Frequently Asked Questions
General Administration Questions:
What is Population Health Navigator (PHN)?
What are some of the features of PHN?
How do I get an account?
How do I get assistance with PHN?
What are some of the strengths and limitations of PHN?
If my command is already using another database or disease registry, do I need to use PHN?
Methodology Questions:
Can an MRI replace mammography and count as breast cancer screening for HEDIS?
What patients are included in the metric displayed on the PHN Dashboard for “Asthmatics with Steroids (Navy)”?
How can I identify why a patient has been included in the Action List?
What do I do if, after researching M2, the Action List still appears to be in error?
How can I remove a patient who has been coded in error from the Action List?
How can I use the PHN action lists?
How does the Action Report differ from the HEDIS® denominator?
Where does the data for PHN come from and how often is it updated?
How is enrollment determined?
Where can I find the methodology for PHN?
How did the PHN derive the methods used?
Why do you put information on high utilizers on the PHN?
Why does the PHN data not reflect what I see in the medical record?
There are patients on my Action List who are no longer enrolled to my facility. How can I get them off the Action List?
How can I update or correct a beneficiary's information in DEERS?
Patients on my diabetes or asthma Action List do not have diabetes or asthmas. How can I have them removed from the Action List?
Why does the Action List provide a lab test date but not a result for some patients?
How can I ensure that a woman who has had a hysterectomy is not included in the Cervical Cancer screening Action List?
How can I ensure that a woman who has had a bilateral mastectomy is not included in the Breast Cancer screening Action List?
Will patients with Gestational Diabetes be on my Action List?
How can a MTF get credit for the lab results and procedures that were not captured by M2?
HEDIS® Questions:
What are HEDIS® metrics?
How do I compare our HEDIS® metrics?
Are all Portal Methods based on HEDIS®?
How do the Portal Methods compare to HEDIS®?
How does the MHS Portal measurement year compare th the HEDIS® measurement year?
Why are the denominators in the HEDIS® metric and the Action List different?
To be continuously enrolled, must a beneficiary be enrolled to the same DMIS for the specified period?
How do I know which patients are in the HEDIS® denominator?
How do I know which patients are HEDIS® eligible?
General Questions
What is Population Health Navigator (PHN)?
PHN is a new secure, web-based tool that has been selected by BUMED as the medical informatics tool to be utilized by Military Treatment Facilities (MTFs). In addition to assisting with population health and process improvement efforts, PHN allows MTFs to assess data quality, enrollment management, demand forecasting, utilization of services, and the quality of healthcare provided to beneficiary populations. PHN also serves as the centralized data source for reporting an MTF's clinical performance in the annual BUMED Business Plan.
The PHN transforms DoD and Network healthcare data into actionable information and identifies MTF TRICARE Prime enrollees in need of clinical preventive, disease management or case management services. PHN allows easy access to standardized metrics and predefined queries for 14 clinical preventive services, diseases and conditions. The modules include: asthma, beta-blocker use following myocardial infarction, cardiovascular risk factors, breast cancer screening, cervical cancer screening, depression, diabetes, hypertension, COPD, hyperlipidemia, low back pain and high utilizers.
What are some of the features of PHN?
PHN is easy to navigate with four primary sections: demographics, preventive services, disease/condition management and administration.
- The Demographics section provides facilities an aggregate view of their enrolled population stratified by age and gender.
- The Preventive Services section provides detailed methodologies, aggregate reports and provider level patient action lists for various screening procedures (e.g., breast cancer, cervical cancer, cardiovascular risk factors, etc.).
- The Disease/Condition Management section provides detailed methodologies, aggregate reports and provider level patient action lists targeting patients with coded diagnoses for numerous diseases/conditions (e.g., asthma, diabetes, high utilizers, etc.).
- The Administration tab contains downloadable administrative data and contact information. It contains documents including a consolidated methodology manual, user’s manual, frequently asked questions, and solutions to commonly encountered data quality issues.
PHN delivers both corporate level (HEDIS®) metrics to compare healthcare quality and patient-level information in easy-to-use action lists. Depending on the module, data includes demographic information, utilization data, laboratory results, pharmacy information, and radiological studies. Within the program, any of the fields can be sorted. Action lists can be manipulated either directly in the program or downloaded into spreadsheets and databases. Data can also be exported into statistical programs for more elaborate analyses.
- For larger files that may take some time to download, you may select to have the report generated by selecting the radio button labeled “File.” When the report is complete, you will be notified via email, and can retrieve the file in the Administration section under “Generated Reports” and quickly download the spreadsheet.
- The ability to filter for a specific PCM provider to display their enrollee panel and search for a specified patient by name to expeditiously locate healthcare information.
- The ability to make annotations within the action lists regarding patient care. Although these notes do not feed back into CHCS, the healthcare team members can utilize them to assist in managing their cohort of patients.
Note: Due to Health Insurance Portability and Assurance Act (HIPAA) and the Privacy Act requirements, the Navy and Marine Corps Public Health Center (NMCPHC) requires assurance from the requesting command or unit that access to sensitive personal health information (PHI) will be protected.
Two-Step Process for Applying for a PHN Account
Step 1: Complete DD Form 2875, System Authorization Access Request (SAAR)
One form per account request must be sent to the Navy and Marine Corps Public Health Center (NMCPHC). This form consists of two pages with information and one page of instructions. Once the form is verified, NMCPHC will activate the account and notify the applicant via phone or email.
- Applicants will need to complete Part I and comply with block 27. Department Head/Director is to complete Part II and sign in block 18. Leave blocks 21-25 and Part III blank.
- Applicants will also need to notify NMCPHC when they leave, transfer, or no longer require access to PHN data so that their account may be terminated or changed to their gaining facility. Military members and Contractors are to specify their PRD or contract expiration date in block 16a.
- DD Form 2875s will be maintained by the PHN Help Desk Administrators.
Applicants may send the DD Form 2875 by one of the following methods below. If assistance is needed, contact the PHN Help Desk at phn-help@nehc.mar.med.navy.mil or by phone at 757-953-0954/0717, DSN 377-0954/0717:
- FAX (secure) – NMCPHC will contact the official listed in Part II to verify the request and activate the PHN account (FAX: 757-953-0685 or DSN 377-0685).
- EMAIL – Complete, sign and scan the form, then send to phn-help@nehc.mar.med.navy.mil
Because the form includes SSNs, the form must be sent by encrypted email or as a password protected file. The password should be sent in a separate e-mail or called in to the PHN Help Desk. If sent by the signing official in Part II, NMCPHC will activate the user account immediately. If sent by the requester, NMCPHC will need to contact the signing official for verification and will not activate the account until such verification is provided.
- MAIL – NMCPHC will contact the official listed in Part II to verify the request and activate the user account. Mail form to:
Navy and Marine Corps Public Health Center
Attn: PHN Help Desk
620 John Paul Jones Circle, Suite 1100
Portsmouth, VA 23708
Step 2: Request Access through the MHS Population Health Portal
In addition to submitting the DD-2875, the applicant needs to log on to the CAC-enabled MHSPHP website (https://pophealth.afms.mil/tsphp), click "Request Access" and complete the online application. Once submitted, the applicant will be given a user name and temporary password. This page should be printed or saved for reference when account is activated. (Note: Proper syntax for upper and lower case letters should be used when entering user name, as improper use interferes with the alphabetical listing of users within the administrator site at the NMCPHC.)
The NMCPHC Help Desk can be contacted at 757-953-0954/0717 (DSN 377) or via email at phn-help@nehc.mar.med.navy.mil.
How do I get assistance with PHN?
If you forget your password, log onto https://pophealth.afms.mil/tsphp/ and click the “Forgot Password?” link. The Service Center staff at Population Health Support Division in San Antonio will promptly respond to your request. If you are experiencing difficulties with establishing your account, please contact the PHN Help Desk at phn-help@nehc.mar.med.navy.mil or by phone at 757-953-0954/0717, DSN 377-0954/0717:
Methodology supporting each metric is included within PHN. Additional PHN resources are available on the NMCPHC website: http://www.nmcphc.med.navy.mil/prevmed/PopHealthNav.htm
If you have more detailed questions or concerns, please contact the PHN Help Desk via email or NMCPHC staff, phn-help@nehc.mar.med.navy.mil.
For assistance with implementation of Population Health Initiatives or obtaining other available resources you can also contact your local Healthcare Support Office (HSO) representative.
What are some of the strengths and limitations of PHN?
Strengths of PHN include:
- Provides both corporate-level data (HEDIS® metrics) to compare clinical quality AND is able to provide patient, provider, and clinic level data.
- Provides data on patient care regardless of where care is provided (e.g., throughout entire military health system, both inpatient and outpatient care, both network- and MTF-delivered care).
- Can be exported and displayed in Excel® and other programs for further manipulation and analysis.
Some of the limitations of PHN included:
- Data is updated monthly with a 4-6week lag time.
- Because PHN data comes from M2, there is some delay in posting of network care. Additionally, lab results from network care is unobtainable.
- PHN only provides data for enrolled beneficiaries.
- PHN only provides data for predefined modules. The database can not be queried for other conditions not specified (e.g., congestive heart failure, otitis media).
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If my command is already using another database or disease registry, do I need to use PHN?
Some commands have the technical expertise and informatics support to have developed their own databases or disease registries. These local resources provide more up-to-date information and allow the commands to create queries besides those already defined by the PHN, but may not be able to collate data provided outside of the local MTF. Assuming that clinical quality relies on the population health interventions and not on the medical informatics program used, any improvement in the provision of healthcare by the MTF will be reflected in the PHN. Thus, commands are able to use other medical informatics programs (e.g., SQL servers, local databases), but the clinical quality metrics that are reported to BUMED (and the Surgeon General’s dashboard) are obtained from the HEDIS® metrics as reported in the PHN. Consequently, it is advised that commands should be familiar with (and have an account for) PHN.
Methodology Questions
Can an MRI replace mammography and count as breast cancer screening for HEDIS?
Do not count biopsies, breast ultrasounds or MRIs for this measure because they are not appropriate methods for "primary breast cancer screening."
Many women have implants and there are certain methods of doing mammograms for pts with implants that are the preferred method of screening. It is up to the patient and provider to determine what is best for a particular patient. However, MRI cannot count towards HEDIS.
MTFs are not expected to reach 100% of their enrolled patients, as there will always be unique circumstances. What the MTF can do is exclude this patient from the action list in the MHSPHP if the provider determines it is "clinically inappropriate" for this patient to have a mammogram. This should be supported by a note in AHLTA (and the note pointed to in the exclusion comment). The provider could simply note the pt had a bilateral MRI of the breasts and doesn't need further breast cancer screening until (specify a date). If the provider believes the pt still needs a mammogram and won't write such a note, then the patient could be excluded from the action list for refusing to have a mammogram, if that is the case. Again, the comment should point to a note in AHLTA that describes the patient refusal. The exclusion will not impact HEDIS, but will take the patient off the medical home metric.
The ICD9 code v76.51 is defined as "Special screening for malignant neoplasms, colon". This code should only be used when a screening test is completed (not just discussed). It is appropriate, though not mandatory, to use this ICD9 code when any colon cancer screening test is performed, to include virtual colonoscopy, colonoscopy, etc. However, the provider must also include the proper CPT codes for the test performed. HEDIS interprets the ICD9 code v76.51 as meeting the same requirements as an FOBT--which means the individual would be considered current for one year from the date of this code. The MHSPHP data will display the date of this code as an FOBT date as per HEDIS definitions. The MHSPHP also displays the dates of colonoscopy, flex sig, virtual colonoscopy as picked up by the CPT codes of the procedure.
In summary, here are examples of how this impacts MTF data:
- An FOBT and colonoscopy with matching dates on a patient list when the pt only had a colonoscopy.
- Although not recommended as a CPS by the USPSTF, virtual colonoscopies would count as a completed colon cancer screening in HEDIS metrics for one year from the test date if the provider used an associated v76.51 code.
As always, providers should consult their local coding staff.
The “Asthmatics with Steroids” measure is a Navy measure rather than a HEDIS measure.
- Age restriction (5-56 age range) is NOT applied. Patients included can be of any age.
- Two year continuous enrollment is NOT applied.
- Inclusion does not have to meet HEDIS asthma criteria for the past 2 years (i.e. in order to be counted in the denominator for HEDIS, a patient must meet the criteria for persistent asthma for the measurement year AND the year prior). Patients only have to meet the criteria for the current year to be included.
How can I identify why a patient has been included in the Action List?
The main source for healthcare data comes from the MHS Management Analysis and Reporting Tool (M2), which can extract data from inpatient and outpatient MTF and network encounters, the Defense Manpower Data Center, and the Pharmacy Data Transaction Service (PDTS). Clinic Managers and Disease Management staff will need to work with their local M2 account holder at times to understand where, when, and why individual patients are captured in the denominator.
What do I do if, after researching M2, the Action List still appears to be in error?
MTFs can contact individuals within their regions who have expertise in using M2 or forward a representative sample of patients, including full names and last-4, in an encrypted email to the PHN Help Desk at phn-help@nehc.mar.med.navy.mil. MTFs can also pose questions of a general nature about coding or methodology.
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How can I remove a patient who has been coded in error from the Action List?
Only the clinician who coded a patient encounter can amend it. This also applies if a patient enrolled at one MTF is seen at another MTF, which often occurs with emergency room visits. If a network encounter coded the patient as having a certain condition, and billing has already been processed for the encounter, it is probably too late to amend the encounter.
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How can I use the PHN action lists?
The PHN provides patient-, provider- and clinic-specific data for enrolled patients for selected conditions along with their demographic data, laboratory results, utilization data and medications. These lists can be downloaded into other programs (e.g., Excel®, Access®) to allow more detailed analyses; to assist with patient tracking, population health and process improvement initiatives; to create mailing lists, contact information and data registries; to compile data for individual providers, clinic teams, and clinic locales; and to assess compliance with more stringent metrics (e.g., HbA1c <7%).
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How does the Action Report differ from the HEDIS denominator?
HEDIS® denominators are based on continuous enrollment, age, and other technical specifications. Patients on the Action Report are those meeting clinical requirements but not necessarily age or continuous enrollment HEDIS® requirements.
Where does the data for PHN come from and how often is it updated?
The data presented in PHN is obtained from DEERS, M2, PDTS (Pharmacy Data Transaction Service) and CHCS downloads (for laboratory results, radiology studies, and PCM information). The dataset reflects inpatient and outpatient care, from both military and network treatment facilities provided to MTF enrollees. PHN is updated monthly with an estimated 4-6 week lag time. PHN states how current the data is (i.e., when the data was last pulled) by providing a banner at the top of the screen, “Information current as of: …â€
The predominant source for measures comes from MHS administrative data from the MHS Management Analysis and Reporting Tool (M2), formerly the All Region Server (ARS) Bridge. The M2 is an informational system built by the Executive Information/Decision Support (EI/DS) Program Office in conjunction with the TRICARE Management Activity, Health Program Analysis and Evaluation (HPA&E) Directorate. The M2 is a set of MHS data files from military treatment facilities, managed care support contractors, the Defense Manpower Data Center, and Pharmacy Data Transaction Service (PDTS) that are incorporated into a central database. The inpatient, outpatient and pharmacy data from both network claims and direct care encounters stored in M2 are used to produce the products seen in the PHN.
Because significant lag times exist from the date of service to the final posting of the network claims records in the M2, timing of the data extraction plays a significant role in the completeness of data for the measures. The time it takes to file, adjudicate and pay a claim and then post the record to the M2 for analysis is not the same for all patient records. Although most claims are adjudicated and paid within a few months of billing (inpatient care sooner than outpatient services), this adjudication may be months from the actual date of service.
The Defense Eligibility Enrollment Reporting System (DEERS) computerized database is used to identify military sponsors, families and others worldwide who are entitled, under the law, to TRICARE benefits. An individual who is eligible for TRICARE medical benefits and is authorized treatment in an MTF is eligible to enroll in TRICARE Prime. TRICARE Prime is a managed care option similar to a civilian health maintenance organization (HMO) that requires active enrollment. All military personnel should complete a TRICARE Enrollment Form at their current duty station to enroll in the TRICARE Prime Program. In some regions, active duty service members may be automatically enrolled; however, most active duty service members are required to actively enroll in TRICARE Prime. Active duty family members, retirees and their family members are encouraged, but not required, to enroll in TRICARE Prime.
Consequently, enrollees are those individuals registered in the DEERS who are enrolled in the MTF TRICARE Prime care option. Those TRICARE Prime enrollees who are enrolled with a network contractor (outside the MTF) as their Primary Care Manager do not meet this criterion and are not included in these PHN reports.
Where can I find the methodology for PHN?
You will need a PHN account to access the methodology document. From the PHN website, click on Population Health Navigator, then click on the Administration tab, then click on Administration Section. Finally, click on Manage Documents.
How did the PHN derive the methods used?
A major challenge in measuring and monitoring our health care is defining measures that relate to a relevant outcome, and that can be systematically applied across the MHS and other healthcare plans. A national standardized set of measures that assesses the performance of managed care organizations have been established by the National Committee for Quality Assurance (NCQA). The Health Plan Employer Data and Information Set (HEDIS®) was developed to provide reliable, comparative data about health care quality, using data from health plans across the country and is intended to monitor how well health plans are delivering preventive care (e.g., breast cancer screening, cervical cancer screening), how well members with acute illnesses (e.g., acute back pain) are managed to avoid or minimize complications, and how well members with chronic diseases (e.g., asthma, diabetes ) are managed to avoid or minimize complications. There are many HEDIS® measures but those selected for use in the PHN are related to outpatient processes of care and include:
- Cervical cancer screening rates (Pap smear exams)
- Breast cancer screening rates (mammography)
- Use of appropriate medications for people with asthma
- Diabetes care (HbA1c testing and control, retinal exams, LDL screening and control).(three measures)
- Colon cancer screening rates
Why do you put information on high utilizers on the PHN?
Analysis of health care service utilization is a key component of population health management. Information indicating the number of provider visits per member per year (PMPY) establishes a comparative baseline and identifies patients with significantly “low or high” utilization. Low utilizers may represent an at-risk group who can be targeted for delivery of preventive services while high utilizers may be potential candidates for disease and case management strategies. Reducing the rate of utilization can effectively reduce demand and facilitate recapture of care from the private sector.
Why does the PHN data not reflect what I see in the medical record?
Some of the main MHS encounter and claims data limitations center around two issues: completeness and consistency. Completeness usually depends on the provider’s willingness to accurately reflect findings and procedures during an encounter. Within a fee-for-service environment (i.e., Network providers), there is great incentive to completely document an encounter because they are paid for what is documented. No equivalent benefit exists within the direct care (MTF) arena to "reward" complete documentation. However, even in the network care setting, complete diagnosis and procedure documentation for each encounter is not always required. For example, prenatal care is often paid for on a "bundled" per-visit basis; no individual encounters are documented since no individual charges were incurred. Additionally, just because someone is enrolled does not mean they actively seek care within the MHS. Despite accessing care through other venues (e.g., Medicare or secondary-party payers), in these analyses the assumption is made that they did not receive care.
Consistency of data is also a problem given the wide latitude in how diagnostic codes are assigned and the level of detail used in reporting services rendered. Since the direct care and network data collection systems are different (encounter vs. claims), consistency issues are magnified within the M2 data set. The use of varying coding structures to meet a clinic’s own administrative needs or the use of different "pick lists" among providers further complicates the issue.
There are patients on my Action List who are no longer enrolled to my facility. How can I get them off the Action List?
The Clinical Informatics Branch (CIB) is not the primary source of DEERS enrollment data; CIB receives a file each month that is a "snapshot" of DEERS on a single date. The date displayed on the MHS Portal represents the date of the DEERS enrollment file used to update the metrics and action lists. This often leads to confusion since MTFs often have access to view "real time" DEERS.
topHow can I update or correct a beneficiary's information in DEERS?
Medical personnel cannot update or alter a beneficiary's information in DEERS. Only the sponsor or beneficiary can initiate changes within DEERS. Any information updated in the patient record will not be reflected in DEERS.
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Patients on my diabetes or asthma Action List do not have diabetes or asthma. How can I have them removed from the Action List?
CIB has access to all encounters in the direct care system and the network, as well as prescriptions, laboratory tests and x-rays. If a patient is included in an Action List, it is very likely that at some point he or she was coded with the condition. Common errors include coding gestational diabetes as diabetes and wheezing as “asthma.” The encounters and/or prescriptions that met the criteria for the patient to be included may be accessed through M2, but if the problem is not visible at the local MTF, contact your service representative/CIB Service Center concerning specific patients. CIB staff should be able to assist you in determining why a patient was included.
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Why does the Action List provide a lab test date but not a result for some patients?
Lab tests that are accomplished in the direct care system and logged in the Clinical Chemistry subscript of CHCS are electronically transmitted to CIB each month, including test results. Lab tests accomplished in the Network are captured via billing data, which do not include test results. Therefore, if a test is accomplished in the Network, the Action List will reflect only the test date. If the test was covered by other health insurance (OHI) or done in the VA system, those data will not be reflected in Portal data.
How can I ensure that a woman who has had a hysterectomy is not included in the Cervical Cancer screening action list?
If a woman undergoes a hysterectomy in Direct Care or the Network and the procedure was captured electronically in the M2, she should be automatically excluded. However, many women may have undergone hysterectomy prior to the implementation of electronic medical records (1998) or their surgery may have been performed outside the direct care system. In these cases, a coded encounter must be created using the ICD-9-CM code V88.01 (acquired absence of Uterus and Cervix), which has replaced the older code of V45.77 1. Once such a coded encounter is captured by the M2, the patient should be excluded from the HEDIS® denominator, as well as from the Action List. In the Quicklook page, a date of '9/9/9999' in the Pap column indicates that the woman has been coded as having undergone hysterectomy.
How can I ensure that a woman who has had a bilateral mastectomy is not included in the breast cancer screening action list?
If a woman undergoes a bilateral mastectomy in Direct Care or the Network and the procedure was captured electronically in the M2, she should be automatically excluded. However, some women may have undergone bilateral mastectomy prior to the implementation of electronic medical records (1998), or their surgery may have been performed outside the direct care system. In these cases, a coded encounter must be created using the ICD-9-CM code V45.71 with the DOD extension of V45.713 (acquired absence of Bilateral Breasts). Once such a coded encounter is captured by the M2, the patient should be excluded from the HEDIS® denominator, as well as from the Action List. In the Quicklook page, a date of '9/9/9999' in the Mammo column indicates that the woman has been coded as having undergone bilateral mastectomy.
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Will patients with Gestational Diabetes be on my Action List?
Patients coded for Gestational Diabetes 648.8x with no history of Type 1 or Type 2 Diabetes will automatically be excluded from the Diabetes HEDIS® denominator and the Diabetes Action List. If a woman is coded with diabetes (250.xx) and is or was pregnant during the measurement year, she will appear on the Action List.
The following information is provided to assist providers in correctly coding women during pregnancy.
Code 648.0X: Diabetes Mellitus Complicating Pregnancy:
This subcategory consists of pregnant women with preexisting diabetes mellitus whose diabetes in some way complicates the pregnant state, is aggravated by the pregnancy, or is a main reason for obstetric care. In practice, this includes virtually all pregnant women with diabetes since pregnancy almost always aggravates diabetes mellitus; the diabetes frequently complicates the pregnancy as well. Therefore, for pregnant women with preexisting diabetes mellitus, code 648.0X is assigned with a secondary code for the type of diabetes. Code 648.0 is the correct code to use for women who are diagnosed with diabetes before pregnancy occurs but who are now pregnant or who were pregnant during the measurement period. Their diabetes may be exacerbated by the pregnancy state but they do not have gestational diabetes. Any woman with diabetes who becomes pregnant and is correctly coded as 648.0 should never be coded later as 648.8. The codes are mutually exclusive.
Code 648.8X: Abnormal Glucose Tolerance Complicating Pregnancy (Gestational Diabetes):
This diagnosis code indicated an abnormal glucose tolerance appearing during pregnancy in previously nondiabetic women and resolving during the postpartum period. These patients are placed on a diabetic diet and may require insulin therapy to maintain normal blood glucose levels during pregnancy as well as may be at increased risk for the subsequent development of Type II {NIDDM}. Women who are NOT diagnosed with diabetes prior to pregnancy but who demonstrate abnormal glucose tolerance during pregnancy should be coded as 648.8, gestational diabetes.
How can a MTF get credit for the lab results and procedures that were not captured by M2?
If no claim was or will be sent to TRICARE for reimbursement (e.g.,
because of VA care or Other Health Insurance), documented results from other
facilities for procedures & labs OR verbal statements from patients for
surgeries such as mastectomies or hysterectomies can be entered in the
Historical Procedures/OMH module of AHLTA (exception: virtual colonoscopies
will not receive credit for colon cancer screening). Reminder: do not enter
items in Historical Procedures that will later be captured through claims
data.
HEDIS® Questions:
The Health Plan Employer Information Set (HEDIS®) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS® are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. The metrics are voluntarily collected and reported by numerous health care organizations and systems throughout the United States. By embracing this existing set of metrics, the performance of Navy Medicine may be compared directly to the performance of health care organizations outside of the military health system. HEDIS® metrics meet the needs of Congress and DoD Health Affairs who are presented with comparative data on the services and are called to justify the cost of our care. From a clinical perspective, HEDIS® metrics are rather liberal and are best seen as a "starting point" for a broader clinical quality improvement metrics set, rather than representative of the current standard of care.
PHN provides these nationally-recognized HEDIS® metrics allowing commands to thereby measure the quality of healthcare provided to their enrolled beneficiaries. The national benchmarks for the various HEDIS® metrics can be found within the respective PHN methodology sections. More information on HEDIS® metrics can be found at: http://www.ncqa.org/Programs/HEDIS/.
How do I compare our HEDIS® metrics?
Although PHN provides clinics and MTFs with their HEDIS® measures, it does not allow access to, or comparisons with, other clinics or MTFs. In order to allow comparison with other facilities, the Navy and Marine Corps Public Health Center (NMCPHC) has worked with Navy Medicine Information Systems Support Activity (NAVMISSA), formerly the Navy Medical Informatics Management Center (NMIMC) to produce the Population Health Navigator Metrics Dashboard.
This dashboard displays HEDIS® performance for all Navy MTFs, Navy averages, and national HEDIS® benchmarks and includes drill-down capability to the level of the individual clinic. The PHN dashboard also provides enrollment denominators for each of the metrics. The dashboards will be updated quarterly and are available at https://dataquality.med.navy.mil/pophealth/. These, along with other Population Health tools, are available as a resource kit on the NMCPHC website at https://www.nmcphc.med.navy.mil/prevmed/popHealthnav.htm.
Are all Portal Methods based on HEDIS®?
Six of the current Portal Methods are HEDIS® based. The current HEDIS® based methods include Asthma – Use of Appropriate Medications, Diabetes Care, Cervical Cancer Screening, Breast Cancer Screening, Chlamydia, and Colorectal Cancer Screening.
How do the Portal Methods compare to HEDIS®?
Methods based on HEDIS® will use HEDIS® methodologies for calculating the numerator and denominator, including ICD-9-CM codes, CPT Codes, and HCPCS codes. These methods are updated annually based on current HEDIS® specifications.
How does the MHS Portal measurement year compare to the HEDIS® measurement year?
The HEDIS® measurement year is 1 Jan – Dec 31. In most organizations, HEDIS® is a retrospective look at a previous year. In the MHS we use the data concurrently so the MHS Portal measurement year is a rolling year. For example, if the Portal display is current as of 31 Jan 08, the measurement year would be 1 Feb 07 – 31 Jan 08. The measurement year for the next refresh would be 1 Mar 07 – 29 Feb 08.
Why are the denominators in the HEDIS® metric and the Action List different?
The purpose of the HEDIS® metrics is to be able to have standardized, nationally-recognized metrics which healthcare organizations can measure and compare their clinical performance. The HEDIS® methodologies are restrictive and prescriptive; they strictly define how to calculate numerators and denominators for their metrics and often specify continuous enrollment, age and other constraints. This ensures uniformity and comparability of populations and ensures that healthcare facilities have equal opportunities for excellence in the provision of healthcare. Because continuity of care is an important consideration when measuring and comparing the appropriateness of care over time, the HEDIS® methodologies are all based on continuous enrollment criteria. The MTF is not benchmarked on individuals who are not enrolled in TRICARE Prime at their facility or who do not meet specific continuous enrollment criteria. Therefore, in order to be eligible for inclusion in the HEDIS® population, eligible enrollees must be continuously enrolled in the MTF TRICARE Prime option for a minimum specified period of time (which varies for each metric).
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To be continuously enrolled, must a beneficiary be enrolled to the same DMIS for the specified period?
The beneficiary must only be continuously enrolled in TRICARE Prime at any DoD MTF. Beneficiaries need not be continually enrolled to the same DMIS during the measurement period. Patients who disenroll from TRICARE Prime at an MTF for more than 60 days during any 12 month measurement period are not considered continuously enrolled.
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How do I know which patients are in the HEDIS® denominator?
JCAHO standard (LD.3.20) requires that healthcare facilities provide the same standard and quality of care to all patients. It would be inappropriate to single out individuals who are HEDIS® eligible with the intent of improving a facility?s performance measure. All patients with the given condition are provided in the Action Report. Processes to improve clinical quality will improve HEDIS® metrics, regardless of whether the identities of the HEDIS® eligible patients are known.
topThe purpose of the Action Lists is to provide providers, clinics and commands a tool to assist with population health and process improvement efforts, by providing patient specific information. Because these efforts need to be all-inclusive, individuals who have the designated condition, who meet the specific inclusion criteria and are currently enrolled to an MTF, are identified by the Action Lists, regardless of age, duration of enrollment, continuous enrollment status or other constraints. This allows commands to target all individuals with the specified condition for demand forecasting, disease/condition management and treatment interventions.
How do I know which patients are HEDIS® eligible?
HEDIS eligible patients are these TRICARE Prime enrollees who, meet specific inclusion criteria for each HEDIS measure, e.g, for continuous enrollment. Although commands may want to know which patients meet the HEDIS® criteria for eligibility, per JCAHO regulations, healthcare facilities are obliged to provide the same standard and quality of care throughout individual clinics and across all clinics at a healthcare facility. To single out those individuals who are HEDIS® eligible, with the intent of improving a facility’s clinical performance metric, would be inappropriate. Consequently, all patients with the given condition are provided in the Action List without any HEDIS® annotation. If processes are implemented at healthcare facilities to improve clinical quality for all beneficiaries, HEDIS® metrics will subsequently improve, regardless of whether the identities of HEDIS®-eligible patients are known.
NMCPHC gratefully acknowledges the staff at the USAF Population Health Support Division and BUMED Clinical Operations for their contributions to the content of the FAQs.
Content last reviewed on October 26, 2010.