future-ready data infrastructure today, so they can improve quality scores, strengthen provider relationships, and lead the way to meeting CMS and NCQA requirements.
The Right Vendor for Digital Quality Measures
We think we are the right vendor for you. Evaluate Smile’s capabilities yourself.Smile Digital Health Can Support Your Transition to Digital HEDIS With Confidence