HEDIS® (Healthcare Effectiveness Data and Information Set.,) is a tool used by more than 90 percent of America's health plans to measure quality of care; access to care; and member satisfaction.  HEDIS® makes it possible to compare the performance of health plans on an "apples-to-apples" basis.  Criteria for these measures come from evidence-based standards of care.  Health plans also use HEDIS® results to see where they need to focus their improvement efforts.

  • Data is collected through a combination of surveys, on-site chart reviews and claims/encounter data.  If the encounter data do not contain evidence of the required visit, test or medication, Harbor Healthcare staff must review the medical record to determine if care was provided. For some measures, data are collected only from claims/encounters. Data from the prior year is reviewed (a measurement year ends on Dec. 31.)
  • Providers can improve HEDIS® scores significantly by submitting accurate and complete coded claims or encounter data for each service rendered.  This is the most efficient method to report HEDIS®, which helps ensure chart reviews and visits to providers are kept to a minimum.
  • HEDIS® contains 80 measures across five domains of care, which are: Effectiveness of care:  i.e., immunizations, cancer screenings, diabetes care, weight assessment, appropriate treatment for acute and chronic illnesses, etc.  Access/availability of care.  Experience of care: measured by a survey called Consumer Assessment of Healthcare Providers and Systems (CAHPS). Utilizations and relative resource use:  i.e., frequency of selected procedures, well-child visits.  Health plan descriptive information. 


  • HEDIS® data ensures that optimal healthcare and service are provided to our members.
  • Helps you identify non-adherent members so you can ensure they receive needed services.
  • Provides information on how you compare with local providers and how you rank nationally.
  • It is also the centerpiece of health plan “report cards” and is the basis for incentive programs.


  • Submit accurately coded claims/encounters data for each service rendered in a timely manner.
  • Keep accurate, legible & complete medical records.  Utilize your EMR templates & reminders.
  • Ensure timely & appropriate preventive screenings, services, tests & vaccines are performed.
  • Perform needed screenings, services, test, or procedures when members are in your office. Many patients may not return for annual preventative care visits or go to a lab as instructed.
  • Consider doing a well-care/preventative exam during sick visits, sports physicals, or during preschool and daycare physicals. 
  • Allow access to or provide records when requested by Harbor Healthcare staff.
  • Evidence shows that clinicians with strong patient-centered communications skills tend to have:
    • Stronger, more trusting relationships with their patients
    • More productive visits because of a more focused and better prepared patient
    • More engaged and activated patients
    • Better patient outcomes and improved quality scores
    • Higher levels of information sharing and adherence
    • Fewer patient requests for unnecessary tests
    • Fewer medical errors and malpractice claims
    • Exceptional patient experiences

HEDIS TIP SHEET Pediatric and Adolescent