What is HEDIS
The Healthcare Effectiveness Data and Information Set, known as HEDIS, is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance, or NCQA. Health plans use HEDIS to measure performance on important dimensions of care and service, enabling apples-to-apples comparisons across plans.
The Role of NCQA
NCQA develops and updates HEDIS measure specifications annually, incorporating input from clinical experts, health plans, and purchasers. NCQA also accredits health plans and certifies HEDIS auditors who validate that health plans report data accurately and in accordance with technical specifications.
Measure Domains
HEDIS measures span multiple domains, including effectiveness of care, access and availability of care, experience of care, utilization, and health plan descriptive information. Examples include measures for cancer screening rates, diabetes care management, immunization rates, and follow-up after hospitalization for mental illness.
Data Collection Methods
HEDIS data can be collected through several methods. The administrative method uses claims and encounter data alone. The hybrid method supplements administrative data with medical record review for a sample of members when administrative data is insufficient to fully capture measure compliance. Survey methods, such as the CAHPS survey, capture member-reported experience data directly from patients.
Star Ratings and Health Plan Reporting
HEDIS results feed into Medicare Advantage Star Ratings, which CMS uses to evaluate plan quality and determine bonus payments. Higher star ratings can significantly affect a plan's revenue and marketability, giving health plans strong incentive to invest in quality improvement initiatives and accurate HEDIS data collection.
HIM Involvement
HIM professionals often support HEDIS hybrid data collection by facilitating medical record retrieval, ensuring appropriate release of information procedures are followed, and validating that abstracted data accurately reflects documented care. Understanding HEDIS methodology helps HIM staff contribute effectively to organizational quality improvement and accreditation efforts.