How to Improve Your HEDIS Reporting

What is HEDIS?

Healthcare Effectiveness Data and Information Set (HEDIS) is a comprehensive set of standardized performance measures designed to accurately measure and compare the healthcare services provided by managed care organizations. The HEDIS scores are based on evidence-based criteria that looks at both preventive and clinical care, such as screenings, immunizations, access to care, diabetes management, patient experience and more. HEDIS reporting informs healthcare providers about their performance in order to help them improve and ensure they're providing quality care for their patients. Additionally, employers and government agencies use the data generated from HEDIS metrics to assess the effectiveness of healthcare plans offered within their networks. By measuring how well healthcare plans perform against standards established by leading health experts, consumers can make informed decisions when selecting a plan.

HEDIS measurement was established in 1991 and has since become one of the most widely used quality measures by both public and private insurers, with more than 90 percent of all commercial health plans using HEDIS reporting requirements and metrics to report on their performance. HEDIS quality reporting provides comprehensive measures across domains such as access and availability, preventive services utilization, clinical care, patient experience and cost. The result is a powerful system that can help ensure better consumer outcomes while providing data-driven insights into an organization’s effectiveness. Additionally, HEDIS metrics are regularly benchmarked against national averages, providing organizations with valuable comparative data to assess how they are performing against peers. With the continued popularity of quality reporting in HEDIS, organizations can use the system to help identify areas of improvement and ensure that they are delivering high-quality care to their consumers.  

Why is HEDIS So Important?

HEDIS metrics are the gold standard for measuring and reporting healthcare quality. It provides organizations with an objective, evidence-based set of measurements to assess performance against accepted standards of care. HEDIS reporting uses a standardized set of measures to evaluate clinical and service quality across healthcare providers and health plans, allowing consumers and employers to compare apples-to-apples when selecting their health plan or provider. The data collected from HEDIS measurements are used to identify best practices and target areas for improvement. Organizations that prioritize quality can use the data to track performance against national standards, set goals, and measure their progress over time. HEDIS quality reporting plays a critical role in improving the overall quality of healthcare by providing objective measurements which can be used to benchmark performance, compare providers, and drive improvement initiatives. As such, it is an invaluable tool for organizations seeking to achieve higher levels of clinical excellence and better health outcomes for their patients.

HEDIS reporting stands apart from other healthcare measurement systems due to its comprehensive approach. HEDIS metrics cover a variety of aspects related to healthcare delivery including access, prevention, treatment effectiveness and patient satisfaction. As such, HEDIS measurement plays an essential role in improving public health by providing accurate measures of individual provider and plan performance that are used to drive improvements in the healthcare system as a whole. By utilizing this data-driven approach, healthcare organizations can ensure they are working towards the common goal of improving patient care and outcomes.

How to Improve HEDIS Reporting and Stay Ahead of the Curve

The best place to start is by looking at the multiple sources of data available to you. That's because data for HEDIS is multi-faceted and depends on more than one department to collaborate and make HEDIS reporting successful. HEDIS measurement is composed of two types of data: billing data, which comes from claims submitted by the billing department; and clinical data which can be either structured or variable, depending on the EHR. The data that makes it to the health plans is STRUCTURED data. The only way UNSTRUCTURED data is used is at the end of the year when manual retrospective chart reviews occur to attempt to find relevant information deeply embedded in progress notes.

Furthermore, some of the money received by the health plans for Quality Improvement (QI) initiatives can trickle down to your organization. Keep in mind that the health plans base metrics on patients assigned to YOU by THEM. Even if you don't see the patient in the calendar year, if they are assigned to you, that patient counts in the denominator. This makes HEDIS reporting (especially QI metrics) extremely challenging.

If your organization collects patient demographic data properly in PM systems, you can run reports specifically looking at unique insurance groups. For example, those insurances that provide HEDIS quality incentives. If this data isn’t being collected or kept up to date properly then your organization will be more reactive than proactive.

Ultimately, the data is all intertwined. Which is what makes establishing a program so difficult. Billing data (ICD and CPT codes) are usually first entered by the medical providers at the time of the medical encounter. Depending on your EHR system, this can either be a breeze or an absolute chore for them. Some institutions have hired back-end coders to help providers code their visits correctly, but not all clinics have the funds to spare. An alternate solution is to configure your EHR clinical data workflows to maximize HEDIS data creation and submission. Work with your EHR to see if triggers can be built in the background, so that when certain items are clicked or picked the appropriate CPT or ICD code gets automatically generated in the background.

HEDIS in healthcare should be a collaborative effort between billing, QI, IT, and Operations. There should be plenty of information being provided to the medical providers of HEDIS metrics and make sure to involve them in addressing gaps in care. Always make sure you are getting your missed opportunities list at least monthly, and you have a process established for getting in touch with your assigned patients and getting them in to receive their care.

If you’re not in the business of hiring tons of coders/nurses to perform manual chart reviews to look for unstructured data, there are alternatives. ForeSee Medical offers a clinical NLP software solution called ForeSee ESP. This tool identifies HCC diseases and gives you coding suggestions at the point of care for those diseases based on NLP findings and machine learning. To give you an idea of just how valuable NLP-based software can be, internal studies have shown a noticeable increase in coding speed and accuracy when compared to human intervention alone.

by Jorge Gaspar, MD, MBA, Clinical Informaticist