The Road to Digital Quality – Astrata’s Maturity Model Approach

As the monumental changes to the Medicare Advantage program just keep coming, many payers are turning to technology and data to help them adapt and build the infrastructure that will be needed to adjust to value-based care models. CMS and NCQA have indicated that 2030 is the date by which they expect a switchover to Digital Quality Measurement and they are signaling that various forms of the current traditional HEDIS® process could be retired by then, including the hybrid methodology and traditional (non-ECDS) measurement reporting. 

And yet, there is almost no guidance about how payers should operationalize this enormous transformation from traditional to Digital HEDIS®. Several key pieces are still missing such as a complete Digital HEDIS® measure set, and a more complete and automated reporting process. While the big nationals are investing in this transition, regional payers and provider-sponsored plans are at risk of falling behind. Quality teams are left guessing at the road ahead. And everyone is asking “How do I get moving?” This blog is meant to help you get on the road to success with a practical maturity model. 

For the rest of this article, I am going to use the term “Digital HEDIS®” to refer to this new way of measuring HEDIS®, and in contrast to our current methods, which I will refer to as “Traditional HEDIS®”. 

The Basics of Digital HEDIS 

At its core, Digital HEDIS® is remarkably different than Traditional HEDIS®. Traditional HEDIS® depends primarily on claims data with some additional supplemental data, but digital quality measurement leverages much more clinical data supplemented with claims data. Traditional HEDIS® happens with timing designed to support the reporting year. But Digital HEDIS® is specifically intended to provide information during the measurement year that will change how you intervene. Traditional HEDIS® is a complex web of intricate processes that must happen on a tight timeline to hit reporting dates. But Digital HEDIS® is a continuous process, managing quality measurement as an everyday activity.

Programs such as the NCQA Digital Content Services (DCS) program offer HEDIS®vendors and health plans a chance to explore the use of the new computable measures – measures written in the CQL computer code instead of described in a PDF. These measures must be executed using a CQL engine, typically on data expressed using the FHIR data standard. NCQA’s computable measures will provide clear and unambiguous measure definitions directly from the regulatory source, implemented at a much faster time scale, with a level of detail and intermediate results that could be transformative for QI programs. These advantages are not available today using Traditional HEDIS® methods.

The Astrata DQM Maturity Model 

Astrata’s eMeasure product is one of the first native FHIR+CQL engines – which is designed to help health plans move their operations to digital quality. As part of our engagements with our clients, we’ve defined a set of maturity stages that our customers move through as they gain familiarity and expertise, moving towards a transition from Traditional HEDIS® to Digital HEDIS®. Our engagements combine technical and data readiness with the use of a sandbox version of our system until the full switchover can be accomplished. The goal here is to limit the tech investment needed during the time you will have to maintain multiple engines.

In Phase 1, we recommend that health plans study and develop a deep understanding of the technical requirements while gauging readiness. During this phase, Astrata works with you to assess data readiness in Astrata’s eMeasure DQM environment. An outcome of this phase is a detailed technical transition plan.

If you’re planning to meet the current 2030 deadline, you’ll want to get started with Phase 1 in 2024 or 2025.

In Phase 2, you’ll be benchmarking your new digital measures against standard traditional HEDIS® measurement. While we don’t expect these measures to perfectly align (as opposed to comparing to traditional HEDIS® vendors), we want to better understand what members flipped from non-compliant to compliant or from compliant to non-compliant, and then dive deeper to understand why. During this phase, Astrata works with you to analyze discrepancies and apply fixes. This is where you’ll start to see first-hand the overall data flow and be able to project the impact of digital measurement on your quality rates.

Later in Phase 2 (let’s call it 2a), you can begin to use this data for quality improvement, (e.g. better managing members with chronic diseases, and increasing your cancer screening rates) even before you have a mechanism for reporting. That provides real value to you that can help drive goals for population health and value-based programs. To keep on target, look to start Phase 2 in 2025 or 2026.

In Phase 3, and once the reporting requirements are better understood, you’ll be moving to using your digital engine across a much wider set of measures and developing your reporting muscles. In this phase, you’ll also be implementing many of the downstream integrations (EHR, bulk FHIR, etc.) that you enumerated in your technical transition plan. This phase is likely going to take a little longer, so expect to get started in 2026 or 2027.

And finally, when you get to Phase 4 you’ve reached the end of one road, but the start of another. Once your digital transformation is complete in 2028 or 2029, you’ll be focused on implementing new work processes, better engaging members, and supporting other teams like care management with this much richer clinical data. And you’ll be tying in other data to your digital engine, like your NLP-based year-round HEDIS® medical record review, so that you get the broadest possible view of each member and help every member get on the road to a healthier future.