HEDIS Measures: What CPHQ Candidates Must Know
The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used performance measurement tools in healthcare. Developed and maintained by NCQA, HEDIS measures are essential knowledge for anyone preparing for the CPHQ exam.
What Is HEDIS?
HEDIS is a set of standardized performance measures that allows consumers, employers, and regulators to compare health plan performance on an apples-to-apples basis. More than 200 million people are enrolled in health plans that report HEDIS data. The measures cover a broad range of clinical and operational areas, making HEDIS one of the most comprehensive quality measurement sets available.
Domains of Care
HEDIS measures are organized into several domains of care. Effectiveness of Care includes measures like breast cancer screening rates, colorectal cancer screening, and comprehensive diabetes care. Access and Availability of Care covers topics such as timely prenatal care and access to preventive services. Experience of Care incorporates CAHPS survey results. Utilization and Risk-Adjusted Utilization tracks metrics like inpatient stays, readmissions, and emergency department visits. Additional domains cover health plan descriptive information and measures collected through electronic clinical data systems.
Data Collection Methods
HEDIS data is collected using two primary methods. The administrative method relies on claims and encounter data to calculate measures. The hybrid method combines administrative data with medical record review for a sample of members. Understanding these methods is important for the CPHQ exam, as questions may ask about appropriate data sources for quality measurement. The shift toward electronic clinical data systems (ECDS) is also worth noting, as NCQA is moving more measures to electronic reporting.
Why HEDIS Matters
HEDIS results are used by employers to select health plans for their employees, by CMS to calculate Medicare Star Ratings, by state regulators to oversee Medicaid managed care plans, and by consumers to compare health plan quality. The standardization of HEDIS measures means that performance can be benchmarked across plans nationally, enabling meaningful comparisons that drive improvement.
Exam Tips
For the CPHQ exam, know that HEDIS is maintained by NCQA and applies primarily to health plans. Understand the difference between administrative and hybrid data collection methods. Be familiar with the major domains of care and recognize that HEDIS enables standardized comparisons across health plans. You do not need to memorize specific measure specifications, but you should understand the purpose and structure of the measurement set.