HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) and any reference thereto by RISE Health does not imply any endorsement by NCQA of RISE Health and its offerings.
The Healthcare Effectiveness Data and Information Set (HEDIS®1 measures) were developed by the NCQA, a private, non-profit organization devoted to improving the quality of health care in the United States. HEDIS® measures are related to many significant public health issues, such as cancer, smoking, heart disease, and diabetes. They are used for collecting data in six specific domains of care:
- Effectiveness of care
- Availability of care
- Experience of care
- Utilization and risk-adjusted utilization
- Health plan descriptive information
- Measures reported using electronic clinical data systems
HEDIS® measures are designed to provide purchasers and consumers with the information required for reliably comparing health plans’ performance. They are one of the most widely used performance improvement tools in the health care industry today, with over 200 million people enrolled in plans that report HEDIS® results.
HEDIS® performance data can be used in many different ways:
- To identify opportunities for improvement
- To monitor the success of quality improvement initiatives
- To track improvement
- To provide a set of measurement standards allowing comparison with other health plans
- To allow identification of performance gaps and establishment of realistic targets for improvement
It is important to identify and improving your HEDIS® score. Maximizing an organization’s HEDIS® score is essential because it’s directly related to improving the quality of care provided by health plans as well as by health care providers (HCPs). HEDIS® scores reflect multiple aspects of quality care, such as closing gaps in care, decreasing the use of expensive emergency department services, and encouraging the implementation of preventive services. However, one tool is critical for evaluating and improving HEDIS® scores: a smooth and effective system of clinical data exchange (CDE). Keep reading to learn how HEDIS® scores and an effective system of CDE are connected.
CDE
CDE is defined as the method we use to transfer clinical data so that information can be easily exchanged for patient care coordination, risk adjustment, claims processing, and determining whether requested services are necessary and appropriate. CDE is important for exchanging information from provider-to-provider, from provider-to-payer, and from payer-to-payer.
Value-based contracts are increasing the need for payers and providers to exchange the right data at the right time, to drive better decision-making and, ultimately, better patient outcomes.
The importance of CDE for HEDIS® quality scores
HEDIS® quality measures are critical to the transition from fee-for-service payment structures to value-based care reimbursement. Success in this new payment landscape requires payers to work toward improving their HEDIS® scores; to close care gaps to collect the data needed to improve their HEDIS® scores, payers require a smooth and effective system of CDE.
Documentation is extremely important to payers to meet the HEDIS ® quality measures and demonstrate improved payer performance. For instance, now that the entire healthcare system has switched to using ICD-10 codes to record diagnoses, any claims sent using ICD-9 or other codes will not count toward their current HEDIS® quality standards. It’s also important to ensure that a patient has all health care services properly documented in their electronic health record (EHR). Any errors in the medical record could be major obstacles to meeting HEDIS® quality measures; the medical record is vital for providing a clear picture of all the procedures and services completed for the patient.
Partnering with providers and patients
CDE enables payers to influence quality of care by making providers partners in closing gaps of care. They can do this using pay-for-performance programs. For instance, health plans can support health care practice partners by:
- Using CDE to provide data of who has versus who has not received cancer screenings or other well-care assessments, so they can provide HCPs with lists of quality-care gaps
- Using this same information to send reminders to patients about their needs to obtain these screenings or well-care services
- Setting up value-based contracts with provider networks, establishing incentives for them to perform preventive screenings
CDE also enables payers to make direct outreach to patients who are plan members. The San Francisco Health Plan credits part of their HEDIS® scores’ success to their direct outreach to members, such as:
- Providing plan members with gift cards for completing recommended well-care services such as annual well-child visits or recommended tests for diabetes
- Providing telephone call reminders to plan members with overdue care
- Working to provide health education materials to support providers in teaching patients about managing their health
These efforts require a highly functional CDE system to provide updated information about missing care services, screenings, etc.
Solutions to facilitate payer-provider CDE
Automated medical chart retrieval: These software platforms deliver interoperability between payers and providers that can automate the medical chart retrieval process. Most of the time, medical charts are pulled individually, then driven or mailed to the requesting health plan, where they are reviewed manually—a process that is time-consuming and resource-intensive. Medical practices require staff to sort manually through patients’ charts and respond to requests, which takes them away from supporting patients and providers.
Automating medical chart retrieval increases chart retrieval efficiency. eChart Courtier operates through the EHR, allowing users to access and supply requested patient charts from within their existing workflow. It also assists data collection for quality measures, such as HEDIS®, by speeding up the information exchange process.
Integration and analytics: This type of solution helps health plans to manage EHR data from multiple sources by automating exchange of medical record information. This increases efficiency, resulting in faster turnaround times and better care coordination which, in turn, helps with data collection for HEDIS® quality scores. In the process, it can also improve payer-provider relations because EHR integration offers the least intrusive method for collecting data from and returning insights to providers.
CDE: An essential tool for improving HEDIS® scores
Improving HEDIS® scores is of critical importance to health plans. Near real-time access to clinical data can help payers to improve their HEDIS® quality scores in several ways. First, effective CDE can accelerate HEDIS® scoring, enabling payers to use that information more rapidly to improve member care. Second, it streamlines payers’ access to in-depth data on the populations they serve, allowing them to improve their plan design, improve interventions, and improve management of member risk profiles.
Veradigm is one leading vendor facilitating clinical data exchange for payers and providers. Contact Veradigm to learn more about how Veradigm can help you streamline the CDE process, or click here to learn more about Veradigm’s leading solutions for CDE.