Healthcare providers must navigate evolving regulatory standards, including the Healthcare Effectiveness Data and Information Set (HEDIS), to ensure high-quality care, improved patient outcomes, and optimal reimbursement.
For 2025, HEDIS compliance focuses heavily on accurate reporting, addressing care gaps, and enhancing health equity. Achieving compliance requires advanced technology to automate data collection, patient engagement strategies to ensure adherence to care plans, and optimized workflows to meet reporting deadlines and standards.
In this blog, we’ll explore best practices for meeting HEDIS measures, highlight case studies that showcase real-world successes, and introduce how DrKumo’s advanced solutions empower providers to meet compliance goals while delivering exceptional care.
HEDIS in 2025: Key Updates and Challenges
The Healthcare Effectiveness Data and Information Set (HEDIS®) continues to evolve to reflect current clinical practices and improve care quality. For Measurement Year 2025, the National Committee for Quality Assurance (NCQA) announced several changes, including new measures, modifications to existing ones, and the transition to Electronic Clinical Data Systems (ECDS) for reporting. Here are the highlights:
Documented Assessment After Mammogram
“The percentage of episodes for members 40–74 years of age with mammograms documented in the form of a BI-RADS assessment within 14 days of the mammogram.”
This measure focuses on timely documentation of mammogram results using the Breast Imaging Reporting and Data System (BI-RADS), which standardizes reporting into six categories for further management. By ensuring quick follow-up, providers can improve breast cancer detection and care continuity.
Follow-Up After Abnormal Breast Cancer Assessment
“The percentage of episodes for members 40–74 years of age with inconclusive or high-risk BI-RADS assessments that received appropriate follow-up within 90 days of the assessment.”
This measure addresses the critical need for timely follow-ups after abnormal mammograms, as delays can worsen outcomes. A publication in BMJ Open discussed various factors contributing to non-attendance at breast cancer screenings and treatments. The study highlighted that non-attendance is influenced by multiple factors, including socio-economic status and cultural barriers, which are prevalent in underserved communities.
Blood Pressure Control for Patients With Hypertension
“The percentage of members 18–85 years of age who had a diagnosis of hypertension and whose most recent blood pressure was <140/90 mm Hg during the measurement period.”
This measure replaces the previous Controlling High Blood Pressure (CBP) measure. It introduces key changes, such as using ECDS reporting and a pharmacy data method to improve accuracy and inclusivity. Stratification by race and ethnicity ensures a focus on health equity in hypertension management.
Transition to ECDS Reporting
NCQA continues to transition HEDIS measures to Electronic Clinical Data Systems (ECDS) reporting. Measures like Childhood Immunization Status and Cervical Cancer Screening will now rely exclusively on ECDS.
ECDS reporting enhances data accuracy, reduces administrative burdens, and promotes interoperability across healthcare systems.
Case Study: Leveraging EHRs for Better Performance
The study Performance Measures Using Electronic Health Records: Five Case Studies highlights how integrating Electronic Health Records (EHRs) can significantly improve compliance with Healthcare Effectiveness Data and Information Set (HEDIS) standards. By leveraging EHR systems, healthcare organizations streamlined data collection and enhanced the accuracy of reporting for key HEDIS measures, such as blood pressure control and diabetes management.
For example, automating the collection of blood pressure readings allowed organizations to reduce manual labor costs and improve compliance with the Controlling High Blood Pressure metric. Additionally, composite measures for diabetes care, which combined multiple HEDIS indicators, encouraged comprehensive patient management and better health outcomes.
The case studies emphasize EHRs’ ability to address HEDIS-specific challenges, such as standardizing data across populations and ensuring timely follow-up for preventive care. Tools like natural language processing further enhanced the ability to extract valuable insights from unstructured clinical notes, improving adherence to measures like smoking-cessation counseling.
While initial barriers included staff resistance and data validation issues, these were overcome with targeted workflows and system refinements. Ultimately, the findings demonstrate that EHR-driven strategies not only optimize HEDIS compliance but also foster more efficient and effective care delivery.
Why HEDIS Compliance Matters in 2025
- STAR Ratings and Reimbursement
High HEDIS scores directly impact Medicare Advantage STAR ratings, influencing financial incentives and marketability. - Improved Patient Outcomes
Compliance with preventive care and chronic disease measures enhances patient satisfaction and reduces hospitalizations. - Operational Efficiency
Technology-driven solutions streamline workflows, reduce administrative burdens, and optimize resource allocation.
Contact DrKumo to learn how our digital health solutions empower healthcare providers and enhance patient outcomes. Let’s transform healthcare to
