The Healthcare Effectiveness Data and Information Set (HEDIS) is a system maintained by the National Committee for Quality Assurance (NCQA) for evaluating the ability of health plans and providers to deliver high-quality care to patients. HEDIS is used by more than 90 percent of America’s health plans to assess performance on important dimensions of care and service. The 2020 HEDIS season is underway and many insurers and physicians are relying on HEDIS medical record review services to complete their annual Healthcare Effectiveness Data and Information Set (HEDIS) reporting requirements. HEDIS medical record reviews reflect the health care services that plans’ members receive that may have not been captured in claims data.

There are more that 90 HEDIS quality measures grouped into six essential dimensions of care and services:

  • Effectiveness of care
  • Access/availability of care
  • Experience of care
  • Utilization and relative resource use
  • Health plan descriptive information
  • Measures collected using electronic clinical data systems

HEDIS also covers preventive care measures such as breast cancer and colorectal cancer screening, and childhood and adolescent vaccinations. HEDIS also includes medical measures associated with different body systems or disease conditions like asthma, diabetes and heart disease, and relate to key health issues like smoking, cancer, opioid use and pharmacotherapy, as well as use of high risk medications in the elderly. Health plans can monitor compliance for regular follow-ups after hospitalizations and during transitions of care.

Providers should be knowledgeable about HEDIS technical specification changes. NCQA revises its list of HEDIS measures every year, adding new measures and removing those that are longer relevant. The important new measures for the measurement year 2019 and reporting year 2020 are:

  • Follow-Up After High-intensity Care for Substance Use Disorder (FUI)
  • Pharmacotherapy for Opioid Use Disorder (POD)
  • Postpartum Depression Screening and Follow-Up (PDS)
  • Prenatal Depression Screening and Follow-Up (PND)

In addition, there are supplemental data requirement changes, global changes, retired and partial retired measures, and significantly revised measures. Addressing and interpreting these technical specifications and implementing timely and effective action plans to address them is crucial to ensure high performance with HEDIS.

Measures to Improve HEDIS Reporting

Here are some ways health plans can work with providers to improve efficiency of HEDIS reporting:

  • Implement an efficient electronic health record (EHR) system: EHRs capture patient information in digital format. A well-designed EHR system will ensure that forms are prefilled accurately with key patient data for HEDIS measures. This will speed up data capture and eliminate redundancies in HEDIS data reporting. A Health Payer Intelligence article points out that EHR technology can also help reduce non-compliance risks. For instance, EHR alerts can be set up to notify health plans that required HEDIS services have been performed. This will ensure that documentation provides claim data that validates utilization of services or referrals, including exclusion criteria for specific measures.
  • Ensure quality documentation: Proper documentation that tells the patient’s story is a key component when it comes to HEDIS scores. Health plans can work with providers to help them improve EHR documentation. HEDIS coding support can ensure coding to the highest level of specificity. This is important not only for accurate billing, but also to provide quality healthcare. To ensure good medical records, health plans providers should ensure:
    • Accurate and complete documentation
    • Current medication
    • Detailed documentation of all active chronic conditions
    • Documentation of evaluations and findings during every visit
    • Provider’s signature with full name and credentials
    • Manual review of the EHR specific to each HEDIS measure including history, lab results, problem list, specialist consultations, and chart notes. Services not performed should be deleted.
  • Encourage effective sharing of data: Health plans and health systems need to share data effectively. To quote Mary Barton, Vice President of Performance Measurement at the NCQA in a 2018 Health Payer Intelligence article: “The more that health plans share information back with practices, the more practices should be able and willing to share information in turn. That is going to create a virtuous cycle of information sharing that will allow both parties to be more open and perform better on these critical patient care tasks.” Effective data sharing will help payers and providers to earn high performance scores and create positive outcomes for beneficiaries.

The Centers for Medicare and Medicaid (CMS) have made HEDIS a major factor in provider and health plan performance. With the increasing emphasis on value-based models of care, efficient HEDIS reporting is essential for financial success. HEDIS medical record review services are a practical option for health plans to manage the complex task of collecting the appropriate data for HEDIS measures. Such support can help health plans locate additional information about a given HEDIS measure, including history, lab results, problem list, specialist consultations, and chart notes. Beginning with HEDIS 2021, HEDIS measure data will be collected in the new format where the data elements under the measures will be more relational, modular, reusable and meaningfully named and structured (www.ncqa.org/hedis/data-submission/idss-redesign).