Understanding the Shift to Digital HEDIS®: Key Terms and Concepts

As NCQA guides the industry toward fully digital quality measurement, it's essential to understand the terminology and what it means for payers. Below is a breakdown of key concepts in the evolving HEDIS landscape:

Traditional HEDIS

NCQA has historically published narrative specifications for each HEDIS measure. Vendors were able to interpret them, and develop proprietary implementations around each measure to submit to NCQA to be “certified”. Traditional HEDIS relies on manual chart review and claims data which can be slow, labor-intensive, and often incomplete. All scores are retrospective and are only received after the annual reporting cycles. As such, Payers neither have the opportunity to ensure appropriate care is delivered in a timely manner, nor to make necessary changes to improve scores and care delivery before the annual cycle ends.

Digital HEDIS

In response to the need for standardization, automation, and real-time data use, NCQA now delivers machine-readable HEDIS measures through its Digital Content Services (DCS) program. These measures are defined in FHIR® and CQL, allowing vendors to directly download and implement official logic. Digital HEDIS improves efficiency, consistency, and real-time measurement. With this model, Payers can check their scores continuously, and rectify care gaps, before the submission process. This ensures the highest level of care delivery as well as submission of the best possible results.

FHIR and CQL HEDIS measures significantly reduce programming and validation efforts, while maintaining clinical logic, context and vocabulary, making digitized HEDIS more accessible, structured and standardized at all levels of healthcare.

Where We Are Now

NCQA ‘Certification’ for traditional HEDIS NCQA Measure Certification refers to the formal review process for traditional HEDIS measures offered by the NCQA. Health plans and IT vendors had to become certified to ensure compliance and accuracy with NCQA’s technical standards. NCQA is moving away from this process in favor of digital HEDIS measures, a model where standardization is built into the measure content itself, thereby removing the need for proprietary interpretation.

Where We Are Headed

NCQA Validation for digital HEDIS NCQA Validation is a process that replaces the legacy ‘certification’. The new Validation process requires the successful running of NCQA’s digital measures on the vendor’s system against the test data decks provided by NCQA. The vendor then submits the results of those measures back to NCQA. If NCQA finds the results accurate, that measure is deemed “validated”. Each individual measure must go through this process to be Validated. These measures are now ready to be used for the next step of Parallel Testing.

Parallel Testing for Digital HEDIS In order to submit digital HEDIS measures, a Payer must undergo 1 year of parallel testing. This involves the comparative measurement of both traditional HEDIS and digital HEDIS. Parallel Testing Results are submitted to independent auditors to verify that the digital measurement process is as accurate as the traditional process. Upon confirmation, the Payer is then approved with that vendor to submit digital HEDIS measures for the following measurement year.

How We Get There: Understanding the Pathway to HEDIS Rates

The Pathway to HEDIS Rates requires an understanding of the following concepts:

Digital Quality Implementers Community (DQIC)
The purpose of DQIC is to develop, advance and standardize tools and platforms for digital quality measurement in healthcare. It is an NCQA-led community with the following main goals:

a) Demonstrating that NCQA-defined digital HEDIS measures can run on a FHIR^® and CQL compliant solution or platform.
b) Demonstrating that digital HEDIS measures can run on a non-NCQA solution or platform.

Unaudited HEDIS Rate
Once measures are run and are validated, they are considered ‘unaudited HEDIS rates’. This means that internal validation has been completed, but measures are not yet approved for HEDIS submission. For Payers, this is an essential metric and concept to understand, as only vendors who have validated measures can move forward to the parallel testing phase.

Parallel Testing
Successful parallel testing on validated measures must be achieved to verify that new digital HEDIS measures are as accurate as the traditional measurement methods. Parallel testing requires 1 year of data for comparative testing between traditional measures and the new digital validation process. The results are then reviewed by HEDIS Compliance Auditors before being declared as ‘HEDIS Rates’. Parallel Testing must take place for every required measure.

HEDIS Rate
Once parallel testing is complete (with one year of measurement data)) a measure can be submitted for audit. Once audited, it is deemed a ‘HEDIS Rate’ and is approved for HEDIS submission.

Smile is the first and only organization to receive NCQA validation for specific measures with its dQM Solution.

11 Measures Validated

31 Meaures Submitted

How Smile’s dQM is Leading the Shift to Digital HEDIS

The shift to digital HEDIS is more than a technical upgrade—it’s a strategic imperative. HEDIS scores directly impact payer revenue, compliance, and the ability to compete for state contracts and federal incentives. That’s why Smile Digital Health has made digital HEDIS a priority. Our FHIR and CQL-native architecture is built to support this transition, helping payers future-proof their quality programs as NCQA moves toward fully digital reporting targeting 2030. Today, Smile has already internally tested over 45 of the 90+ HEDIS measures, demonstrating our proactive commitment to accelerating digital readiness.
As a leading member of the DQIC, Smile has 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. Bryn Rhodes, Director of Standards Strategy at Smile, is the technical lead of DQIC and continually shares learnings with the organization to propel everyone toward digital HEDIS. Our dQM for HEDIS Measures solution is capable of running the DQIC digital HEDIS measures, and has already received NCQA validation for one of the four approved DQIC measures.
Smile Digital Health is an expert in open standards and practical deployments. The team actively leads more than 31 HL7 Technical Working Group (TWGs) to evolve standards like HAPI FHIR, CQF Ruler and CQL. In addition to the 190+ successful global FHIR implementations, Smile fosters community, cultural and technical maturity through organizational training programs like FHIR Essentials, and hosting active connect-a-thons for Payers to test real-world FHIR and CQL engine results.
Smile’s FHIR and CQL engine boasts break-through performance, processing data for over 5 million members/ patients in under 12.5 hours. That’s over 5 billion data points across 80 quality measures, which is. Our engine dramatically reduced the time and manual effort taken to run quality measures. As such, Payers can access care standards more frequently, act on the opportunity to improve delivery in near real-time, and ultimately achieve better scores.

The transition to Digital HEDIS is a phased process over the next few years. Let Smile help you create and implement your Clinical Quality Intelligence Roadmap.

Start by contacting us about Digital HEDIS.

Understanding the Shift to Digital HEDIS®: Key Terms and Concepts

Where We Are Now

Where We Are Headed

How We Get There: Understanding the Pathway to HEDIS Rates

How Smile’s dQM is Leading the Shift to Digital HEDIS

The transition to Digital HEDIS is a phased process over the next few years. Let Smile help you create and implement your Clinical Quality Intelligence Roadmap.

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