How to Be More Efficient in HEDIS Reporting

Improving the collection and reporting of high-quality data provides a financial advantage to health plans capable of demonstrating the ability to deliver efficient and effective care to patients.

Over the past decade, the Healthcare Effectiveness Data and Information Set (HEDIS) has become the most widely used system for health plans to measure their performance against their peers.

According to the National Committee for Quality Assurance (NCQA), 90 percent of health plans in the United States rely on the standardized system for measuring performance in healthcare.  HEDIS sets a standard for how health plans “collect, audit and report performance information” so that employers, regulators, and others can compare performance across health plans. The system also makes plans eligible for financial rewards in the forms of bonus payments (e.g., Star ratings) or savings under value-based care contracts.

What’s more, an estimated 190 million Americans are enrolled in a health plan that reports quality results using the standards.

Contracted by the Centers for Medicare & Medicare Services (CMS), NCQA is responsible for maintaining HEDIS as a system for evaluating the ability of health plans and providers to deliver high-quality care to patients. Currently, HEDIS measures comprise more than 90 measures across six domains:

• Effectiveness of care
• Access/availability of care
• Experience of care
• Utilization and risk-adjusted utilization
• Health plan descriptive information
• Measures collected using electronic clinical data systems

Collecting the appropriate data for HEDIS measures can be a complex undertaking. In some cases, plans employ a registered nurse to perform a medical chart review to locate additional information about a given HEDIS measure.

Reviewing medical records — otherwise known as a medical record review (MRR) — costs health plans and providers alike. The latter already dedicate substantial time and dollars — in 2015, 15.1 hours per week and an estimated $15.4 billion annually to report quality measures — and health plans are coming to the realization that they must work to automate the MMR process to reduce costs and efficiently demonstrate the value of their plans over others.

With CMS making HEDIS a major factor in provider and health plan performance, inefficiencies in HEDIS reporting have a financial consequence, and the importance of HEDIS reporting is only going to increase given the federal agency’s plan to tie more reimbursement to value-based models of care.

Health plans and providers, therefore, must identify and remediate inefficiencies in data collection and reporting to ensure financial success in the future. By working closely with providers, and partnering with companies that can leverage EHR capabilities, health plans can streamline HEDIS reporting in a handful of ways, especially by getting upstream of the documentation gaps most commonly leading to medical records requests.

Automating data collection and reporting

Forms play a critical role in capturing key patient data for HEDIS measures. Forms provide a standardized method for obtaining data about patient health, care, and experience. But forms can also introduce a level of variation that runs counter to data collection and reporting efforts and requires staff to compile data from multiple sources to calculate HEDIS measure performance.

A properly designed and implemented EHR system can prefill portions of forms needed to avoid errors in the patient’s record to collect essential HEDIS data. Generating auto-populated forms speeds the capturing and reporting of patient data by eliminating redundancies.

Tracking and addressing non-compliance

Documentation plays an equally important role in data collection and reporting for HEDIS. According to John Hopkins Medicine, high-quality clinical documentation “is the key to economic health.” Health plans have the opportunity to work with contracted providers to counter negative quality scores by improving the consistency, completeness, and accuracy of their documentation. Many health plans make available provider toolkits to improve EHR documentation specifically.

EHR technology can counter non-compliance as well. Health plans can work with EHR vendors to assign flags and alerts to notify them when required HEDIS services have been performed. By doing so, health plans can ensure that documentation is thorough and provides claim or encounter data to support the utilization of services or referrals. This must include exclusion criteria for specific measures.

Automating EHR data extraction and sharing

Health plans collect HEDIS data in two ways. Under the administrative method, data is collected from the claims database directly. Under the hybrid method, the claims database identifies cases for medical chart review to score HEDIS measures. The hybrid method for HEDIS reporting takes the longest and costs the most, but the data it yields is comparatively more accurate than that collected through the administrative method. The bulk of the cost is the time and resources needed for pulling information from the medical record.

Thanks to the widespread adoption of EHR technology under meaningful use, most providers use a comprehensive EHR system and support common standards for exporting data. That said, the sharing of data via fax and the use of manual processes for reviews remains prevalent.

But new and emerging tools are now available to allow providers to extract and share EHR data in a readable format based on common standards (e.g., C-CDA). Layering this functionality atop the EHR eliminates the need for many manual reviews and dedication of resources to that end. Additionally, data is reported quickly.

Preparing for digital quality measures

The healthcare industry is already suffering from administrative burdens imposed by quality reporting. NCQA is proposing a future of HEDIS reporting that is fully digital with the goals of transforming the speed, cost, and value of quality measurement. Over the next three years, 20–25 HEDIS measures will be replaced by digital measures. By setting the long-term goal to digitize and automate the HEDIS reporting process, providers and health plans can provide for this next phase in the evolution of quality measurement.

Time is a highly valuable but relatively rare commodity in healthcare, but time is of the essence when it comes to improving HEDIS reporting. Value-based care models increasingly tie health plan and provider payment to quality measures like HEDIS. High-performing plans can use their HEDIS scores to promote the quality of their offerings to current and prospective enrollees.

Health plans should be working with providers to protect revenue and improve patient care by adopting new workflows that emphasize clinical documentation improvement and more automated reporting. By also partnering with vendors, health plans can take steps toward automating data exchange and improving the efficiency of data collection and quality reporting, for both themselves and their network providers.

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Veradigm^TM – Transforming Health Insightfully

Veradigm is an integrated data systems and services company dedicated to simplifying healthcare with next-generation health insights and technologies.  Our solutions are designed to help increase efficiency, manage costs and improve outcomes for health plans and other healthcare stakeholders.  To learn more, visit www.veradigmhealth.com.