The Healthcare Effectiveness Data and Information Set (HEDIS) performance data can be used to identify and track improvement, monitor the success of quality improvement initiatives and provide a set of measurement standards that allow purchasers to compare health plans.

The Healthcare Effectiveness Data and Information Set (HEDIS) is one of healthcare’s most widely used health performance improvement tools. HEDIS measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes. HEDIS performance data can be used to identify and track improvement, monitor the success of quality improvement initiatives and provide a set of measurement standards that allow purchasers to compare health plans. This data also helps to identify performance gaps and establish realistic targets for improvement. The Healthcare Effectiveness Data and Information Set performance data can be used to identify and track improvement, monitor the success of quality improvement initiatives and provide a set of measurement standards that allow purchasers to compare health plans.

HEDIS hybrid measures are those for which information in a medical record obtained from a provider office can be used to complement claims data. This can paint a more complete picture of the care/services delivered to a patient. Administrative measures in HEDIS limit the data to what is available in claims and in some supplemental data sources such as labs, pharmacy, EMR (Electronic medical records) and HIE (Health information exchange) databases. Hybrid medical record review may provide details often not found in a claim for medical services such as:

  • Notification of inpatient admission: Documentation of inpatient admission on the day of or the day following admission.
  • Receipt of discharge information: Documentation of discharge information on the day of or the day following discharge.
  • Patient engagement: Evidence patient engagement was provided within 30 days of discharge (follow-up visit, telehealth and home visit).
  • Medication reconciliation: Evidence medication reconciliation completed within 30 days of discharge.
  • Blood pressure readings.

This HEDIS hybrid season optimizes the “chart chasing” process by ensuring a comprehensive chase logic that encompasses a plan’s specific model. The key is to capture every place a member may have accessed and received care and services, without exhausting or causing frustration among the plan’s provider network.

The best approach is to break the process down into categories:

  • Understanding timeframes, volumes and resources
  • Understanding the plan model
  • Following specialty and provider care rules
  • Utilizing a strong secondary pursuit process to ensure that relevant compliant data can be located and captured for reporting.

All of this will help plan leaders maintain momentum—and achieve success—throughout the chart retrieval season.

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 Understanding timeframes, volumes and resources

It’s important to get out of the starting gate early. In fact, launching a HEDIS collection and abstraction effort by the end of January allows for approximately 12 weeks to complete the entire project by the Hybrid Medical Record Review deadline. First, it’s important to evaluate priority chases to ensure there is enough to meet needs/goals at the measure level. Second, evaluate the volume of second level pursuits or inactive pursuits in the project and which chases are valuable to pursue.

Third, ensure there is a process to activate the second level/inactive chases immediately after review of priority chases that don’t produce a medical record with compliant data. Fourth, knowing that the deadline is unchangeable, develop a back-up plan for the project in case it falls behind schedule.

Finally, two key questions to address:

  • Are additional resources available to do collection or abstraction work if these are being done in-house?
  • If using a vendor, what is the alternative if deliverables are not being met?

Understanding the plan model

For plans that are primarily capitated, it is important that the chase logic has assignment provider rules. Since claims are often not submitted or submitted timely, chasing only claim providers can compromise efforts to identify areas where compliant services can be found. If the plan is primarily fee-for-service based, claim-related chase logic must be applied. In most cases a combination of both are used. Plans will also want to ensure that specialty rules relevant for the measures are applied. This should include consideration of telehealth in CBP, CDC and TRC measures.

Examples of assignment-based rules include:

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  • A provider assigned at the end of the measurement period (anchor date) or alternatively at the measure event date.
  • A provider assigned for the longest timeframe during the measurement period.
  • A provider assigned at the beginning of the measurement period.

Examples of claim-based rules include:

  • Primary care provider (PCP) seen most during the measurement period
  • PCP provider seen latest in the measurement period
  • PCP provider seen earliest in the measurement period

 Following Rules

There are specific specialty providers that are critical to chase logic beyond the PCP. To ensure that logic accounts for specialties that are specific to the measure being chased consider the following:

  • CDC = endocrinologist
  • CDC Eye Exam = ophthalmologist or optometrist
  • CDC Nephropathy = renal specialist or urologist
  • CBP = renal specialist or cardiologist
  • COA FSA = eye care provider, audiologist and pain specialist
  • CCS and AWC = OB/Gyn
  • COL = GI specialist or surgeons
  • PPC = OB/Gyn specialist is your priority rule over PCP
  • TRC, CBP and CDC = telehealth records

 Consider the development of all-claim providers rules that incorporate all the specialty types (including PCP and specialists) that would qualify for the measure, and keep this as a second level review repository:

  • Include all providers that wouldn’t be chased unless higher priority chases come back with negative results
  • Understand that some second level pursuits cannot be identified by chase logic (i.e. referral to specialists not captured in administrative data)

 Strong Second Level Pursuit Process

Some plans attempt 100% of all chases identified through chase logic and then cancel chases as compliant records come in. Plans using this approach must consider the challenges in prioritization and be aware of added costs and resource time as chases are worked (retrieval, abstraction and/or overread) before they can be canceled.

Some plans start with priority chases and activate others only when necessary. With this approach it’s best to include the non-priority chases as “inactive” at the outset of the project so that they can be activated quickly mitigating the risk of insufficient time to complete. Plans must also recognize the risk to provider abrasion if recontact for additional records is necessary.

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The best approach is to find a solution that supports either method. In this case, a vendor should only bill for active chases and allow chases to be canceled if not past the point of no return. This point includes when an onsite is scheduled, a record has been collected and is undergoing a quality check or is allocated for vendor abstraction.

Review of a negative record should always look for evidence that a member might have been seen for that service elsewhere. Specifically:

  • For CCS, AWC has this member been referred to an OB/Gyn for any service?
  • For CCS was there a pregnancy identified in the past five years?
  • For COL was a member referred to a GI specialist, or any referral for colonoscopy or sigmoidoscopy?
  • Is there any documentation that the member was seen elsewhere that was not captured in claims or encounters?
  • Was the member referred for labs or procedures not captured in administrative data?
  • For W15 was an immunization provider missed?

Some second level pursuits are for providers that a plan might not have within their systems—and thus there is no provider number or information to add a chase. In this case, the plan needs to be able to identify and utilize this information when second level review identifies a provider who saw a member for a compliant service not within the network.

 Recommended Process

When any record is collected it is reviewed for compliant data against the technical specifications for the measure. If the record is negative for that measure, a second level review should be completed. This review should include, but not be limited to:

  • Review for an additional chase identified within chase logic. These should be activated if found.
  • Review for any evidence of service done elsewhere not originally seen in administrative data. A new chase should be added, and plan resources dedicated to ensuring collection.
  • Thorough check of all prescriptions, authorizations, lab, and supplemental data sources.
  • Consideration of a member contact call to determine where to find relevant medical records for measures such as PPC, CCS, COL, CIS, IMA, W15.
  • Have a process to mark all negatives as exhausted so you don’t duplicate your work.

 Ultimately, the most effective approach is to partner with a comprehensive chase logic provider that uses multiple provider rules that can be prioritized to plan needs. Furthermore, utilization of a secondary pursuit repository, that identifies all pertinent provider touches the member(s) had during the measurement period, is recommended. This allows the plan to activate and chase additional providers if the priority chases do not find compliant information. Putting a considered plan in place, including the most comprehensive and effective chase logic, deployment of appropriate chase files, and careful review of records to deploy secondary pursuits, are critical stepping stones to successful HEDIS reporting.

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David Wedemeyer is vice president of quality solutions, Advantmed LLC.

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