The Relationship Between HEDIS Scores and Clinical Data Exchange

Blog Posts  |  29 June 2023

Written by: Cheryl Reifsnyder, PhD

The Healthcare Effectiveness Data and Information Set (HEDIS®1 measures) were developed by the National Committee for Quality Assurance (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 6 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 healthcare 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

In our previous post, we discussed the importance of identifying 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 healthcare 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 preventative 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.

Clinical data exchange (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 healthcare 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 healthcare 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 preventative 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.

Veradigm solutions to facilitate payer-provider CDE

Veradigm offers 2 solutions that can help facilitate CDE: Veradigm eChart Courier™ and Veradigm Integr8.

Veradigm eChart Courier™

Veradigm eChart Courier is an easy-to-use solution that automates 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 with Veradigm eChart Courier 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.

eChart Integration and Analytics: Electronic Medical Record (EMR) analytics and integration software

eChart Integration and Analytics 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 EMR 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.

Contact us to learn more about how Veradigm can help you streamline the CDE process.

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