What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It is the most widely used set of performance measures in the managed care industry. HEDIS was developed, and is maintained, by the National Committee for Quality Assurance (NCQA).

HEDIS has become more than a set of performance measures; it is part of an integrated system to establish accountability in managed care.

HEDIS reporting is mandated by NCQA for compliance and accreditation. It is important that health care providers and their staff members become familiar with HEDIS to understand what health plans are required to report to help improve the quality of care provided to patients.

HEDIS is a multipurpose tool originally designed to address private employers’ needs and has been adopted by public purchasers, regulators and consumers. Quality improvement activities, health management systems and provider profiling efforts all have used HEDIS as a core measurement. HEDIS is a part of purchaser requests, an element of NCQA accreditation and the basis of a consumer report card for managed care. HEDIS data are collected through a combination of surveys, provider medical chart reviews and insurance claims/encounter data.

To ensure the validity of HEDIS results, all data are rigorously audited by certified auditors using a process designed by NCQA. Consumers benefit from HEDIS data through the State of Health Care Quality report, a comprehensive look at the performance of the nation’s health care system. HEDIS data also are the centerpiece of most health plan “report cards” that appear in national magazines and local newspapers.

Data collection begins with queries of the claims/encounter data. If the encounter data do not contain evidence of the required visit, test or prescription during the specified time frame, then the health plan staff must review the member’s medical record to determine if care was provided. For some measures, data are collected only from claims/encounters, and medical record reviewers do no validation of the care. 

Health care providers can improve HEDIS scores significantly by submitting accurately coded claims/encounters data for each service rendered, and by keeping accurate, legible and complete medical records for their patients. Chart documentation must reflect services billed. Claims/encounters data are the most efficient method to report HEDIS, which helps ensure medical chart reviews and reviewer visits to providers are kept to a minimum.

HEDIS 2011 contains 75 measures across eight domains of care, which are as follows:

Effectiveness of care, i.e., immunizations, cancer screenings, diabetes care, weight assessment, appropriate treatment for acute and chronic illnesses, etc.

Access/availability of care

Satisfaction with experience of care (member satisfaction surveys)

Health plan stability

Use of services, i.e., frequency of selected procedures, well-child visits

Cost of care

Informed health care choices

Health plan descriptive information

Actions health care providers can take: 

Submit appropriately coded claims/encounters data for each service rendered in a timely manner

Submit encounters electronically and work reject reports completely 

Provide lab data as requested

Keep accurate, legible and complete medical records for their patients

Help ensure HEDIS-related preventive screenings, tests and vaccines are performed timely and in an appropriate manner

Allow access to or provide records as requested (online capability)

Also see ‘CAHPS‘ and ‘HOS‘