Streamline HEDIS Data Collection to Support Gap Closures

November 1, 2023


The evolving nature of quality improvement programs has challenged health plans to deliver quality care through care gap initiatives are targeted, data-driven and member-centric. Achieving all three of these components requires a high level of technical sophistication and reliable access to accurate clinical data.

By refining data collection processes to rapidly ingest and consolidate member-level data, health plans can accelerate quality improvement initiatives to improve health outcomes and reduce costs. Uncover the role HEDIS data plays in these programs and how to use data optimization to improve plan performance.

What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is a series of quality metrics developed by the National Committee for Quality Assurance (NCQA) to evaluate performance within healthcare organizations. Composed of over of 90 measures, HEDIS provides insights into where organizations can direct resources to improve:

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

HEDIS’s Role in Healthcare Quality

The NCQA designs HEDIS measures with unique mathematical frameworks that evaluate whether patients have received appropriate care. Measures directly correlate to specific interactions with providers, such as receiving preventive care, chronic disease management, use of emergency services and health screenings. When members complete these activities, their related HEDIS measures are considered fulfilled.

Gaps in care, also called care gaps or HEDIS gaps, refer to measures that are unfilled and represent a healthy activity that members need to complete to achieve optimal health. Plans can review medical claims, patient surveys and member records to determine which HEDIS measures members still need to fulfill.

NCQA uses this data to calculate annual HEDIS scores and help government agencies rank health plans based on the quality of care members receive. These scores are calculated based on the total number of members eligible for a measure divided by the actual number of members who fulfilled that measure each year.

Why does HEDIS Matter to Health Plans?

HEDIS is the most widely used method of evaluating plan performance within the healthcare industry. By monitoring measure scores, plans in all markets can determine which quality areas they need to improve to increase usage of preventive care and reduce emergency room utilization rates.

Federal and state quality improvement programs also use average quality scores to develop HEDIS benchmarks. Everything from the Medicare Advantage Star Ratings to state-based quality programs for Medicaid and Affordable Care Act plans rely on these benchmarks for determining plan rankings and financial incentives.

Even for commercial health plans, HEDIS is a valuable tool for tracking care gaps. In most cases, members with a high number of care gaps also do not receive appropriate preventive care and can develop serious chronic conditions. By assessing where members are in their health journeys with accurate HEDIS data, health plans can identify member engagement opportunities to improve health outcomes and resolve issues as they arise. If care gaps are left unattended, these conditions can worsen and contribute to higher healthcare utilization rates.

3 Ways to Improve HEDIS Data Collection

Implementing an automated, fast and accurate data collection methodology enables health plans to closely monitor care gaps and support better health outcomes. To start refining HEDIS data collection process, plans should:

1. Audit Current Data Processes to Reduce Silos

The majority of HEDIS data is sourced directly from providers through claims. Even when captured in a standardized format, this data can become siloed due to a reliance on outdated platforms, poorly managed servers and a lack of cohesion within a health plan’s technical infrastructure.

Breaking down these silos starts by reviewing how patient data flows between provider and plan systems and identifying opportunities to streamline the process with modern technology. The NCQA recommends that plans implement cloud-based servers, application programing interfaces (API) and longitudinal health records to improve HEDIS data quality.

2. Improve Analytics by Consolidating Member Records

As data silos are broken down, HEDIS metrics should be centralized in electronic health records rather than traditional, encounter-based reports. Incorporating member preferences, survey data, enrollment information, health statuses and care gaps into a single record allows plans to rapidly evaluate patient needs and deliver whole-person care. Standardizing these records across contracts will further increase a plan’s ability to analyze care gaps across different populations and create more equitable solutions.

3. Close Data Gaps with Health Assessments and Surveys

Once member data is laid out clearly in longitudinal records to view, health plans may identify gaps in HEDIS metrics. Overtime, plans may fill this data by helping members receive health assessments from providers, but this will take a significant amount of time depending upon appointment availability and member urgency.

A faster approach is to incentivized members to complete health risk assessments and member feedback surveys. When completed digitally and paired with relevant rewards, members are more likely to share their current health statuses and care gaps with plans. Engaging members with digital questionnaires give plans access to real-time details surrounding HEDIS metrics, as well as additional data points like language preferences, demographic information, health plan feedback, social determinants of health and lifestyles.

Overcome Emerging Data Challenges with Healthmine

The NCQA has made it a goal to continuously evolve HEDIS measures with new reporting standards, tools and systems. Electronic clinical data systems and digital quality measures are just two major changes that plans need to adapt to see success. In addition to innovating on a technical front, member experiences and whole-person care will also need to remain at the forefront of every initiative.

Plans do not need to make this transition alone, however. With the support of Healthmine’s technology solutions and API feeds, plans can actively improve HEDIS data collection and funnel member information into targeted engagement. Our digital tools enable plans to actively ingest HEDIS metrics, clinical data and member preferences into a centralized platform to create personalized outreach and care plans.

Accelerate HEDIS performance and data optimization with a digital suite of member engagement and experience tools. Contact us for a demo.

Healthmine is the leading member engagement and rewards solution focused on empowering people to take the right actions to improve their health.

More Resources from Healthmine

More Like This