What You Need To Know About HEDIS Medical Record Review

Standardized performance measures are indicators or metrics that are used to gauge program performance. They provide information from a medical record request needed to measure the extent to which a practice is achieving its intended results and outcomes. 

So what do you need to know about HEDIS Medical Record Review? HEDIS scores are used by more than 90% of American health plans to compare how well the plan performs on important dimensions of care and service such as quality of care, access to care, and satisfaction with the plan and providers. A HEDIS review is performed by a payer or health care provider to measure the quality and effectiveness of patient care delivered to their covered patient population.

What Is HEDIS Medical Record Review?

What Is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is the most widely used array of performance measures in the United States health care delivery system. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA). Some common HEDIS quality measures involve childhood immunization status, cancer screenings, asthma medication management, prenatal care, mental health problems, heart attack treatment, mental healthcare, flu shots, and high blood pressure treatment.

Medical record reviews are also the data source used by the NCQA to determine any incentives or financial rewards for health plans.  HEDIS performance data can also be used to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards that allow comparison with other plans. Medical record review also allows identification of performance gaps and establishment of realistic targets for improvement.

What Is The Process Of HEDIS Medical Record Review?

State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company's preventive health outreach efforts. Physician specific scores are being used as evidence of preventive care from primary care office practices and their ability to deliver appropriate treatment. These rates then serve as a basis for physician profiling and incentive programs. 

NCQA collects HEDIS data using health care insurance claims, surveys, and clinical documentation of hospitals, pharmacies, laboratories, and physician offices. The agency utilizes the Healthcare Organization Questionnaire as well as the Interactive Data Submission System for the HEDIS data collection.

An NCQA-approved auditing firm will then audit the medical record data before reporting HEDIS quality measures publically. Once the results are available for public viewing, consumers may use the HEDIS specifications to compare multiple health plans, clinical quality and local medical facilities.

Types Of Reviews

1. Administrative

For the administrative review, health plans have to identify the eligible candidates for the particular HEDIS measure. Datais collected from insurance claims and registration systems in medical offices, clinics, hospitals, labs and pharmacies. Health plans will also have to find out the number of eligible candidates who have received the particular service required for that measure. Administrative data collection captures measures such as breast cancer screening and antidepressant medication management.

2. Hybrid

In the hybrid data, a random selection is made of eligible candidates. Data is obtained from both practices' claims database and medical record data. The hybrid specification method allows plans that have more complete and accurate administrative data systems. It is also used to reduce the number of chart reviews required by achieving a higher proportion of numerator using administrative data alone. Measures in which this methodology is used include comprehensive diabetes care, childhood immunizations and prenatal and postpartum care.

3. Survey

The survey method is used to measure members' satisfaction with the care provided to them in areas such as customer service, claims processing and speed with which the required care was provided. This survey is conducted by an NCQA approved external survey organization. Encounter data is obtained from member medical records and provider surveys.

Importance Of HEDIS Medical Record Review

As state and federal governments move toward a quality-driven healthcare model, HEDIS rates are becoming more and more important, not only to the health plan but to providers as well. HEDIS quality measures have a significant role in the healthcare industry regarding closing gaps in care and decreasing the use of costly acute care through preventive services. 

HEDIS chart review is beneficial to the health plans, managed care industry as well as consumers. While health plans such as medicare use the data to gain insight into areas where quality improvement efforts are to be made, the managed care industry utilizes it to compare performance between health plans. Consumers are also benefited by this data because it will help them select a health plan that best meets their needs.

Work With Calysta For HEDIS Medical Record Review

Calysta is committed to delivering complete and accurate data collection with their Calysta Electronic Medical Records (EMR) which reflects the health care services provided. We want to equip as many practices as possible with the single, complete solution they need to truly launch their clinic and team, and provide the highest-quality service to all clients.

To learn more about Calysta solutions and our EMR, schedule a two-week free trial today.