HEDIS includes standardized measures that assess care quality in key areas such as preventive screenings, chronic condition management, behavioral health and child and adolescent wellness.

Examples of HEDIS Measures:

• Cancer Screenings: Breast, cervical and colorectal cancer
• Diabetes Care: Eye exams, glycemic control, kidney evaluations
• Cardiovascular Care: Blood pressure control
• Immunizations: Childhood and adolescent vaccination rates
• Mental Health: Antidepressant medication management, follow-up after hospitalization or ED visits
• Other Measures: Chlamydia screening, prenatal/postpartum care and well-child visits

Partners works with Carolina Complete Health (CCH) to collect HEDIS data and collaborates with providers to ensure timely, high-quality care delivery. Visit CCH’s website for additional HEDIS resources.

HEDIS rates are determined using two main data collection methods:

• Administrative Data: Derived from claims or encounter data submitted to the health plan. Common examples include screenings (e.g., Pap tests), medication adherence and mental health services.
• Hybrid Data: Combines claims data with chart reviews of sampled medical records. This captures services not reflected in claims, such as immunizations or blood pressure readings.

Why it matters: Accurate, timely claims help reduce the need for medical record reviews and ensure providers get full credit for the care they provide.

HEDIS scores are calculated using weighted measures, based on the impact of each type:

• Triple-weighted (3 points): Outcome-focused (e.g., blood pressure control, A1c levels, immunizations)
• Double-weighted (1.5 points): Patient experience measures
• Single-weighted (1 point): Process measures (e.g., screenings)
• Partial-weight (0.5 points): Race/ethnicity diversity of membership

Partners’ current triple-weighted HEDIS measures include:

• BPD – Blood Pressure Control for Patients with Diabetes
• CBP – Controlling High Blood Pressure
• CIS-E – Childhood Immunization Status (Combo 10)
• GSD – Glycemic Status in Diabetes
• IMA-E – Adolescent Immunizations (Combo 2)

Partners uses the Model for Improvement, developed by Associates in Process Improvement and supported by IHI, to drive performance enhancements.

This model includes:

• Three Fundamental Questions:

1. 1. What are we trying to accomplish?
   2. How will we know a change is an improvement?
   3. What change can we make that will lead to improvement?

• PDSA Cycle (Plan-Do-Study-Act): Used to test and refine changes before wide implementation.

Visit IHI Open School to learn more.

Launching a successful improvement initiative begins with structured planning:

Steps include:

• Forming a cross-functional team
• Writing a SMART aim (Specific, Measurable, Attainable, Relevant, Time-bound)
• Defining eligible populations and performance measures
• Creating a data collection plan

SMART Aim Example:
“Increase the rate of postpartum care visits among eligible members from 45% to 65% by December 31, 2025.”

Reliable data collection is essential for evaluating improvement.

Your plan should include:

• Clearly defined data sources
• Assigned data collectors (internal or vendor)
• Tools (e.g., spreadsheets, logs)
• Step-by-step process documentation

Baseline and remeasurement data must be collected using the same methodology to ensure valid comparisons.

Care gaps occur when recommended care isn’t received, often due to:

• Missed screenings or vaccinations
• Delayed diagnoses or follow-ups
• Difficulty accessing behavioral health services
• Medication nonadherence
• Infrequent well-child visits

Strategies to close gaps:

• Educate and engage patients
• Promote preventive care
• Use telehealth and patient portals
• Coordinate across care teams
• Submit accurate and complete claims data

Some gaps may reflect data capture issues, not actual missed care. Ensure services are documented via:

• Correct coding on claims
• Supplemental data through electronic feeds

Electronic data feeds (Electronic Data Interchange) enable secure transfer of clinical information, improving reporting accuracy and reducing administrative burden.

Data feed sources may include:

• Electronic Health Records (EHRs)
• Electronic Clinical Data Systems (ECDS)
• Electronic Data Capture (EDC) systems
• Lab and imaging systems
• Medical devices and wearables

Benefits:

• Captures services not found in claims
• Reduces medical record requests
• Enhances HEDIS reporting
• Lowers admin costs
• Improves care management

Partners can assist with file formatting and setup to streamline your data-sharing process.

After implementing changes, it’s essential to evaluate impact and plan for sustainability.

Steps include:

• Reviewing which interventions were most effective
• Identifying what can be scaled to other areas
• Documenting lessons learned
• Embedding improvements into long-term processes

This ensures quality initiatives continue to deliver value beyond the life of the project.

Stay informed and aligned with HEDIS MY2025 expectations. Use these quick-reference guides to support accurate coding, improve care delivery and close gaps in care.

Practitioner Clinical Guide – HEDIS MY2025: Adult Measures
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Outlines preventive and chronic care measures relevant to adult populations, including screenings, diabetes care, cardiovascular health and more.

Practitioner Clinical Guide – HEDIS MY2025: Pediatric Measures
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Covers pediatric and adolescent measures including immunizations, well-child visits and behavioral health screenings.

Practitioner Clinical Guide – HEDIS MY2025: Behavioral Health Measures
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Focuses on key behavioral health measures, such as medication adherence, follow-up after hospitalization and emergency department visits.

Practitioner Clinical Guide – HEDIS MY2025: Pharmacy Measures
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Details pharmacy-specific HEDIS measures, focusing on medication adherence, appropriate prescribing and medication safety.