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The Role of Analytics in the Future of HEDIS

We know data analytics play an important role in healthcare. In experienced hands and with the right tools and technologies, analytics provide valuable insights that can be used to solve many healthcare challenges.

There are almost limitless possibilities for what analytics can do, and we know they definitely have a place in healthcare quality control. HEDIS[1] (Healthcare Effectiveness Data and Information Set) is one of the healthcare industry’s most widely used performance-improvement tools. Today, more than 90% of U.S. health plans use HEDIS to measure performance in vital areas of care and service. This represents approximately 191 million people enrolled in health plans that use the tool.

HEDIS measures are evolving for many reasons, based largely on this: The National Committee for Quality Assurance (NCQA) wants to ensure that its measures are, as always, relevant. The changes to HEDIS measures, which are in the works now and set for delivery next year, are intended to improve risk stratification and promote health equity.

The future of HEDIS focuses on six core ideas:

  • Allowable adjustments: Enhanced flexibility that allows measures to be modified without changing their clinical intent
  • Licensing and certification: Ensures the updated requirements have been understood and coded correctly so that measure results are consistently accurate
  • Digital measures: HEDIS specifications that download directly into data systems, bringing greater ease of use
  • Electronic Clinical Data Systems (ECDS): A new reporting method that enables better use of electronic clinical data in managing the health of individuals and groups
  • Equity: Closing gaps to enable better, more equitable care
  • Telehealth: Access to care that telehealth enabled during the COVID-19 pandemic that is still vital to quality now

Improving HEDIS outcomes

Using analytics can help organizations meet the most important criteria when it comes to HEDIS reporting measures. Organizations use NCQA-certified HEDIS measures to show they’re achieving acceptable results and ratings. Those that fail to attain passing ratings can lose their accreditation.

You’re probably familiar with the adage, “Knowledge is power.” In the context of HEDIS, it relates to this: If you can see your data and act on it, you’re more likely to maintain your accreditation. There are many ways analytics can help you improve your measure results, including these examples:

  • As pharmacy costs become an ever-ballooning share of medical spending, organizations will need to be increasingly aware of measures pertaining to usage and management. Leveraging data-driven insights will be key to getting ahead of—and bending—the pharmacy cost curve.
  • HEDIS ratings historically have been done on a yearly basis. A different schedule might make more sense. Calculating rates on a monthly or quarterly basis can indicate who, for example, has not had their breast cancer screening done. You can then reach out to those members and encourage them to talk to their physician and schedule their mammogram.
  • Better information enables more effective outreach and healthier outcomes. Reaching out to members proactively to take care of preventative screenings and immunizations can help avoid serious and costly illness later. Plus, this effort can increase your screening and immunization rates.
  • Because HEDIS measures are based on what has already occurred, predictive analytics can help indicate how a rate may increase based on that previous data.  
  • Benchmarking against past and peer performance can help you identify and pursue areas for improvement and where prior quality improvement projects have helped drive higher rates.

HEDIS quality measures are vitally important to helping healthcare organizations identify their strengths and weaknesses and use the information to improve care access and quality, manage data and reduce costs by promoting preventive services. Improving your HEDIS score can ultimately lead to better health outcomes that factor in social determinants of health, risk and other elements that affect health equity.

Preparing for the future of HEDIS

These changes in HEDIS are on the way, and organizations need to be aware of and prepared for them—not only to retain your accreditation but to seize the opportunity to improve the quality of care for members while enhancing efficiency and value for your organization.

As the changes approach, and analytics become more sophisticated, Gainwell Technologies is prepared to be a knowledgeable advisor and partner to organizations focused not only on improving HEDIS quality measure scores, but on the end outcome of healthier members and communities.

[1] HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).