DISCUSSION
The PHITA tool was designed to help PFs rapidly categorize practices
into low, medium, or high levels of readiness for clinical reporting so
that they may provide appropriate TA. Both technical capabilities and
the presence of staff with the requisite knowledge and skills,
separately and combined, are associated with the ability of a practice
to report on clinical quality measures for cardiovascular risk factors.
Further, qualitative data extracted from PFs’ site visit documentation
describing successes and challenges of practices with low and high PHITA
scores add support for the validity of the scores. Least prepared sites
struggled with data reporting challenges and a distrust of data that
impeded their ability to do QI work, while best prepared sites put
energy into improving data accuracy and engaging in QI activities. Both
groups showed commitment to engaging in QI work and a need for on-going
technical assistance.
A high PHITA score did not guarantee an ability to report CQMs.
Practices with high scores on both sub-scales were generally those with
centralized health IT resources, but these shops were often inundated
with competing reporting priorities. In such settings, availability of
tools and skills did not translate to producing additional reports
unless the practice or health system leadership was willing to make
reporting for H2N a strategic priority.
A few limitations deserve mention. The study was required to use the
newly revised 2015 cholesterol guidelines for which canned reports were
only available to a few participating sites at the time, limiting the
ability of many practices to report on this measure. PHITA scores were
assigned by interviewing the PFs rather than individuals in the
practices. It is unknown how closely practice personnel would have
agreed with the PF’s assessment, or with each other. PHITA scores were
assigned after PFs had 7 – 8 months of interaction to understand the
health IT environment of each practice, whereas use of the PHITA as a
field tool would entail an assessment based on more limited observation.
Although few practices experienced improvements in software capability
or skill set during that short time period, however, technical
assistance provided by the PFs may have helped identify work-arounds
that would improve the ability to produce two or more CQM reports. Error
introduced by this would likely reduce the difference in reporting
abilty between levels of preparedness for both the sub-scales.
There is growing evidence for the importance of practice facilitation to
support implementation of evidence into primary care practices
12, 18, 19. A significant portion of a PF’s effort
must be directed toward using available HIT tools effectively. The PHITA
can help PFs set realistic expectations for data reporting and quickly
identify strategies to meet reporting/analytic needs. For example,
practices with limited reporting capability might create EHR patient
lists and export them to spreadsheets where data can be manipulated to
produce reports to identify patients with care gaps. In practices with
limited reporting skills, a PF may be able to facilitate direct support
from the vendor or help select a third-party registry.
Finally, the low levels of HIT capability and HIT analytic skills found
among small-to-medium sized enrolled practices have serious implications
for primary care infrastructure in the U.S. Barely over 20% of
practices engaged in the H2N study had the necessary reporting and
analytic skills for this work, and independent small practices were the
least prepared. These findings are consistent with those of Cohen and
colleagues 5 who reported challenges due to lack of
functionality for generating reports, discordance between clinical
guidelines and measures, questionable data quality, and unreceptive
vendors. Our findings expand on prior work by documenting the lack of
individuals with the software and analytic skills to write and validate
reports. It is clear that clinicians need more than a meaningful use
certified EHR to make significant progress in improving clinical
outcomes as required for value-based reimbursement.