Improving HEDIS Data Quality in a Digital World
July 23, 2025 · Becky Kolinski
As the industry advances toward digital quality measurement—driven by widespread EHR adoption and new interoperable data standards, such as FHIR®-based APIs—health plans and care delivery organizations are relying on electronic clinical data to manage, measure and improve health outcomes.
The Centers for Medicare & Medicaid Services has outlined a strategic plan for the future of digital quality, with the goal of enabling automated, interoperable quality measurement in real time. NCQA is closely aligned with this vision, and is executing on a roadmap to make HEDIS® fully digital by 2030.
“Data quality is foundational to improving health care quality,” says Ben Hanley, NCQA’s Director of Product Management. “As an industry, we’ve invested a lot of resources in building pipelines for transmission of electronic clinical data, but we’re still evaluating the quality of the data flowing through the pipes—and that can have significant impact on downstream processes, like HEDIS reporting.”
Why HEDIS Data Quality Matters
HEDIS is one of health care’s most widely used performance improvement tools. More than 235 million people are enrolled in plans that report HEDIS results. HEDIS measures are used in a variety of functions, including care management, population health, analytics and value-based incentive payments.
HEDIS reporting aggregates data from multiple sources, and involves different types of organizations: health plans, providers, HIEs, EHRs, health IT vendors, HEDIS vendors. All invest time and resources to identify and resolve HEDIS data quality issues.
Given the complexity of the process and the volume of data, organizations must be vigilant to ensure that data are accurate, complete and usable. “No single organization holds the key to improving data quality,” says Hanley. “Everyone has a stake in the process, and everyone needs to contribute.”
HEDIS Data Quality Assessment: Where We Are Today
The HEDIS Compliance Audit™ evaluates whether an organization has the appropriate controls and capabilities to process clinical, member and provider data to produce accurate, reliable and complete HEDIS reporting.
Primary source verification (PSV) helps verify that data used in HEDIS calculations are accurate by comparing clinical data elements in data files—lab values, procedure codes, diagnosis codes—with their original source, such as EHRs.
Clinical data validation is complicated because of the “many-to-many” problem—many health plans contracting with many practitioners and health delivery systems That means many organizations need to perform PSV on the same data sources.
NCQA established the Data Aggregator Validation program in 2021 to help reduce the burden of PSV. Data vendors, such as HIEs, can validate their clinical data streams through the program so individual health plans don’t need to conduct PSV on those data streams during their HEDIS audit.
“Data quality assessment and improvement is ongoing. The work is never done,” says Hanley. “That’s why we continue to evolve our data quality assessment tools and processes: to respond to changes in the industry and in customer needs.”
Exploring the Potential for Automation
Evaluating the quality of clinical data through PSV requires manual review, which is time consuming and covers only a small percentage of the data. As health plans incorporate more clinical data into their HEDIS workstreams, they need a more efficient way to assess data quality.
NCQA is investing in both new and existing products that assess and drive improvement in data quality while reducing the burden of manual data verification. Our primary focus is the use of automated data quality assessments to build trust in the data exchanged through interoperable formats and inform the HEDIS audit process.
“Automated assessments are more efficient, and could allow organizations to analyze more data, recognize patterns and identify issues faster,” says Hanley. “These benefits would extend beyond annual HEDIS reporting because the same data is also used for value-based contracting, analytics, population health programs and other purposes.”
The rigor and standardization of HEDIS reporting makes it a valuable tool for performance measurement and benchmarking. Our goal is to streamline processes and workflows while maintaining the level of rigor our customers expect from NCQA.
Learn More
- Find out how NCQA advocated for accelerating the transition to digital quality measurement in response to the HHS Health Technology Ecosystem RFI.
- Explore more resources in NCQA’s Digital Quality Hub.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
HL7® and FHIR® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.
