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.