Quality Solutions

Quality improvement in healthcare is the ongoing process of measuring clinical performance, identifying gaps in care, and using data-driven interventions to help improve outcomes, reduce costs, and strengthen quality program performance. For health plans, effective quality improvement supports higher HEDIS® performance, Star Ratings, value-based care initiatives, and regulatory compliance. 

The most important quality measures vary by population and program, but many organizations focus on measures tied to HEDIS, Star Ratings, chronic condition management, preventive care, medication adherence and care coordination. Effective quality management for health plans requires visibility into performance trends throughout the year so leaders can focus resources on the measures most likely to help positively influence member outcomes, regulatory performance and value-based care contracts. 

HEDIS (Healthcare Effectiveness Data and Information Set) is one of the healthcare industry’s most widely used set of quality measures, helping health plans and providers evaluate performance, identify care gaps and improve patient outcomes across preventive, chronic and acute care services. More specifically, HEDIS measures define a patient population (the denominator) and the care or outcome that represents high-quality performance for that population (the numerator). 

Strong HEDIS performance also affects Star Ratings, quality incentive payments, member satisfaction and competitive positioning, making year-round quality measurement increasingly important for health plans.

Successful HEDIS gap closure programs rely on more than retrospective reporting. Leading organizations use year-round quality measurement, clinical data, provider engagement and targeted outreach to identify and address gaps before reporting deadlines. Connecting quality insights with day-to-day activities can help care teams identify and address the opportunities most likely to support improved quality performance.

Quality measurement helps health plans and provider organizations understand performance across preventive, chronic and acute care measures that influence Medicare Star Ratings, quality scores, financial incentives and value-based care outcomes. Because quality performance is increasingly tied to reimbursement and contract performance, organizations need timely insights to identify care gaps, prioritize interventions and monitor progress through the measurement year. 

Digital quality measurement uses standardized electronic data and measure definitions to evaluate and report healthcare quality performance, replacing many manual and retrospective processes. This helps organizations identify care gaps earlier, support year-round quality improvement and reduce administrative burden. In fact, NCQA has announced plans to phase out hybrid HEDIS reporting by 2029 and move to digital-first measurement by 2030. To succeed, organizations will likely need streamlined, standardized data foundations that support interoperable reporting and more timely insights. 

Organizations should establish a centralized, trusted source of quality data by integrating claims, clinical, EMR and supplemental data into a standardized FHIR-based framework. Strong data governance, validation process and interoperability standards help ensure that quality measures are calculated consistently and accurately across programs, creating a scalable foundation for digital quality reporting and performance improvement. 

Electronic clinical data systems management helps organizations bring together data from electronic health records, claims, labs, pharmacy systems and other clinical sources to support quality measurement and reporting. As healthcare organizations prepare for digital quality measures and evolving reporting requirements, integrated clinical data can help improve visibility into performance, support care-gap identification and enable more timely quality improvement activities. 

Optum Value Connect is positioned to help organizations not only measure quality performance but also connect insights to meaningful actions. By connecting measurement, analytics and care-gap workflows, organizations can identify opportunities earlier, prioritize interventions and support continuous quality improvement throughout the year.