HEDIS Explained: Goals, Benefits, and Future Improvements

HEDIS (Healthcare Effectiveness Data and Information Set) is a quality check tool utilized to measure the level of care services in healthcare plans. HEDIS has been designed by the National Committee for Quality Assurance (NCQA) and includes over 90 measurements within different care domains that involve chronic disease management, preventive care, and usage of medication.

HEDIS collects and analyzes health plan data to provide indicators of health care performance. HEDIS metrics allow for the comparison of health plans that provide recognition of opportunities for change in quality initiatives, making a difference to employers, consumers, and policymakers. In sum, HEDIS is used to benchmark the overall effectiveness of healthcare delivery.

Value-based healthcare has created a fervor of culture in relentless improvements in patient care; improvements that seek to get enhanced patient outcomes without the accompanying unnecessary costs. This coincides with one of the most important consumer priorities in choosing a health plan.

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Goals and Objectives of HEDIS

HEDIS measures are important to realize the following, among many others, in healthcare:

• Improvement in Preventive Care: HEDIS helps to point out outlets for improved disease prevention and ways to reduce costs, including the processes of services such as screenings and immunizations. Preventive screening, such as mammograms, colposcopy, and prostrate screening leads to the early detection and subsequent tracking of diseases; hence, the chances of better patient recovery and thus low healthcare costs.
• Chronic Disease Management Improvement: Chronic-condition-focused HEDIS measures, such as diabetes and hypertension, can evaluate care management programs and the gaps within the program. Essentially, these measures look into the aspects of the use of evidence-based medication, patient adherence to the treatment plan, and frequency of complications. Data on these measures is useful in coming up with areas to be improved for chronic care management programs.
• Care Coordination Optimization: HEDIS measures related to care transitions and communication between providers help assess the effectiveness of care coordination efforts and patient outcomes. It means that effective care coordination ensures that patients receive continuous care irrespective of any setting along the line during their healthcare journey. This includes transitions among primary care physicians, specialists, hospitals, and other health care providers. Effective communication among the providers is a critical component in ensuring proper and timely care is delivered, which decreases duplicate services and possible medication errors.
• Member Satisfaction and Engagement: HEDIS measures patient experience through surveys about member satisfaction with access to care, provider communication, and global rating of quality of care. These data, if collected and analyzed, provide very useful insights regarding patient perceptions of healthcare organizations and are useful in quality improvement. Including member satisfaction in HEDIS goals places more emphasis on patient-centered care. People are much more likely to take a serious interest in and commitment to their health and well-being if they feel they are being heard, their views respected, and are involved in decisions about their care. That means adherence to a treatment plan, better health outcomes, and therefore lower costs to the healthcare system.
• Benchmarking and Continuous Quality Improvement with HEDIS: HEDIS provides several benchmarks against which healthcare organizations can compare their performance to that of the best in the industry. This type of comparative analysis therefore assists in areas of excellence or improvement by drawing out the best practices from high performers. Any healthcare provider with the capability to incorporate HEDIS data with internal metrics will have insights into their relative strengths and weaknesses within the broader market. Moreover, HEDIS data drives quality improvement by identifying poor performance areas, setting measurable goals, and developing specific interventions. This is a data-driven approach tracking change over time, which gives a measure of effectiveness for the quality improvement efforts and performance as it ties to the national and regional averages.
• Ensuring Regulatory Compliance: Adherence to HEDIS measures demonstrates a healthcare organization's commitment to quality care and helps them meet regulatory requirements established by federal and state agencies. High performance on HEDIS measures can also serve as a benchmark for accreditation organizations, potentially influencing a healthcare organization's eligibility for certain programs or certifications. By consistently meeting or exceeding HEDIS standards, healthcare organizations can ensure they are delivering care that meets or surpasses minimum quality thresholds established by regulatory bodies. This compliance not only mitigates the risk of penalties or sanctions but also positions the healthcare organization as a leader in quality care delivery.

HEDIS Data Collection Sources

• HEDIS data is primarily sourced from administrative claims which encompass information on hospitalizations, doctor visits, procedures, and prescription drug use. This data is analyzed to reflect the care received by health plan members.
• To capture the patient's perspective on care, patient surveys are conducted using the CAHPS (Consumer Assessment of Healthcare Providers and Systems) methodology. This data offers insights into member satisfaction and experience.
• For measures requiring more comprehensive information, a hybrid approach is employed, combining administrative claims with data extracted from patient medical records. This provides a more detailed picture of care delivery.

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The ideal scenario is to minimize the need for hybrid reviews by encouraging accurate and comprehensive coding on claims. This facilitates the data collection process and makes the data reliable.

HEDIS Enhancements: Driving Improved Healthcare Performance

HEDIS has undergone a lot of development to become a robust tool for measuring quality in health care.  Key improvements include:

• Technological Advancements: Some technological advances include the integration of HEDIS with high-tech software solutions, whereby data collection, analysis, and reporting procedures advance the accuracy and efficiency of the processes.
• Expanded Data Sources: By incorporating data from EHRs and other sources beyond claims, HEDIS provides a more comprehensive view of patient care and health outcomes.
• Real-time monitoring: HEDIS data assists healthcare organizations in performance monitoring and trend identification for interventions in real-time.
• Customization and Flexibility: HEDIS can now be tailored to meet the needs of specific populations or the goals of individual organizations, making it much more relevant and applicable.
• Interoperability: Improved data exchange between healthcare systems enhances data accuracy and completeness for HEDIS reporting.

Conclusion

HEDIS holds a prominent place in value-based healthcare since it provides standardized measures for the assessment of health plan quality. It focuses on preventive care, chronic disease management, care coordination, and satisfaction of members, all emphasizing continuous improvement to improve patient outcomes and resource use.

Beyond benchmarking and compliance, HEDIS drives quality improvement, guides business strategy, and furthers patient-centered care. Sources of data used to calculate HEDIS measures include administrative claims, hybrid, medical records, and CAHPS.

High HEDIS scores, therefore, keep health plans very competitive and more attractive to consumers. Meeting the HEDIS criteria to improve patient care is a sign of improved reimbursement and an improved bottom line; HEDIS thus becomes a standard of paramount importance in effective healthcare delivery for sustained success in a value-driven industry.

If you are a healthcare provider and wish to discuss more about HEDIS, feel free to write to us at partnerships@homrcm.com.

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