What is HEDIS® in Healthcare and How Do You Improve It?
Written by: Kate Wormington, Director Solutions Mangement-Quality, Veradigm and Katie Wilson, Veradigm
Dedicated to advancing healthcare quality, the National Committee for Quality Assurance (NCQA) is a private, non-profit organization that has become a cornerstone in healthcare performance measurement. Working under contract with the Centers for Medicare and Medicaid Services (CMS), NCQA created the Healthcare Effectiveness Data and Information Set (HEDIS®). What is HEDIS in healthcare? It’s a widely recognized framework used to assess and improve the quality of care delivered by health plans.
Each year, the NCQA works closely with CMS to ensure HEDIS remains a reliable tool for calculating healthcare quality. It includes updating measures to reflect developing priorities, collecting performance data from health plans, and auditing results to maintain accuracy and integrity.
Currently, over 90 HEDIS measures are in use and span six specific domains of care:
- Effectiveness of care
- Access and availability of care
- Patient experience
- Utilization and risk-adjusted utilization
- Descriptive health plan information
- Reporting using electronic clinical data systems
Common HEDIS quality measures include immunizations, cancer screenings, diabetes care management, medication adherence, and high blood pressure management.
How HEDIS measures are used
HEDIS measures are one of the most widely used tools for performance improvement in healthcare, with over 200 million Americans enrolled in plans that report HEDIS scores. Over 90% of U.S. health plans rely on HEDIS metrics to evaluate care quality and guide improvements.
What is HEDIS in healthcare, and why does it matter? These metrics empower stakeholders by:
- Helping consumers and purchasers: Compare health plans based on quality data.
- Supporting providers: Identify care gaps, monitor progress, and improve patient outcomes.
- Enabling health plans: Benchmark performance and transition to value-based care models.
Improving HEDIS scores is vital, because it directly contributes to closing care gaps and reducing reliance on costly acute care services by emphasizing preventive interventions.
Payers’ challenges in improving HEDIS measures
Success in today’s payment landscape demands that healthcare payers work to improve HEDIS scores, yet they face significant challenges:
- Data fragmentation: Inconsistent data from various providers undermines accuracy.
- Administrative burden: Increased documentation leads to provider burnout.
- IT limitations: Many providers lack effective systems for tracking quality.
- Low preventive screening rates: Screening for key cancers often falls short of benchmarks.
Overcoming these challenges requires robust IT solutions, streamlined workflows, and effective collaboration between payers and providers.
What’s new in HEDIS MY2025
NCQA has updated HEDIS for Measurement Year 2025, and these changes help HEDIS remain a leading tool for understanding what is HEDIS in healthcare and for driving quality improvements:
- Documented assessment after mammogram: Tracks BI-RADS within 14 days for women 40–74.
- Follow-up after abnormal breast cancer assessment: Ensures 90-day timely follow-ups for high-risk cases.
- Blood pressure control for patients with hypertension: Uses ECDS reporting with race and ethnicity stratification.
Changes to existing measures
HEDIS MY2025 transitions key measures from the hybrid data collection method and/or to ECDS methods and revises criteria for others:
- Mental health follow-up measures expanded to include new diagnoses and follow-up options.
- Telehealth visits for well-care metrics were removed post-pandemic.
Additionally, NCQA has retired measures that no longer meet evolving clinical guidelines. These include certain pain assessment indicators and aspects of antidepressant medication management.
Strengthening quality improvement with Veradigm® Quality Analytics
Effectively addressing quality gaps is essential in today’s changing healthcare ecosystem. With Veradigm Quality Analytics, health plans can quickly pinpoint and prioritize opportunities which allow them to provide superior care across medical, dental, pharmacy, and other services.
Data-driven analytics
Veradigm has combined advanced analytics with actionable insights to help health plans:
- Target care gaps strategically: Focus efforts on gaps that generate the highest return for the least effort.
- Optimize workflows: Prioritize interventions using dashboards and reports that identify members predicted to be included in quality metrics.
- Streamline reporting: Generate detailed reports for easy data visualization or processing directly within the software.
Integration with Veradigm Payer Insights
Working seamlessly with your existing workflows, Veradigm Payer Insights delivers real-time data and analytics for closing gaps quickly. This integration equips health plans with insights exactly when and where they’re needed to support informed decision-making.
HEDIS submission excellence with expert support
Veradigm’s Quality Analytics is NCQA Measure Certified™ for HEDIS MY2024 and currently undergoing certification for HEDIS MY2025, underscoring its commitment to accuracy and reliability. Beyond HEDIS, the software supports a broad range of quality measures, including:
- Quality Rating Systems (QRS)
- Star Ratings
- Pharmacy Quality Alliance (PQA) measures
- State-specific benchmarks
To further foster success, Veradigm offers access to subject matter experts who help align strategies with HEDIS, NCQA, CMS, and other reporting requirements. Their guidance ensures health plans optimize gap closures efficiently without incurring the expense of hiring dedicated analysts.
Driving better care: Unlocking the full potential
More than a set of metrics, HEDIS is a dynamic tool that shapes how we understand and improve healthcare quality. Continuously updating HEDIS measures and adopting innovative solutions like Veradigm® Quality Analytics allows health plans to better close care gaps, implement preventive services, and ultimately, achieve superior patient outcomes.
As you work to meet the critical submission deadlines for HEDIS MY2025, it’s integral to stay ahead of the curve. Timely and accurate submission reinforces regulatory compliance and also drives continuous improvement across your quality initiatives.
Contact us to learn how Quality Analytics can transform gap closure workflows and refine HEDIS quality measures within your practice, so you can provide better care to your patients.