The new face of quality reporting

Over the past several years, interoperability has increasingly become a priority in the healthcare industry — and it’s easy to see why. When health information systems exchange data quickly and efficiently, providers can see a complete picture of each patient’s health. This allows them to make fully informed decisions on care and helps to achieve better patient outcomes.

The drive toward interoperability will impact the quality of healthcare metrics and reporting. If your organization is not currently using an interoperable solution for quality reporting, it’s time to start.

Given the potential benefits of interoperability, governmental agencies and bodies that oversee healthcare have endorsed it in various ways. Guidelines and legislation such as the 21st Century Cures Act, the Centers for Medicare & Medicaid Service’s (CMS) Interoperability and Patient Access Final Rule and the Medicare Access and CHIP Reauthorization Act have all included mandates for interoperability.

The National Committee for Quality Assurance (NCQA) has signaled its support for digital, interoperable solutions to report on quality metrics. With its Healthcare Effectiveness Data and Information Set (HEDIS^®), NCQA provides quality reporting for health plans throughout the country. This reporting provides consumers with valuable third-party evaluations on the quality of care they can expect.

More than 235 million people are enrolled in health plans that participate in the HEDIS program. Additionally, CMS Star Ratings also leverage HEDIS-reported rates for contract performance to help consumers in decision-making for Medicare enrollment.

Electronic Clinical Data Systems (ECDS) are data networks that bring together information regarding a patient’s medical history as well as their care experiences. In 2015, NCQA introduced ECDS to make quality reporting more efficient and standardized. Artificial intelligence and machine learning tools can search through such data to efficiently extract clinical quality information for reporting purposes. ECDS include data points such as:

• Electronic health records (EHR) and personal health records: Patient records that are only available to authorized users
• Health information exchanges: Systems from public health agencies, regional health agencies, and immunization data
• Case management systems: Member information databases that include care planning, care coordination, and member assessment
• Additional data from administrative claim processing systems, member management files and more. This means that the current administrative data used for traditional measures can continue to be used for ECDS measures.

For organizations that report quality, there is an urgency regarding ECDS and what it will mean to the traditional reporting measure within HEDIS. While NCQA currently allows a hybrid model for reporting — combining traditional administrative data and data sourced from manual medical record review — that hybrid model is being phased out.

NCQA has announced a phased approach to transition from traditional measure to the ECDS formatted measure for HEDIS. This phased approach allows organizations to compare their traditional measure results against the ECDS version of the same for a set time.

Furthermore, NCQA has set a Measurement Year (MY) timeline for the retirement of hybrid reporting, which equates to the full retirement of the traditional measure. This will result in reporting of only the ECDS version of the measure by MY2029.

This shift toward ECDS and digital reporting can have significant repercussions for healthcare organizations. It may require organizations to invest in new technology to support digital reporting. It may also necessitate a transition to prospective strategies.

Transitioning now will help your organization to maintain compliance, improve operational efficiency, achieve better quality outcomes and remain aligned with evolving industry standards.

New technology, new strategies and new processes may sound daunting and overwhelming, but an experienced technology partner can guide you. Optum offers comprehensive support that many organizations have relied upon while moving to digital quality reporting. Solutions we provide include:

• Digital data orchestration
• Seamless digital engine
• Prospective supplemental data collection
• Comprehensive digital solutions

A digital, interoperable future doesn’t have to be intimidating. With the right partner by your side, you can achieve a successful digital transformation. As a result, you can experience better care delivery to patients and enhanced operational efficiency with fewer manual processes.

Each healthcare organization is different, but the following tips can help you as you consider the transition to digital quality and interoperability:

Take a digital-first approach moving forward

The future is digital so embrace that mindset. Utilize robust digital connections and continuity of care documents (CCD) to enhance digital transformation and interoperability. The more you embrace digital, the more opportunities you may have to expand coverage, improve quality performance and enhance data abstraction.

Adopt prospective supplemental data collection

If you currently rely on retrospective strategies, consider moving toward a more forward-looking approach with prospective strategies. Leverage AI/NLP-enabled solutions year-round for chart abstraction and pseudo-claim generation for engine ingestion.

Get an advanced CQL engine with FHIR capabilities

Assess your current technology to determine if it’s really setting you up for interoperability. An advanced CQL engine will support FHIR/HL7 capabilities. These are the standardized specifications for the secure exchange of digital healthcare data.

Analyze the impact of the hybrid model

You will want to understand exactly how the switch from traditional reporting to digital reporting will impact your organization. With analytics, you will be able to evaluate performance and identify any problems now before NCQA sunsets the hybrid model.