Core Measure Specifications Manual

©️ 2024 Kaiser Foundation Health Plan, Inc.

This resource is part of the Data Quality & Reporting Implementation Guide, offering steps and activities to ensure your practice is capable of reporting valid and reliable data for selected population health measures. It is the first in the “Building the Foundation” series of implementation guides.

This manual provides the measure specifications and reporting instructions to guide community health centers (CHCs) to submit their Population Health Management Initiative (PHMI) core quality measures via the PHMI’s Data Reporting Tool (DRT).

This document is meant to support accurate and complete reporting of the seven core measures that are the focus of the PHMI. The intent of these resources is to support building reporting capacity while learning more about your patient population needs. It will also support alignment with payment models such as managed care plan (MCP) pay-for-performance (P4P), California Department of Health Care Services (DHCS) and California Primary Care Association (CPCA) alternative payment methodology (APM). The key concepts and general guidelines in this manual are also applicable to supplemental measures.

Background and Performance Measure Alignment

Core measures for PHMI were specifically chosen to align with the APM measure set and meaningfully overlap with MCP P4P measures. This document supports CHCs to adopt the APM measures and to be successful in this new reimbursement structure. The alignment of core measures for PHMI with other quality initiatives aims to ensure the efficient use of CHC resources that support reporting and improvement activities.

Data Quality and Reporting Goals

The implementation guide and associated resources are meant to assist CHCs in achieving the data quality and reporting goals under the program. By working with a practice coach and subject matter experts as necessary, each CHC can achieve these goals and leverage improvements in data quality and reporting to drive their ongoing population health improvement work. To achieve PHMI data quality and reporting goals, it is recommend that each CHC complete the following steps:

• Report on the seven identified core HEDIS measures for PHMI on a quarterly basis.
• Accurately apply the defined specifications for the measure and report all relevant data.
• Have a validation process in place to ensure the accuracy of measurement and reporting.
• Incorporate the above data reporting capabilities in health center processes, policies and procedures to ensure sustainability.
• Use the proficiencies and processes gained in reporting the core HEDIS measures for PHMI to inform and improve their ability to report the supplemental measures.
• Submit their Uniform Data System (UDS) rates that align with the core and supplemental measures for their health center UDS population.

To align with APM and MCP P4P, the PHMI quality measures utilize HEDIS specifications with certain modifications provided by PHMI. This section is a resource to help CHC quality managers and reporting leads understand HEDIS and use its specifications and value sets for PHMI performance measures.

HEDIS Overview

What Is the Difference Between UDS and HEDIS Measures?

Many HEDIS measures are similar to the UDS measures CHCs routinely report to the Health Resources and Services Administration (HRSA). One key difference is who is included in the measurement: HEDIS measures performance for the population the health center is responsible for, not just for the patients who come in for services.

HEDIS is a standardized set of healthcare performance measures developed by the National Committee for Quality Assurance (NCQA). HEDIS measure specifications are developed through a committee of experts including payers, consumers, health plans, clinicians and policy makers.

The measure set allows organizations to measure, report and compare quality based on a national standard. HEDIS is used by more than 90% of America’s health plans including Medi-Cal plans and is required by regulatory agencies including CMS (federal) and DHCS (state).

While HEDIS measures are specified for health plans, many other healthcare entities adapt the measures for use in other settings (e.g., DHCS APM pilot and the MCP P4P program). Industry-wide acceptance and the broad use of HEDIS allows for comparisons across organizations and against national standards and benchmarks, and offers parity with measures used in other healthcare programs.

HEDIS Specifications from NCQA

HEDIS measure specifications are proprietary to NCQA and require purchasing a license to acquire and use full measure specifications.* It is recommended that CHCs purchase their own license to acquire an electronic copy of HEDIS specifications if the CHC does not already have access and/or does not have a population health management platform with HEDIS specified metrics included. For the PHMI, purchasing HEDIS specifications is an allowable use of grant funds.

• HEDIS® Measurement Year 2023 Volume 2: Technical Specifications for Health Plans can be found here.
• These specifications will be used in conjunction with the PHMI modifications described below to report the PHMI quality measures.

Where can I find out more about HEDIS?
General HEDIS information, technical resources and NCQA-sponsored training opportunities can be accessed through the NCQA website.

*Note: Volume 2 manuals are published annually on August 1 of the year prior to the measurement year. A Volume 2 Technical Update released on March 31 of the measurement year incorporates any updates into the specifications and value sets. If purchased prior to March 31, the MY 2023 Technical Update file must be redownloaded after the update is released on March 31, 2023, to ensure access to the updated specifications and value sets.

Each HEDIS measure specification defines the type of data collection allowed for the measure. Measures are classified by three main types: administrative, hybrid, and electronic clinical data systems (ECDS) measures. They are described below.

ADMINISTRATIVE MEASURES

Administrative measures rely on transaction or administrative data and are the least burdensome for measure calculation. They do not require manual efforts to review medical records.

Examples:

• Claims.
• Encounters.
• Lab and pharmacy codes.
• Revenue codes.

The reported rate is based on all individuals who meet the criteria in the eligible population found via administrative data.

Numerator: Includes all patients in the eligible population that received services using administrative data in compliance with requirements.

Denominator: Includes the entire eligible population for the measure.

Challenges: Most reliant on accurate medical coding and can be inaccurate if medical coding is underreported.

HYBRID MEASURES

Hybrid measures rely on transaction or administrative data, can include medical record data. Specifications for hybrid measures include administrative and medical record review specifications, including sampling.

Examples:

• Claims.
• Encounters
• Lab and pharmacy codes.
• Revenue codes.
• EHR/medical record data.

Challenges: It can be resource intensive and time consuming to collect medical record information. It is often done less frequently due to the intensity of the data collection process, which makes it harder to track progress on a quarterly basis.

The PHMI program is focused on building health center capacity to measure and report HEDIS measures using the administrative methodology with the entire eligible population as their denominator. CHCs should follow only the administrative portion of HEDIS specifications for these measures.

ELECTRONIC CLINICAL DATA SYSTEMS (ECDS) MEASURES

ECDS measures are newer versions of HEDIS measures. Of over 90 total measures, 16 are specified for ECDS with plans to expand over time. These measures collect more data than administrative measures while encouraging data exchange among health care systems.

Examples:

• Member eligibility files.
• EHRs, personal health records (PHRs).
• Clinical registries.
• Health information exchanges (HIEs).
• Administrative claims systems.
• Electronic laboratory reports.
• Electronic pharmacy systems.
• Immunization information systems.
• Disease/case management registries.

Like administrative measures, ECDS measures use the entire eligible population, which is referred to as the “initial population” for ECDS measures.

Challenges: Requires more sophisticated data processes and interoperability.

ECDS specifications may be considered at a future time but are not the focus of this specifications manual. CHCs should follow only the administrative portion of HEDIS specifications for these measures.

Supplemental Data

Across all measure types, HEDIS specifications also allow the organization to look for numerator compliance through other forms of supplemental data (e.g., a case management database, a lab file from a vendor, a record from a specialist’s EHR). These data help organizations capture services that may not be reflected in claims and encounters or within the organization’s EHR. However, supplemental data can be burdensome to collect and, due to its variability, NCQA typically applies a high level of audit scrutiny. For these reasons, NCQA and health plans are shifting away from supplemental data when possible. In alignment with this shift, PHMI will be focused on maximizing administrative data reporting and processes to ensure these external data are properly stored within the EHR in ways that are accessible to data analytic platforms used for calculating the measures.

Understanding and Interpreting HEDIS Specifications and Value Sets

To support CHCs in understanding HEDIS specifications and value sets that will be used for PHMI measurement, this section provides a general orientation to the format and terminology found in the measure specifications and value sets. Full HEDIS measures specifications include some components that are not used or are redefined for PHMI to ensure applicability to PHMI and relevance for reporting at the clinic level rather than at the health plan level. Figure 2.1 provides a sample HEDIS measure and defined components with modified or removed components for PHMI noted in blue. A table of PHMI modifications is also provided in Appendix B.

FIGURE 2.1. GENERAL FORMAT OF A HEDIS SPECIFICATION

Using Value Sets

HEDIS value sets are a companion to the technical specifications and consist of a set of codes that are used to determine whether the services or diagnoses needed for the measure were performed or are present. Each measure specification indicates which specific value sets are needed to produce the measure and how they should be applied. HEDIS® Measurement Year 2023 Volume 2: Technical Specifications for Health Plans capitalizes and underlines each value set embedded in the specifications.

For example, as shown in Figure 2.2, the Prenatal and Postpartum Care Measure Specification indicates that a postpartum visit is can be identified by a code within one of four different value sets (Postpartum Visits Value Set, Cervical Cytology Lab Test Value Set, Cervical Cytology Result or Finding Value Set, or Postpartum Bundled Services Value Set), and exclusions can be identified by two additional value sets (Acute Inpatient Value Set or Acute Inpatient POS Value Set).

FIGURE 2.2. EXCERPT FROM HEDIS® MEASUREMENT YEAR 2023 VOLUME 2

Users must reference the specifications to determine what value sets are needed and how they will be applied to the measure (e.g., to demonstrate numerator compliance, as an exclusion, etc.), and then refer to the HEDIS Volume 2 Value Set Directory (VSD) for codes in the value sets needed to report HEDIS measures. The VSD (an Excel workbook) and a HEDIS VSD User Manual are included in the purchase of HEDIS® Measurement Year 2023 Volume 2: Technical Specifications for Health Plans. An example is shown below in Figure 2.3.

FIGURE 2.3. HEDIS VALUE SET DIRECTORY

The VSD also includes Summary of Changes tabs, which list the changes to codes and value sets from the previous release. Users who are familiar with the codes and value sets can use these tabs as a quick reference. Programmers should also utilize these tabs to make applicable changes to the measure source code.

This section is a resource to be used in conjunction with the full HEDIS specifications for each of the seven core HEDIS measures for PHMI. It provides:

• An overview of the basic components of the measure.
• Which sub-measure is used for PHMI (for HEDIS measures that have more than one sub-measure within the measure).
• A reference to the full specifications.
• Any PHMI modifications from the full HEDIS specifications.

CHCs may also refer to the Data Quality and Reporting Resource 5: Documentation and Coding Playbook for more measure-specific resources from PHMI, including documentation and coding to best capture the numerator for each measure.

FIGURE 2.4: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - HEMOGLOBIN A1C CONTROL FOR PATIENTS WITH DIABETES (POOR CONTROL >9%)

FIGURE 2.5: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - CONTROLLING HIGH BLOOD PRESSURE

FIGURE 2.6: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - PRENATAL AND POSTPARTUM CARE (POSTPARTUM CARE)

FIGURE 2.7: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - COLORECTAL CANCER SCREENING

FIGURE 2.8: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - WELL CHILD VISITS IN THE FIRST 30 MONTHS OF LIFE (FIRST 15 MONTHS)

FIGURE 2.9: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - CHILDHOOD IMMUNIZATION STATUS (COMBO 10)

FIGURE 2.10: CORE HEDIS MEASURE SPECIFICATIONS FOR PHMI - DEPRESSION SCREENING AND FOLLOW-UP FOR ADOLESCENTS AND ADULTS

HEDIS measures for PHMI that have a comparable UDS measure are listed in the table below. While some notable differences in the specifications can lead to significantly different rates, tracking UDS measures in addition to HEDIS measures for PHMI will allow CHCs to understand performance for patients seen in the clinic from other lines of business.

The table also provides the National Quality Forum (NQF) identification number. NQF is a national body composed of over 400 organizations representing consumers, health plans, medical professionals, employers, governments, other public health agencies, pharmaceutical and medical device companies, and other quality improvement organizations that, through a process of consensus, vets and endorses quality measures.

FIGURE 2.11: ALIGNMENT OF HEDIS MEASURES FOR PHMI WITH UDS MEASURES AND NQF

HEDIS measures for PHMI have been adapted for applicability to provider and site level reporting, as opposed to the health plan level of reporting, with permission from NCQA.

General modifications to all measures are included in Table 2.12, and measure specific modifications are described under each measure in the core measure specifications section.

FIGURE 2.12: GENERAL MODIFICATIONS TO HEDIS MEASURES FOR PHMI