Data Quality and Reporting Guide

1. Review the core measures and supplemental measures.

PHMI aims to improve health outcomes and patient experience of care, provide better access to care, and increase health equity. To promote success in value-based reimbursement structures that support these goals, Performance measures were specifically chosen to align with measures in the APM measure set, as well as for
meaningful overlap with managed care plans’ (MCPs) Pay-for-Performance (P4P) measures. By working to understand and accurately report these measures now, practices will be better prepared to succeed in the MCP P4P programs, CA APM and other value-based payment structures.

The measures of focus include seven core measures and 10 supplemental measures, all from the HEDIS measure set.

Core HEDIS Measures for PHMI

Supplemental HEDIS Measures for PHMI

The measures utilize HEDIS specifications, a standardized set of healthcare performance measures developed by NCQA, with certain modifications to make them relevant to providers. HEDIS measures are used by a wide variety of institutions and initiatives in the healthcare field, promoting industry-wide alignment and opportunities for benchmarking performance, including: APM, MCP P4P, California Department of Health Care Services’ Managed Care Accountability Set (MCAS), Center for Medicare and Medicaid Services (CMS) and 90% of America’s health plans.

For more about HEDIS measures, visit the NCQA HEDIS and Performance Measurement webpage or access the full list of HEDIS measures and brief descriptions.

While HEDIS measures are specified for health plans, many other healthcare entities adapt the measures for use in other settings, including at the provider level for programs like APM and provider P4P. This is because the industry-wide acceptance and broad use of HEDIS allows for comparisons across organizations and with national standards and benchmarks, and uniformity with measures used in other healthcare programs.

Health centers may find that HEDIS measurement is a shift from the more familiar Uniform Data System (UDS) measures that are routinely reported to the Health Resources and Services Administration (HRSA). One key difference is that HEDIS measures capture all patients who are assigned to the health center from a health plan, including those who have not had an encounter. In contrast, Uniform Data System measures capture only patients who have had an encounter at the health center within the year. Using HEDIS measures offers an examination of the population that the practice is responsible for and identifies opportunities for outreach, engagement and improvement in care. Understanding the importance of this new measurement set will require education across the organization.

All staff within the practice have a role to play in performance measurement, including office staff or medical assistants who schedule patients and enter information into the patient’s medical record; clinical staff who provide and document care and services; quality and analytics staff who produce and monitor the measures; and the leaders who oversee and determine the resources available for services and performance measurement.

Each staff member should have a strong understanding of:

• What is HEDIS performance measurement?
• Why is it being done?
• How does it contribute to patient care and the organization’s overall mission?
• What is their specific role in the process to ensure team buy-in and support and the fulfillment of responsibilities?

Creating understanding of the overall purpose of PHMI, its measures and their specifications requires a multipronged approach that tailors messaging and education to the type of staff.

2. Ensure all staff understand PHMI and measures.

All staff need to understand the purpose of PHMI, the purpose and function of reporting core measures, and their personal role in measurement and reporting. An all-staff training is an opportunity to inform and engage staff on their central role in measurement and performance. Training should include all staff and providers, and be understandable by a nontechnical audience. Data Quality and Reporting 101 is a PowerPoint deck developed for health centers and intended to support this kind of training in partnership with your practice coach and subject matter experts (SMEs).

Whether you use the deck provided by PHMI or one you design independently, the training content should include:

• Explanations of the overall purpose of PHMI and the measures to be reported.
• A plain language overview or “101” of HEDIS measures.
• The basics of measure specifications and reporting.
• An explanation of each performance measure and what the care team would need to provide and document to demonstrate performance.

The key functions critical to performance measures that are shared across staff, which should be covered in the training, include:

• Providing appropriate care in a timely manner.
• Recording accurate and complete patient demographic information in the medical record, including race and ethnicity.
• Recording accurate and complete documentation of care in the medical record, and properly coding the services.
• Ensuring documentation of information related to services provided outside the practice is reflected in the medical record (e.g., following up on specialist care).

3. Ensure data and quality leads have a detailed understanding of measures and specifications.

Staff responsible for data quality and reporting activities need a thorough understanding of the technical aspects of the core measures for PHMI, their specifications and reporting requirements. Accessing, understanding and accurately applying the measure specifications is important to ensuring alignment with other reporting efforts and having accurate data to monitor population health improvement efforts.

The Core Measure Specifications Manual was developed to provide a complete orientation to the technical aspects of PHMI measurement and reporting via the PHMI Data Reporting Tool (DRT). It is targeted toward a technical audience of quality and data analytics staff, and defines and describes the following:

• PHMI background and performance measure alignment.
• Reporting timelines and instructions.
• Understanding and interpreting HEDIS specifications and value sets.
• PHMI modifications to HEDIS reporting requirements.
• General guidelines for PHMI reporting and understanding specifications.

Convene staff responsible for data and quality reporting to orient them to the manual. Have these staff fully review measure specifications independently, and then reconvene to discuss issues of clarity as well as the data governance protocols that have been established to ensure timely, accurate data collection and performance measure monitoring and reporting.