What Is HEDIS in Healthcare? A Practical Guide for Leaders
HEDIS in healthcare is the standardized set of quality measures health plans report to show how well their members' care meets evidence-based standards. This guide explains the six domains, the four data sources, and where your clinicians' documentation decides whether delivered care gets credit.
Ask "What is HEDIS in healthcare?" and most answers stop at the acronym. However, spelling out the acronym tells quality, documentation, and revenue cycle leaders very little about how HEDIS shapes their daily work.
HEDIS is a set of standardized quality measures that health plans use to score and report on the care their members receive. Screening scores depend heavily on clinician documentation; if a screening is performed but not recorded, it counts as not done.
In this article, we cover what HEDIS measures, how plans collect the data, why results affect Medicare Star Ratings, and where documentation decides whether delivered care gets credit.
TL;DR: HEDIS in Healthcare at a Glance
The key takeaways:
Why it matters: HEDIS results feed Medicare Star Ratings and plan quality bonuses.
Where data comes from: Claims, chart review, electronic clinical data, and member surveys.
What closes a measure: A documented value, date, or exclusion in the record.
Where to act: Capture measure details before the note is signed.
What Is HEDIS in Healthcare?
HEDIS stands for the Healthcare Effectiveness Data and Information Set. The National Committee for Quality Assurance (NCQA) develops and maintains it, and NCQA's HEDIS overview describes more than 90 measures across six domains of care.
The same overview notes that more than 235 million people are enrolled in health plans that report HEDIS results. That reach makes HEDIS a common yardstick for comparing how plans perform on prevention, chronic condition care, access, and member experience.
Two roles shape how HEDIS works in practice:
NCQA Maintains the Measures
NCQA keeps the measures current, updating them every year and opening new and revised measures to public comment before they take effect.
It also certifies the auditors who run the HEDIS Compliance Audit, which protects the validity and reliability of reported results.
Health Plans Report the Results
Health plans handle reporting, including commercial, Medicare Advantage, and Medicaid managed care plans.
Provider organizations supply most underlying data through claims, medical records, and electronic clinical data.
What Are the Six HEDIS Domains of Care?
NCQA groups every HEDIS measure into one of six domains. Knowing the domains helps your team see which measures depend on clinical documentation and which come from surveys or plan data.
Each domain answers a different question about plan performance:
Domain | What It Looks At |
|---|---|
Effectiveness of Care | Whether members receive recommended screening, prevention, and chronic condition care, such as Breast Cancer Screening and Colorectal Cancer Screening |
Access/Availability of Care | Whether members can get timely care from the plan's network |
Experience of Care | How members rate their care and their plan, gathered through surveys |
Utilization and Risk-Adjusted Utilization | How members use services such as hospital stays and readmissions |
Health Plan Descriptive Information | Background on the plan and its membership that gives results context |
Measures Reported Using Electronic Clinical Data Systems | Measures built on EHR, registry, and health information exchange data, such as depression screening and immunization status |
How Do Health Plans Collect HEDIS Data?
Each measure specifies which data sources a plan may use. The method matters to your organization because it determines whether a measure reads your claims, your charts, or your structured EHR data.
Plans draw on four main data sources:
Administrative Claims Data
Plans start with claims and encounter data, so the diagnosis and procedure codes on each claim carry measure evidence. CPT Category II codes are optional tracking codes, four digits followed by the letter F, that the American Medical Association (AMA) created to report performance data such as test results with less chart review.
Payers differ in how they use Category II codes as evidence, so check each payer's guidance before building them into your coding workflow.
Hybrid Medical Record Review
The Hybrid method combines administrative data with a review of a sample of medical records. NCQA has announced a phased retirement of the Hybrid method to ease the burden of manual record retrieval.
Electronic Clinical Data Systems
The ECDS reporting standard lets plans report from EHRs, health information exchanges, clinical registries, and case management systems. NCQA continues to move measures to ECDS, so your EHR data structure increasingly determines what counts.
Member Surveys
Experience-of-care measures come from member surveys such as the CAHPS health plan survey. Under contract to the Centers for Medicare and Medicaid Services (CMS), NCQA also supports the Medicare Health Outcomes Survey for Medicare Advantage members.
Why Do HEDIS Results Matter for Health Plans and Providers?
For Medicare Advantage, HEDIS is one of the data sources CMS uses to calculate Star Ratings, alongside member surveys and plan reporting, as the Star Ratings technical notes describe. Medicare Advantage contracts that include drug coverage are rated on up to 43 unique measures.
Those ratings carry financial weight. CMS's Star Ratings fact sheet states that each year's ratings affect Medicare Advantage quality bonus payments in the following year.
Reporting accuracy has consequences as well. When a HEDIS auditor designates a measure as a biased rate or not reported, the same technical notes assign the contract one star for that measure.
The pressure flows into provider networks. Plans use HEDIS to gauge the care their network providers deliver, and many build measure goals into quality programs and value-based agreements, where documentation under value-based care shapes what your organization earns.
Terms vary by payer, so review each contract's quality provisions with your revenue cycle and quality teams.
How Does HEDIS Differ From HCC Risk Adjustment?
HEDIS and Hierarchical Condition Category (HCC) risk adjustment draw on the same clinical record, so a specific, complete note supports both programs at once. They differ in what each program does with that record.
The differences show up in three places:
Point | HEDIS | HCC Risk Adjustment |
|---|---|---|
Steward | NCQA | CMS |
Purpose | Measures whether recommended care happened and what results it achieved | Adjusts payment to reflect expected cost based on a patient's documented conditions |
Effect of a documentation gap | An open care gap and a lower measure rate | An uncaptured condition and a lower risk score |
Teams that already run HCC coding reviews can extend the same discipline to quality measures. One review of the note can then serve both programs.
Where Does Clinical Documentation Affect HEDIS Results?
Every HEDIS measure defines the patients it applies to and the evidence that shows the right care happened. When a patient qualifies for a measure but the plan finds no qualifying evidence in claims, supplemental data, or the chart, the care gap stays open, and the patient counts against the plan's rate.
Two common measures show how this plays out in a note:
Measure | What Closes the Gap | Note That Leaves It Open | Note That Closes It |
|---|---|---|---|
Controlling High Blood Pressure (CBP), for adults 18 to 85 with hypertension | The most recent reading in the measurement year is below 140/90, recorded as exact systolic and diastolic numbers | "BP reviewed, stable on current medication." | "BP 148/92 at intake; recheck 134/86." |
Eye Exam for Patients With Diabetes (EED), for adults 18 to 75 with diabetes | A retinal or dilated eye exam by an optometrist or ophthalmologist in the measurement year, or a negative exam the year before | "Eye exam up to date per patient." | "Dilated retinal exam by outside optometrist (OD) on 3/14; no diabetic retinopathy in either eye." |
In both examples, the care happened. What changes the outcome is whether the note records the exact reading, or the exam date, eye care professional, and result.
NCQA revises measure specifications each year, and documentation rules vary by plan. Confirm the details against each plan's current measure guidance.
As our VP of Business Operations, Gautam Kumar, puts it, "If the note is incomplete, or for whatever reason it is inconsistent, or if there is some, you know, clinical specificity is missing, every downstream process becomes reactive."
Quality teams look for four things in the note:
Specific values: The actual reading or result, such as blood pressure numbers or a lab value, recorded in the encounter.
Dates and outside care: When a screening or exam happened, including care delivered outside your organization.
Clinical exclusions: The documented reason a patient falls outside a measure, so the record reflects your clinician's judgment.
Structured placement: Values written to discrete EHR fields, where electronic clinical data reporting can find them.
We built InstaNote clinical documentation to capture these details while the encounter is fresh, from ambient conversation or dictation, in inpatient and outpatient settings. Its speech recognition is designed not to add anything that wasn't said, and its coding suggestions help providers hand off a better-quality note for your coders to review and approve.
InstaNote CDR, our Clinical Documentation Review capability, reviews the current encounter's draft note for completeness, consistency, specificity, and quality support, including HEDIS measures where relevant. The clinician confirms every suggestion before sign-off.
Quality evidence either reaches the record at the point of care or turns into a chart chase later. At DeliverHealth, our AI-powered solutions help capture it the first time, with InstaNote for clinical documentation and InstaCode for accurate, defensible codes with credentialed coders in the loop.
InstaNote follows each provider's preferred templates and is trusted by more than 40,000 healthcare providers.
Book an InstaNote demo to watch a sample note in your specialty come together with the detail your quality measures depend on.
How Can Your Organization Improve HEDIS Performance?
Record requests and retrospective chart review are the familiar ways to close HEDIS gaps. Moving that work closer to the encounter reduces the gaps your team has to chase at reporting time.
Five practices connect documentation to measure performance:
Build measure elements into note templates: Add the values each priority measure needs to the templates your clinicians already use. A template that asks for a reading during the visit saves a record request months later.
Close gaps before the note is signed: Review notes for missing measure elements while the encounter is still open. Each gap caught before sign-off is one fewer record request during reporting season.
Record care delivered outside your organization: Capture the date and result when records arrive from outside clinics, labs, or pharmacies, so the measure reflects care that already happened.
Align coding with quality reporting: Confirm which Category II and diagnosis codes each payer accepts as measure evidence, and train coders to apply them consistently. The same steps that improve medical coding accuracy also strengthen the claims data HEDIS draws on.
Prepare your data for digital reporting: Move key measure values into discrete EHR fields that electronic reporting can read. Clean, traceable data also holds up better in a plan's HEDIS Compliance Audit.
Our InstaCode solution supports the coding side of this work, coding from InstaNote, traditional dictation, operative reports, or existing EHR notes with no change to how documentation happens.
InstaCode stays current on code updates and payer rules, keeps credentialed coders in the loop, and tracks the AI's output and every human change, with the reasoning behind it, in a built-in audit system.
Frequently Asked Questions (FAQs)
These questions come up often when teams start working on HEDIS performance:
What Is a HEDIS Care Gap?
A care gap is a member who qualifies for a measure but has no record of the recommended service, such as a screening or follow-up visit.
Some gaps reflect care that never happened, while others reflect care that happened but never made it into the record.
Is HEDIS Reporting Mandatory?
CMS requires Medicare Advantage contracts to report HEDIS unless it approves an exemption, as the Star Ratings technical notes describe.
Requirements for commercial and Medicaid plans vary by state, program, and accreditation status, so check the rules that apply to each plan.
How Often Does NCQA Update HEDIS?
NCQA updates HEDIS each year and publishes technical specifications for every measurement year.
New measures, retirements, and changes to reporting methods go through a public comment period first.
What Is a HEDIS Measurement Year?
The measurement year is the period of care a measure evaluates, and plans report results after it closes.
Medicare Star Ratings draw primarily on data from a measurement year about two years before the ratings year.
Do Physicians Report HEDIS Data Directly?
Health plans report HEDIS results to NCQA and, for Medicare Advantage, to CMS.
Physicians and provider organizations contribute the underlying data through claims, medical records, and electronic clinical data feeds.
Final Thoughts on HEDIS in Healthcare
HEDIS turns everyday clinical work into a public measure of quality, and most clinical measures are met or missed in the record first. As more measures move to electronic clinical data, the detail your clinicians capture at the point of care will carry even more weight.
Documentation is the practical place to start. At DeliverHealth, we support enterprise-level health systems, physician groups, and small and mid-size practices with AI-powered documentation and coding solutions that keep clinicians and credentialed coders in control.
InstaNote captures the encounter through ambient conversation or dictation, InstaCode turns the finished note into defensible codes with human-in-the-loop review, and the first agent on our agentic RCM layer submits prior authorization at note signing.
InstaNote returns a near-final, structured note with coding suggestions in about three minutes and works across more than 50 EHRs. InstaNote runs on our eSOne platform, which is HITRUST i1 certified.
Schedule an InstaNote demo and walk through a sample note in your specialty that captures the values, dates, and exclusions your HEDIS measures look for.
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