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The Healthcare Effectiveness Data and Information Set (HEDIS@) is a registered trademark of the National Committee for Qualtiy Assurance (NCQA). HEDIS@ was originally titled the "HMO Employer Data and Information Set" as of version 1.0 of 1991. In 1993, Version 2.0 of HEDIS@ was known as the "Health Plan Employer Data and Information Set". Version 3.0 of HEDIS@ was released in 1997. In July 2007, NCQA announced that the meaning of HEDIS@ would be changed to "Healthcare Effectiveness Data and Information Set."
HEDIS@ is a widely used set of quality performance measures which are used by over 90 health insurance programs to measure whether the purchasers of healthcare, generally employers, are getting “their money’s worth” with the services they are buying. The 75 HEDIS@ measures are divided into six "domains of care":
- Effectiveness of Care
- Access/Availability of Care
- Experience of Care
- Utilization and Relative Resource Use
- Health Plan Descriptive Information
Only the first of these domains is directly dependent upon the healthcare provider’s performance. The HEDIS@ measures for quality performance in effectiveness of care are divided into three categories:
- Effectiveness of Acute Care
- Effectiveness of Preventive Care
- Effectiveness of Chronic Care
The following is a screen shot of SETMA’s deployment in our electronic medical record of these three categories of HEDIS measures:
The measures are color coded In SETMA’s deployment of HEDIS@. If the measure is in red, it applies to the patient and has not been completed. If it is in black, it means that the measure applies to the patient and has been done, and if it is in gray it means that the measure does not apply to the patient. The following is the detail on one of the measures which lets the provider know what must be done to fulfill the measure.
Historically, healthcare provider’s performance was audited on the HEDIS@ standard by companies hired by insurance carriers who did chart audits to determine how providers were performing. Typically, providers received their results 12-24 months after the audited services were delivered. While the purpose of HEDIS@ was to measure quality, HEDIS@ did not significantly affect quality as very few healthcare providers knew what HEDIS measures were and being published one to two years after the care was delivered, providers largely did not care.
As emphasis on quality and safety increased, and as more and more emphasis was placed on both for the purposes of payment, interest in HEDIS@ and other quality metrics also increased. In 1999, SETMA determined that the only way we were going to sustain improvements in the quality of the care we provide was to measure that quality ourselves. In 2008, the American Medical Association published their Performance Improvement Continuous Medical Education (PI-CME) program. This program was adopted by primary care specialty boards.
PC-CME included three steps:
- Providers auditing their performance on quality metrics related to disease management.
- Providers designing their own education programs to improve deficiencies in care.
- Providers then re-auditing their performance to see if their study had improved their performance.
SETMA would argue that in order to sustain improvement, a four step was required. Because providers very often lost focus on performance improvement after the conclusion of the PI-CME process, that the designing of a Clinical Decision Support tool was required. This tool helped the provider sustain their performance at a very high level and also allowed for the provider to update their performance when evidenced-based studies demonstrated the need for a change.
In 2000, SETMA realized that in order to improve, we had to know the standard on the basis of which we were being judged. In 2005, we began tracking our performance on HEDIS@ measures internally. In 2009, SETMA began to publicly report by provider name on our performance on HEDIS@ measures.
The following is the rationale for the above steps taken by SETMA. SETMA determined that if we were going to be:
- Given a test for quality performance
- Where the test questions were going to be given to us before the test
- Where the test is an “open book test”
- Where there is no time limited on taking the test
Why not look up the answers before the test?
Furthermore, in that the purpose of the test should not only be to evaluate the one being tested but also hopefully to teach the one being tested, it is necessary for the provider to know his/her performance at the point of care. This means that if HEDIS@ is going to affect the quality and safety of the care being given, the provider has to know the measures and how he/she is performing on HEDIS@ at the time the care is being given.
Eventually, quality performance became the basis for payment to physicians. This was particularly true in two major areas. One was in the shared-savings plan with Accountable Care Organizations (ACO). In order to benefit from the savings the ACO achieved, the providers have to fulfill a set of quality metrics taken from HEDIS@. The other was in the Medicare Advantage STARS program where organizations were rated on the basis of quality performance from another set of measures taken from HEDIS@. Their rating determined the payments made through health maintenance organizations (HMO).
This presentation summaries SETMA’s deployment of:
- all HEDIS@ measures,
- HEDIS@ measures for ACO payments, and
- HEDIS@ measures for the STARS program.
For a detailed explanation of each, see the following links to tutorials on SETMA’s website:
HEDIS@ is the foundation of the quality measurements ACOs which measures must be successfully completed in order for a medical practice to receive additional payments from CMS, and is the foundation of quality measures for the Medicare Advantage STARS rating system for practices to receive enhanced payments from CMS.
In our February 12, 2015 Your Life Your Health, we will examine SETMA’s use of HEDIS@ in more detail.
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