Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS® (Healthcare Effectiveness Data and Information Set) is a set of performance measures developed by the National Committee for Quality Assurance (NCQA) for the managed care industry. HEDIS results assist health plans with demonstrating improvement in their preventive care and quality measurements and demonstrate the provider’s commitment to quality care and improved health outcomes for the individuals they serve.

This site contains information related to HEDIS measures currently reported by Alliance Health using paid claims, medical/lab procedures, pharmacy data, and electronic data feeds. HEDIS measures are derived from the NCQA HEDIS Technical Specifications which are released annually. Alliance Health’s HEDIS processes and rates are audited annually by an NCQA-certified HEDIS auditor.

HEDIS measures are developed by NCQA and cover a range of health issues. Several are listed below.

• Cancer: breast cancer screening, colorectal cancer screening, cervical cancer screening
• Diabetes: retinal eye exams, glycemic status assessment, kidney health evaluation
• Heart disease: controlling high blood pressure
• Immunizations: childhood immunization status, immunization for adolescents,
• Mental health: antidepressant medication management, follow-up after hospitalization for mental illness, follow-up after ED visit for mental illness
• Other health care: chlamydia screening, prenatal and postpartum care, well-child care

Quality performance metrics such as HEDIS, Medicare Advantage Star Ratings, Health Plan Ratings (HPR), and standardized Core Quality Measures (CQMs) can give consumers an indication of health care quality members are receiving. These measure the quality of care and coverage a health plan provides based on the regularity of services performed, improvements in patient health, and consumer satisfaction. They measure similar healthcare services and consumer-facing operations which in turn give a health plan a quality score.

Measure weights are taken from the standard list of health plan ratings released by NCQA every year. Each required performance measure has a standard weight, which is used in the overall score calculation (maximum score of 3). A triple-weighted measure counts more heavily than single-weighted measures and is important for a health plan’s performance score.

• Race/ethnicity diversity of membership measure is given a weight of 0.5.
• Process measures (such as screenings) are given a weight of 1.
• Patient experience measures are given a weight of 1.5.
• Outcome and intermediate outcome measures (e.g., blood pressure control, HbA1c, and childhood immunizations) are given a weight of 3.

Note: Typically, new measures used for scoring are assigned a measure weight of 1.0 and then reassessed to determine their weight going into the second year.

Alliance Health currently has five triple-weighted measures which are listed below.

• BPD: blood pressure control for patients with diabetes
• CBP: controlling high blood pressure
• CIS-E: childhood immunizations status (Combo 10)
• GSD: glycemic status assessment for patients with diabetes (<8)
• IMA-E: immunizations for adolescents (Combo 2)

Gaps in care refers to the discrepancy between the care provided to patients and the recommended best practices in healthcare. Care gaps can lead to missed or delayed diagnoses, higher medical costs, and more costly and potentially more invasive treatments.

Gaps in care can occur in several ways:

• A patient in an at-risk age group fails to comply with recommended screenings or preventative care (i.e. does not get a yearly mammogram or blood pressure screening, or misses a vaccine booster).
• A patient’s new diagnosis is not shared with their PCP or specialist for another related condition.
• A patient cannot schedule a behavioral health appointment in a timely fashion and leaves for another provider.
• A patient does not follow recommended prescription guidelines for a chronic condition.
• A child who is not scheduled for regular well visits or vaccinations.
• A patient is not able to find the care they need in their network or area.

Effective patient engagement helps reduce gaps in care which is more than just knowing the patient’s medical history. It also requires knowing their ability for an in-person visit, their means for engaging with a telehealth option (if available), access to transportation and other social determinants of health, current health condition, and other risk factors.

Ways to close care gaps:

• Understands patients: Understand their needs, communication preferences, and how they want to engage with you
• Emphasize preventive care: Patients may not know about recommended screenings, immunizations, or tests
• Educate and engage patients: Educating patients about their conditions, medications, and risk factors empowers them to manage their health actively, leading to better outcomes
• Conduct patient outreach: Automated outreach can help maintain patient-provider relationships and save staff time
• Coordinate care: Tailored care coordination can improve the quality and efficiency of care and reduce the potential for unnecessary hospital admissions
• Use telehealth options: Telehealth can help improve access to care, especially in rural areas. Telehealth can also be used as a prevention tool for at-risk patients
• Use patient portals: Patient portals can reduce travel expenses for patients and give physicians more time to oversee other issues

One challenge related to care gaps is determining whether there is a true gap in care or if it is a gap in the data being submitted related to the services provided. There are a couple of ways to prevent the care gap relating to the data being submitted not capturing the care provided.

• Appropriate coding: Submitting claims with the appropriate codes to capture the service provided
• Electronic data feeds: Information can be exported from your Electronic Medical Record (EMR) system which captures the services provided to a patient and sent to Alliance

In health care, electronic data feeds are also known as Electronic Data Interchange (EDI). They allow the exchange of computer-processable healthcare data in a secure, standardized format among healthcare professionals, healthcare institutions, patients, and payers.

Electronic data feeds can:

• Capture additional information was not captured through claims
• Assist in closing care gaps
• Reduce requests for medical records for HEDIS
• Lower administrative costs
• Improve productivity

Electronic data feeds can come from a variety of sources, including but not limited to:

• Electronic Health Records (EHRs): Contain a patient’s demographics, medical history, medications, vital signs, laboratory data, consultation notes, etc.; EHRs can improve patient care by reducing medical errors, improving the accuracy of medical records, and reducing delays in treatment
• Electronic Clinical Data Systems (ECDS): Contain a plan member’s personal health information and records of their experiences within the health care system. ECDS can support care-related activities like evidence-based decision support, quality management, and outcome reporting
• Electronic Date Capture (EDC) systems: Can receive data transmissions from ePRO instruments and connected medical devices (DHT)s; EDC systems can automate the data collection process
• Administrative claims databases: A source of electronic health data
• Laboratory and imaging systems: A source of electronic health data
• Medical and consumer devices: A source of electronic health data

Alliance will be happy to discuss how to set up an electronic data feed and provide information regarding file formatting along with the set-up process.

Scroll down to access MY2025 clinical guides and pocket guides.

MY2025 Clinical Guides:
Behavioral Health Measures Practitioner Clinical Guide for HEDIS (MY2025)
Adult Measures Practitioner Clinical Guide for HEDIS (MY2025)
Pediatric Measures Practitioner Clinical Guide for HEDIS (MY2025)
Pharmacy Measures Practitioner Clinical Guide for HEDIS (MY2025)

MY2025 Pocket Guides:
Adult Pocket Guide for HEDIS (MY2025)
Pediatric Pocket Guide for HEDIS (MY2025)

For additional information or questions, contact the HEDIS Clinical Team.