Introduction to HEDIS & Quality
Healthcare Effectiveness Data and Information Set (HEDIS) is a set of criteria for evaluating if patients are receiving preventative care checkups relevant to them based on factors such as age and gender.
“HEDIS”, sometimes called “Quality“ is an uncommon lexicon but it plays an extremely important role in how patients are cared for. It has also been groundbreaking in changing how the US healthcare system operates but for the average insured healthcare member it has gone relatively under the radar.
HEDIS data extraction is a regular part of Tenasol’s business in helping health plans collect evidence for reporting to Centers for Medicare and Medicaid Services (CMS) to demonstrate that they are taking preventative care action for their patients.
HEDIS was created by National Committee for Quality Assurance (NCQA), started in 1991, and has expanded presence in 1991, 1997, 2002, and then in 2010 as a part of the Affordable Care Act.
HEDIS is Important to Health Plans
HEDIS clinical outcomes are one of the 5 major factors that go into a health plans “star rating“ which determines how much CMS funds the plan on a per-member basis. If the plan has a high enough star rating due to the factors shown relative to other plans, they receive extra funding to help grow their plan and attract more members from CMS.
Additionally, there is a significant amount of reputation that comes with getting a high star rating, which will also attract more members to a plan as that plan is considered more desirable.
A health plans funding is a function of the number of members it has coupled with 5 factors, which include HEDIS outcome ratios.
HEDIS is Important to Patients/Members
Before HEDIS, federal healthcare programs paid out money only via risk adjustment - that is patients were only compensated for the conditions they already had. But it is just as important to get preventative care and catch critical conditions early so they may be treated quickly.
To solve this, the HEDIS “measures“ aim to evaluate patients for dozens of different checkups they need, and make sure they are getting them on at least (usually) an annual basis.
As a result, plans will work extra hard to reward patients for coming into the hospital for these routine checkups. These checkups can far more likely result in a patient discovering a severe condition much earlier so it may be treated before it becomes a chronic illness.
What is meant by a “Checkup“ in HEDIS?
Example: Cervical Cancer Screening (CCS) is a measure that makes sure that women between the ages of 21 and 64 are getting screened for cervical cancer.
170 patients are Excluded: These patients are either:
Men
Women outside of the required age range of 21-64, and/or
Women within the age range specified, but with medical evidence demonstrating no need for a test - these include being in hospice, having previously had the cervix removed, or already having cervical cancer.
150 patients are in the HEDIS Denominator: These patients are:
Not excluded
Are eligible for testing, regardless if they have already been or not.
100 patients are in the HEDIS Numerator: These patients are:
Not excluded
Have received a relevant test
NOTE: Previously NCQA permitted patients to be optionally excluded, however this was recently retied and no longer relevant.
NOTE: each year, NCQA releases new HEDIS measure ratio definitions, one method of which is via the use of HL7 CQL.
What Constitutes Checkup Evidence in HEDIS?
Presently, HL7v2 ADT messages, rendered medical charts (PDF/TIFF), and claims codes are commonly used for evidence of patient information. While electronic data (HL7v3 C-CDA, HL7v4 FHIR) is permitted in a limited capacity today, it is likely that it will also be used significantly more in the future for evidence of checkups.
How Does a Health Plan Report HEDIS Measures?
Each year in spring, payers are assessed for their HEDIS scores by CMS. For each of about 100 ‘measures’, the government selects a sample of each payer’s population for each measure and assesses whether each of those patients are getting the tests they should be. If the ratio of patients that got the check-up to patients that need the check-up is sufficiently high, the plan is doing well. These plans get a high rating which results in a bonus if it is high enough as incentive to grow and attract more members.
HEDIS reviews can be very time consuming because of the amount of information that goes into them and the amount of work required to collect these evidences.
As a result, a HEDIS staff may spend time in the off-season collecting evidences that their population has high quality scores for each measure, by analyzing their claims data and reviewing medical records of patients. The actual HEDIS season starts around January when the government selects the populations, and payers work extra hard to gather evidences for these patients in a 2-3 months span by reviewing a large quantity of medical records. At the end of this period, they are no longer able to collect evidences and must report their measure scores for audit. They will then start focusing on scores for the following year.
HEDIS Evidence from Healthcare Data Sources with Tenasol
As a regular part of our business, Tenasol extracts HEDIS measure evidences using multiple methods of machine learning and healthcare natural language processing within every type of medical record. This includes:
HEDIS data extraction for HL7v2 ADT (*.hl7, *.txt)
HEDIS data extraction for HL7v3 C-CDA (*.xml, *.json)
HEDIS data extraction for HL7v4 FHIR (*.json)
HEDIS data extraction for unstructured PDF/TIFF/TIF/JPG/JPEG/PNG data
HEDIS data extraction for RTF - rich text format
…and others
We are able to take data and determine if the evidence is numerator evidence or exclusionary evidence in multiple formats for our clients. If you are interested in this offering reach out to our sales team!
Conclusion
HEDIS plays a pivotal role in shaping the quality of healthcare in the United States, bridging the gap between preventive care and clinical outcomes. HEDIS encourages health plans to prioritize patient well-being and preventive care over reactive treatment.
For health plans, the process of collecting, analyzing, and reporting HEDIS data is demanding but essential. It not only ensures compliance with CMS standards but also provides an opportunity to identify gaps in care and improve patient outcomes.
As patients, providers, and payers continue to collaborate in advancing care quality, HEDIS stands as a testament to the power of structured data and evidence-based measures in transforming healthcare. Understanding and engaging with HEDIS is not just a technical task but a critical step toward a healthier, more equitable healthcare system for all.
Reach out to our team to see how we can help you with your HEDIS performance ratios.