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:

2009 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 2009 ·          3 Hepatitis B ·          1 VZV, positive serology, or documented chicken pox disease before 2nd birthday ·          4 pnemococcal conjugate 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.
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 50-80	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. ·          Spirometry testing must occur 730 days prior to or 180 days after the diagnosing event.
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 5-56		Children and adults identified with asthma that received prescription for long-term control of asthma.   NOTE: Long acting beta-2 agonists do not count by themselves. They are considered add-on therapy.
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  and had a LDL-C performed.   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. ·          Home BP readings will be used if documented in the medical chart.
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		Adults with annual screening of the following: ·          HbA1c testing ·          HbA1c (> 9.0 % = poor 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 who were diagnosed with rheumatoid arthritis that 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)