{"id":20686,"date":"2019-01-16T09:00:09","date_gmt":"2019-01-16T14:00:09","guid":{"rendered":"http:\/\/www.carecloud.com\/continuum\/?p=20686"},"modified":"2025-10-21T17:35:39","modified_gmt":"2025-10-21T17:35:39","slug":"healthcare-effectiveness-data-and-information-set","status":"publish","type":"post","link":"https:\/\/carecloud.com\/continuum\/healthcare-effectiveness-data-and-information-set\/","title":{"rendered":"What is HEDIS? Goals, Benefits, Improvements"},"content":{"rendered":"<h2><b><span data-contrast=\"none\">HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)<\/span><\/b><\/h2>\n<h2><span data-contrast=\"none\">INTRODUCTION<\/span><\/h2>\n<p><span data-contrast=\"none\">Most health plans measure their quality and performance with the Healthcare Effectiveness Data and Information Set (HEDIS), one of the most widely used healthcare performance measurement tools. HEDIS provides consumers with measurement standards to compare health plan performance to help select their optimal healthcare coverage.<\/span><\/p>\n<p><span data-contrast=\"none\">In addition to guiding client choices, HEDIS serves as a benchmark for carriers to assess their care delivery and align it with industry standards. By figuring out gaps in care and highlighting possibilities for improvement, HEDIS contributes to improved patient experiences, reduced expenses, and a better healthcare structures. With the ever-growing attention on fee-based care, understanding and optimizing <a href=\"https:\/\/www.talkehr.com\/post\/what-is-hedis-in-healthcare\">HEDIS<\/a> measures is essential for attaining better health outcomes and fostering trust among healthcare workers and patients.<\/span><\/p>\n<h2><b><span data-contrast=\"none\">DEFINITION &amp; OBJECTIVES<\/span><\/b><\/h2>\n<p><span data-contrast=\"none\">HEDIS consists of quality measures created by the National Committee for Quality Assurance (NCQA). This data is tracked yearly to measure health plan performance and provides valuable information about the patient populations served. <\/span><span data-contrast=\"none\">The measures <\/span><span data-contrast=\"none\">track the care received, not just what was ordered. The data collected serves various purposes which include:<\/span><\/p>\n<ul>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"1\" data-aria-level=\"1\"><span data-contrast=\"none\">Monitor the population health<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"1\" data-aria-level=\"1\"><span data-contrast=\"none\">Evaluating treatment outcomes and procedures<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"1\" data-aria-level=\"1\"><span data-contrast=\"none\">Providing\u00a0an external performance measurement<\/span><\/li>\n<\/ul>\n<p><span data-contrast=\"none\">The number of HEDIS measures changes yearly as new measures are added and outdated\u00a0measures are retired. The measures encompass various aspects of healthcare, including preventative care, such as screenings and immunizations, management of physical and <a href=\"https:\/\/www.talkehr.com\/post\/features-for-ehr-systems-in-mental-health-practices\">mental health<\/a> conditions, access and availability of care, patient experience, healthcare utilization, and resource use.<\/span><\/p>\n<h2><b><span data-contrast=\"none\">HEDIS MY 2024 Updates:<\/span><\/b><\/h2>\n<h3><b><span data-contrast=\"none\">NCQA Confirmed Updates for the HEDIS Measurement Year (MY) 2024<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">The National Committee for Quality Assurance (NCQA) recently confirmed several proposed changes for the HEDIS measurement Year (MY) 2024, following public comment earlier this year. These updates, described in the HEDIS Measurement Year 2024 Part 2: Technical Specifications for Health Systems released in August, bring changes to three key areas that affect health systems in various ways.<\/span><\/p>\n<h3><b><span data-contrast=\"none\">Consolidation and Simplification of\u00a0Measures<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">N<\/span><span data-contrast=\"auto\">CQA&#8217;s focus on electronic clinical data access has streamlined many features. Follow-up care for children with ADHD medication (ADD) and antipsychotics like Metabolic Monitoring for Children and Adolescents (APM) will transition to the ECDS standard, while eye exams for diabetic patients (EED) will remain hybrid for MY 2024. Four options, including Ambulatory Care (AMB) and Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS), will be eliminated.<\/span><\/p>\n<h3><b><span data-contrast=\"none\">Changes in Reporting Guidelines and Value Sets<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">The general guidelines have been revised, and the &#8220;Required Exclusions&#8221; description of resources now includes hospice and bereavement guidelines. NCQA has also simplified the value units, abolished the pension-based value units, and consolidated others. Significantly, ICD-9 diagnosis and procedure <a href=\"https:\/\/www.carecloud.com\/icd-10-codes\/\">codes <\/a>will be removed from the value sets for MY 2025.\u00a0<\/span><span data-contrast=\"auto\">Additionally, clarity requirements have been revised, standards simplified, and specific research prioritized.<\/span><\/p>\n<h3><b><span data-contrast=\"none\">Inclusion and Diversity Policy<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">NCQA is expanding gender-specific measures to reach out transgender members. The breast cancer screening (BCS-E) and cervical cancer screening (CCS, CCS-E) pathways were expanded to include members with other gender identities than man or women and additional exclusions were introduced. Additionally, new methods of reporting racial and ethnic stratification (RES) have been added to promote health equity.<\/span><\/p>\n<h3><b><span data-contrast=\"none\">Consistency and Specificity in Measurement<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">NCQA continues efforts to ensure consistency and specificity in measures and changes to terminology and measurement systems. Notable changes include the use of &#8220;days&#8221; instead of &#8220;months&#8221; or &#8220;years&#8221; in the measurement language and the addition of detailed requirements to the specification. Also, new accounting information has been introduced, while requirements for certain elements revised for consistency and clarity.<\/span><\/p>\n<p><span data-contrast=\"none\">This update underscores NCQA&#8217;s commitment to advancing healthcare quality measurement and ensuring that it is aligned with industry standards and evolving priorities. As health systems explore and understand these changes, it is important to remain informed and adapt strategies to meet HEDIS reporting requirements better and improve overall quality of care.<\/span><\/p>\n<h2><b><span data-contrast=\"none\">BENEFITS OF HEDIS<\/span><\/b><\/h2>\n<p><span data-contrast=\"none\">The scores on measures can assist healthcare plans in understanding the quality of care provided to their members in the most common chronic and acute illness <a href=\"https:\/\/www.carecloud.com\/continuum\/population-health-tools\/\">populations<\/a>. Other benefits of HEDIS include:<\/span><\/p>\n<ul>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"4\" data-aria-level=\"1\"><span data-contrast=\"none\">Identifying gaps in healthcare network performance and the provision of care<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"4\" data-aria-level=\"1\"><span data-contrast=\"none\">Improving patient outcomes and reducing costs through preventative care<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"4\" data-aria-level=\"1\"><span data-contrast=\"none\">Providing beneficial data on public health issues affecting large patient populations, such as cancer, heart disease, smoking, asthma, and diabetes<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"4\" data-aria-level=\"1\"><span data-contrast=\"none\">Monitoring the success of quality improvement initiatives<\/span><\/li>\n<\/ul>\n<h3><b><span data-contrast=\"none\">HEDIS DATA COLLECTION<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">HEDIS data is collected from three sources, <\/span><span data-contrast=\"auto\">primarily derived from billing claims, and analyzed to reflect the clinical care provided to plan members.<\/span><\/p>\n<p><span data-contrast=\"none\">Although billing claims are the major source for data collection, specific measures may allow plans to survey members or access medical records for data that are not readily available in claims. The goal is to encourage providers to submit claims with accurate <a href=\"https:\/\/www.carecloud.com\/medical-coding-services\/\">coding<\/a> that captures all the necessary data by HEDIS through administrative efforts to decrease or eliminate the need for a hybrid review. The three sources for data collection include:<\/span><\/p>\n<ul>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"8\" data-aria-level=\"1\"><b><span data-contrast=\"none\">Administrative <\/span><\/b><span data-contrast=\"none\">\u2013 Measures claims for hospitalizations, medical office visits, procedures, and pharmacy data<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"8\" data-aria-level=\"1\"><b><span data-contrast=\"none\">Hybrid<\/span><\/b><span data-contrast=\"none\"> \u2013 If additional data is necessary to provide a better overall picture of the care and services provided, then administrative data obtained from claims is combined with the member&#8217;s medical record information<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"8\" data-aria-level=\"1\"><b><span data-contrast=\"none\">Patient Survey<\/span><\/b><span data-contrast=\"none\">\u2014<\/span><span data-contrast=\"none\">This survey focuses on the patient&#8217;s experience with the provider. Patient provides data through a survey conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS), which gains input about the patient&#8217;s satisfaction with their healthcare delivery.<\/span><\/li>\n<\/ul>\n<h3><b><span data-contrast=\"none\">HEDIS AND HEALTHCARE PROVIDERS<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">To remain competitive, <\/span><span data-contrast=\"none\">achieving higher HEDIS scores<\/span><span data-contrast=\"none\"> helps encourage more consumers to choose a specific health plan. HEDIS measures have certain documentation requirements and specific standards contributing to the score. These scores are improved by providing timely and appropriate patient care with clear, accurate documentation in the claim codes of all the healthcare services offered.<\/span><\/p>\n<p><span data-contrast=\"none\">Most providers choose healthcare to serve their patients, not specific standards. However, a lack of awareness and not instituting efforts to meet quality and preventative care requirements can negatively impact HEDIS scores. As HEDIS rates increase, the provider may earn additional revenue through <\/span><span data-contrast=\"none\">pay-for-performance models<\/span><span data-contrast=\"none\">.<\/span><\/p>\n<h3><b><span data-contrast=\"none\">IMPROVING HEDIS SCORES<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">Provider can improve their HEDIS score by:<\/span><\/p>\n<ul>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Understanding measurement requirements.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Focusing on preventative screening.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Responding timely to requests for medical records for review.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Adhering to specified timelines.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Ensuring claims are coded accurately.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Identify care gaps of patients before their arrival to address them during the visit.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Providing clear discharge instructions and scheduling the next appointment before the patient leaves to rule out non-compliance.<\/span><\/li>\n<li data-leveltext=\"?\" data-font=\"Symbol\" data-listid=\"2\" data-list-defn-props=\"{&quot;335552541&quot;:1,&quot;335559685&quot;:720,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;?&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" aria-setsize=\"-1\" data-aria-posinset=\"11\" data-aria-level=\"1\"><span data-contrast=\"none\">Educating and collaborating with the patient on goals for their care.<\/span><\/li>\n<\/ul>\n<h3><b><span data-contrast=\"none\">COMPARING QUALITY<\/span><\/b><\/h3>\n<p><span data-contrast=\"none\">As healthcare continues to move toward more <\/span><a href=\"https:\/\/www.carecloud.com\/continuum\/value-based-reimbursement\/\"><span data-contrast=\"none\">value-based care<\/span><\/a><span data-contrast=\"none\">, the focus remains on the quality of healthcare delivered and working toward better patient outcomes. HEDIS allows consumers to compare health plans to ensure that the one they choose meets their healthcare needs.<\/span><\/p>\n<h4><b><span data-contrast=\"auto\">Conclusion<\/span><\/b><\/h4>\n<p><span data-contrast=\"auto\">HEDIS plays a pivotal role in shaping the future of healthcare by creating measurable requirements for quality care and performance. For healthcare carriers,\u00a0it\u2019s a tool to recognize care gaps, strive for improvements and foster trust with patients. As the world shifts toward value-based care, using HEDIS updates and insights can provide better results for patients and doctors alike. By prioritizing quality and transparency, the healthcare industry takes a step toward delivering care that truly makes a difference.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) INTRODUCTION Most health plans measure their quality and performance with the Healthcare Effectiveness Data and Information Set (HEDIS), one of the most widely used healthcare performance measurement tools. HEDIS provides consumers with measurement standards to compare health plan performance to help select their optimal healthcare coverage. In addition [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":43385,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[389],"tags":[2,42],"class_list":["post-20686","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-resources","tag-growth","tag-leadership"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>What is HEDIS? 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