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What Is HEDIS and Why Is It So Important?

No matter how good healthcare practice and plan is in providing medical services to patients, there is always room for improvement. However, methods often need help finding areas of improvement in their patient care and overall performance. HEDIS is a tool that helps them know about places with scope for improvement. So in this guide, we will discuss in detail what HEDIS is and why it is so important.

What is HEDIS?

HEDIS, which stands for Healthcare Effectiveness Data and Information Set, is a data set tool used for performance measurement of health plans in the United States. As of 2023, more than 90% of health plans use HEDIS to measure their performance in terms of service and care. In addition, more than 190 million Americans are enrolled in various health plans that report to HEDIS, so its collected data is reliable.  

How Does HEDIS Work?

HEDIS assesses the quality of service and healthcare provided by health plans and healthcare organizations all across the U.S. and compares them to identify areas of improvement. Moreover, HEDIS helps in evaluating patient outcomes and tracking the general population’s health.     

What Are The 6 Domains of Care for HEDIS?

1- Effectiveness of Care

The effectiveness of care is the first domain of care that HEDIS considers for measuring performance. This includes analyzing how good a health plan is with screening and preventing various illnesses. These illnesses have respiratory disease, cardiovascular condition, diabetes, musculoskeletal illness, and illness related to behavioral health.  

HEDIS also considers factors such as care coordination and medication management in the effectiveness of care domain. In addition, it includes measures collected via the CAHPS health plan survey and Medicare health outcomes survey.

2- Experience in Care

The quality of healthcare service offered to patients has much to do with the experience of care that a provider or practice has. HEDIS also considers this an important aspect of measuring the overall performance of a healthcare practice. Those practices that have providers with years of experience in healthcare will be going to get better HEDIS scores. 

3- Availability of Care / Access to Care

Another domain of patient care that HEDIS seriously considers for performance measurement is access to care. HEDIS analyzes if an adult has access to preventive and ambulatory health services or if a child has access to a primary care practitioner in practice.

Moreover, it considers factors like access to postpartum and prenatal care, use of first-line psychosocial care for adolescents and children on antipsychotics, and annual dental visits along with engagement in drug abuse or dependence treatment. 

4- Health Plan Descriptive Information

The health plan description information is about HEDIS getting data from Medicaid agencies and CMS about various aspects such as race (white, black, Asian, etc.) and ethnicity (Hispanic, Non-Hispanic).  

5- Utilization & Risk Adjusted Utilization

This domain includes consideration of children’s well-care visits, identification of drug services, and frequency of particular procedures. In addition, it contains utilizations such as antibiotic utilization, emergency department utilization, mental health utilization, and acute hospital utilization.

There are a few other factors, such as HAI standard infection ratio, plan all-cause readmissions, and hospitalization for potentially preventable complications, that HEDIS considers in this domain.

6- Measures Collected Using ECDS (Electronic Clinical Data Systems)

HEDIS also has a domain that includes measures that are collected using ECDS. These measures include depression screening and follow-up, the use of PHQ-9 for depression symptoms monitoring, and pneumococcal vaccination coverage for older age people. 

It also includes measures such as depression remission or response and screening and follow-up of unhealthy alcohol use.

Why HEDIS is Important?

HEDIS offers excellent insight into a medical plan to identify performance gaps for improved care and service. Moreover, HEDIS is essential because it helps practices track their performance over time so they can later take quality improvement initiatives for better patient outcomes.    

How Can I Improve My HEDIS Score?

There are a few ways through which a health plan can improve its HEDIS score: 

1- By Adopting a Value-Based Care Model 

– Provide quality care services

– Make the experience of your patients better

– Deliver cost-efficient healthcare service

2- By Effectively Managing Documentation for HEDIS Reporting

– Streamline the documentation process

– Leverage technology in data collection

– Take action to secure patient documents

3- By Making Engagement Between Provider and Patient Better

– Speed to care

– Level of care offered 

– Diversity among providers

– Medication adherence

4- By Tracking & Monitoring HEDIS Quality Measurements

– Readmission rates to emergency rooms

– Time taken by patients to have access to care

– Positive patient outcomes rates

– Access to medications with providers

5- By Increasing Reimbursement for Payers and Providers

– Provide the highest level of care to patients for increased reimbursements

– Offer competitive salaries to practice staff

– Give financial incentives to providers


HEDIS is an excellent data tool for healthcare plans to find out inefficiencies and specific areas of improvement in their service. With a comprehensive set of measures, healthcare plans can effectively evaluate and improve various aspects of patient care for increased patient satisfaction. 

Frequently Asked Questions (FAQs)

Who collects HEDIS data?

National Committee for Quality Assurance (NCQA) is a non-profit organization that collects HEDIS data from various health plans, organizations, and government agencies. 

How many measures are there in HEDIS?

Overall, around 92 measures in 6 domains of care in HEDIS are used to measure a health plan’s performance.  

What is the HEDIS measurement period?

HEDIS usually collects 12 months of data, starting from 1 January to 31 December. 

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