Optima Health uses Healthcare Effectiveness Data and Information Set (HEDIS®) to assess performance in meeting quality of care for our members.  Developed by the National Committee for Quality Assurance  (NCQA), HEDIS measures the care and service provided by health plans, evaluates health plans’ effectiveness of care, access, use of services and member satisfaction.

The majority of HEDIS information is from claims; however, medical record results are also incorporated into our data.

As physicians you can help facilitate the HEDIS process by:

• Providing the appropriate care within the designated timeframes
• Accurately coding all claims and encounters
• Documenting all care in the patient’s medical record

Here are some measures with tips that will help meet HEDIS documentation requirements:

2010 HEDIS® Measures

Healthcare Effectiveness Data and Information Set

Download a printable copy of the 2010 HEDIS® Measures Healthcare Effectiveness Data and Information Set

*Measures collected with medical record review

Prevention and Screening
Measure	Screening, test or care needed
* Adult BMI Assessment   Members 18-75 years of age who had an outpatient visit in the measurement year and had their body mass index documented.	Documentation in the medical record must include: ·          Date of the BMI ·          BMI value   Members younger than 19 years, documentation of BMI percentile will meet criteria: ·          BMI percentile documented as a value (75th percentile) ·          BMI percentile plotted on an age- growth chart.    Documentation of height and weight only does not meet HEDIS criteria.
*Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents   Members 2-17 years of age, who had an outpatient visit with a PCP or OB/GYN and had evidence of the following documented: ·          BMI percentile ·          Counseling for Nutrition ·          Counseling for Physical Activity	BMI Percentile documentation must includes: ·          Date of the BMI and evidence of either ·          BMI percentile ·          BMI percentile plotted on age-growth chart   Counseling for Nutrition documentation must includes: ·          A note indicating the date and evidence of at least one of the following: ·          Engagement in discussion of current nutrition behaviors ·          Checklist indicating nutrition was addressed ·          Counseling or referral for nutrition education ·          Member received educational materials on nutrition ·          Anticipatory guidance for nutrition   Counseling for Physical Activity documentation includes: ·          A note indicating the date and evidence of at least one of the following: ·          Engagement in discussion of current physical activity behaviors ·          Checklist indicating physical activity was addressed ·          Counseling or referral for physical activity education ·          Member received educational materials on physical activity ·          Anticipatory guidance for physical activity
*Childhood Immunization   Vaccines must be completed by the 2nd birthday	·          4 DTaP/DT (do not count any before 42 days of age) ·          3 IPV (do not count any before 42 days of age) ·          1 MMR ·          2 HiB (do not count any before 42 days of age) Due to shortage, only 2 required for HEDIS 2010 ·          3 Hepatitis B ·          1 VZV, positive serology, or documented chicken pox disease before 2nd birthday ·          4 pnemococcal conjugate ·          2 Hepatitis A ·          2 or 3 Rotavirus vaccine ( Dosage depends on the vaccine administered) (do not count any before 42 days of age) ·          2 Influenza with different dates of service (do not count any vaccine given prior to 6 months after birth) NOTE: Medical record documentation of “immunizations are up-to-date” is not acceptable.
*Lead Screening in   Children   (Medicaid only)   Children Age 2	Children who received at least one capillary or venous lead test on or before the child’s 2nd birthday.
*Immunizations for Adolescents Vaccines must be completed by the 13th Birthday	1 dose Meningococcal 1 tetanus, diphtheria toxoids and acelluar pertussis (Tdap)  OR 1 diphtheria toxoids (Td)
Breast Cancer Screening Ages 40-69	Women who have received a mammogram in the measurement year or one year prior.
*Cervical Cancer Screening Ages 21-64	Women who have received a PAP test within the measurement year or prior two years.
*Colorectal Cancer     Screening   Ages 50-75 Age requirement lowered to 75	Adults who received one or more of the following screenings: ·          Colonoscopy in past 10 years ·          Double contrast enema (DCBE) in past 5 years ·          Fecal occult blood test (FOBT) annually ·          Flexible sigmoidoscopy in past 5 years
Chlamydia Screening   Ages 16-24 and presumed sexually active	Women identified by claims or pharmacy data indicating potential sexual activity ·          Annual test for chlamydia
Glaucoma Screening on Older Adults (Medicare only)   Age 65 and older	Older adults without a prior diagnosis of glaucoma or glaucoma suspect who received a glaucoma eye exam by an optometrist or ophthalmologist
Respiratory Conditions
Measure		Screening, test or care needed
Appropriate Testing of Children with Pharyngitis   Ages 2-18 years		Children diagnosed with pharyngitis that were prescribed an antibiotic and received a Group A streptococcus test 3 days before or after the prescription.
Appropriate Treatment of Children with Upper Respiratory Infections   Ages 3 months- 18 years		Children diagnosed with URI and were not dispensed an antibiotic prescription within 3 days of URI diagnosis.
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis   Ages 18-64		Adults diagnosed with acute bronchitis who were not dispensed an antibiotic prescription.
Use of Spirometry Testing in the Assessment and Diagnosis of COPD   Age 40 and older		Adults with a new (within the measurement year) diagnosis or newly active COPD who received spirometry testing to confirm diagnosis.
Pharmacotherapy Management of COPD Exacerbation   Age 40 and older		Adults who had an acute inpatient discharge or an ED encounter with a primary diagnosis of COPD who were dispensed both: ·          A systemic corticosteroid within 14 days of discharge ·          A bronchodilator within 30 days of discharge
Use of Appropriate Medications for People with Asthma   Ages 5-50		Children and adults identified with asthma that received prescription for a preferred asthma therapy medications.   For a list of Preferred Medications using HEDIS criteria, please contact QI@757-5527350.
Cardiovascular
Measure		Screening, test or care needed
*Cholesterol Management   for Patients with   Cardiovascular Condition   Ages 18-75		Adults who were discharged alive for any of the following: ·          Acute myocardial infarction (AMI) ·          Coronary artery bypass graft (CABG) ·          Percutaneous transluminal coronary angioplasty (OTCA) or who had: ·          Diagnosis of ischemic vascular disease for 2 years with each of the following tests in the measurement year: ·          LDL-C screening and LDL-C control (<100 mg/dl)   Documentation must include data and results of a LDL-C
*Controlling High Blood   Pressure   Ages 18-85		Adults who had a diagnosis of hypertension with blood pressure control (<140/90) in the most recent blood pressure reading in medical chart in the measurement year: ·          The lowest systolic and lowest diastolic reading will be used if there are several BP recorded on the same date the. ·          Member reported BP readings are not acceptable.
Persistence of Beta-   Blocker Treatment After   Heart Attack   Age 18 and older		Adults who were hospitalized and discharged alive after an acute myocardial infarction who received persistent treatment with beta-blockers for six months after discharge.
Diabetes
Measure		Screening, test or care needed
*Comprehensive Diabetes   Care    Ages 18-75   **Additional exclusion criteria are  for this indicator.		Adults with annual screening of the following: ·          HbA1c testing ·          HbA1c (> 9.0 % = poor control) ·          HbA1c (< 8.0 %= good control) ·          HbA1c (< 7.0 %= good control)** ·          LDL-C ·          LDL-C (<100mg/dL) ·          Retinal eye exam ·          Nephropathy screening test or evidence of nephropathy ·          Blood pressure < 140/90 ·          Blood pressure < 130/80
Musculoskeletal
Measure		Screening, test or care needed
Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis   Age 18 and older		Adults diagnosed with rheumatoid arthritis and received at least one prescription for a disease modifying anti-rheumatic drug.
Osteoporosis Management in Women who had a Fracture   Age 67 and older		Women who received the following within 6 months of suffering a fracture: ·          Bone mineral density (BMD) test ·          Rx for a drug to treat or prevent osteoporosis
Use of Imaging Studies for Low Back Pain   Age 18 and older		Adults with a primary diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis.
Behavioral Health
Measure		Screening, test or care needed
Antidepressant Medication Management   Age 18 and older		Adults newly diagnosed with depression and treated with an antidepressant who remain on medication. The rates reported are: ·          Effective acute phase: remained on antidepressant for 84 days of the acute treatment phase ·          Effective continuation phase: remained on antidepressant for 180 days   To qualify as a new diagnosis, 2 criteria must be met: 1.        A 120-day negative depression diagnosis history on or before the start date 2.     A 90-day negative medication history on or before the start date
Follow-up Care for Children Prescribed ADHD Medication   Ages 6-12 years		Children who received an initial prescription for ADHD medication and: ·          At least one follow-up visit with a prescribing practitioner within 30 days of medication initiation ·          Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two visits within four weeks and nine months.
Follow-up After Hospitalization for Mental Illness   Ages 6 and over		Patient discharged from an inpatient mental health admission and receive: ·          One follow-up outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner on the date of discharge or up to 30 days after discharge.
Medication Management
Measure		Screening, test or care needed
Annual Monitoring for Patients on Persistent Medications   Age 18 and older		Adults on persistent medications (at least 180 days) who received the following annual lab test monitoring:   Medications Annual monitoring lab test(s) ACE inhibitors/ ARBs Digoxin Diuretics Serum potassium (K+) and either serum creatinine (SCr), or blood urea nitrogen (BUN) Anticonvulsants:   Carbamazepine   Phenobarbital   Phenytoin   Valproic Acid Anticonvulsants drug serum concentration
Potentially Harmful Drug-Disease Interactions in the Elderly (Medicare only)   Age 65 and older		Older adults who have an underlying disease, condition or health concern and who received an ambulatory prescription for a contraindicated medication, at the same time or after the diagnosis.
Use of High-Risk Medications in the Elderly (Medicare only)   Age 65 and older		Older adults who have received at least one high-risk medication and older adults who have received at least two different high-risk medications.
Measures Collected through CAHPS Health Plan Survey
Measure		Screening, test or care needed
Flu Shots for Adults   Ages 50-64		Adults who received an annual flu shot.
Flu Shots for Older Adults (Medicare only)   Age 65 and older		Older adults who received an annual flu shot.
Medical Assistance with Smoking Cessation   Tobacco users 18 and older		Current smokers who were seen by a practitioner and: ·          Advised to quit smoking ·          Cessation medications were recommended or discussed ·          Cessation strategies were recommended or discussed
Pneumonia Vaccination Status for Older Adults (Medicare only)   Age 65 and older		Older adults who received a pneumococcal vaccine.
Access/Availability of Care
Measure		Screening, test or care needed
Adult Access to Preventive/Ambulatory Care   Age 20 and over		Adults with annual ambulatory or preventive care visit.
Children and Adolescents’ Access to PCPs   Age 12 months to 19 years		Children and adolescents with a visit with their primary care physician.
Initiation and Engagement of Alcohol and Other Drug Dependence (AOD) Treatment   Age 13 and older		Adolescents and adults diagnosed with alcohol and other drug dependence who: ·          Initiate treatment within 14 days ·          Receive at least 2 AOD services within 30 days of treatment initiation
Prenatal/ Postpartum Care   Pregnant Women		Women who have received: ·          Prenatal visit within first trimester (or within 42 days of enrollment) ·          Postpartum visit between 21 and 56 days after delivery
Use of Services
Measure		Screening, test or care needed
*Well-child Exams   Ages 0-15 months		6 well-care visits (at least 2 weeks apart) with a PCP. Must show evidence of all of the following: ·          Health and development history (physical and mental) ·          Physical exam ·          Health education/anticipatory guidance
*Well-child Exams   Ages 3-6 years		At least one well-care visit with a PCP or OB/GYN. Must show evidence of all the following: ·          Health and development history (physical and mental) ·          Physical exam ·          Health education/anticipatory guidance
*Adolescent Well-Care Visit   Ages 12-21 years		At least one well-care visit with a PCP or OB/GYN. Must show evidence of all the following: ·          Health and development history (physical and mental) ·          Physical exam ·          Health education/anticipatory guidance
Antibiotic Utilization		This measure summarizes data on outpatient utilization of antibiotic prescriptions stratified by age and gender.
Outpatient Drug Utilization		This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age.

To request a copy of Optima Health's HEDIS® Performance Measures or to ask questions, please contact us.