Table 5.

Experiences and Attitudes toward Quality Measurement and Reporting: Thematic Analysis of Interviews with CHIPRA Quality Demonstration Grant Program State Leaders and Participating Primary Care Physicians in North Carolina and Pennsylvania

Theme	Sub-themes	Illustrative Quotes
Facilitators to engaging providers in quality measurement and reporting efforts	Alignment of measurement and reporting with existing practice services and priorities	“Being a pediatrician, I think if you look at 24 measures, it could be considered overwhelming. But when I look at it, it is part of what I was doing.”
	Introduction of a limited number of measures at a time	“If you really want to do something with QI [quality improvement], you’ve got to focus it down. Doing QI and moving measures doesn’t happen overnight, especially trying to introduce population management and going through those steps, it takes time. I think there are way too many measures…” “We’re down to 8. They were all great measures. The challenge of some of the 24 was that some were hard to get good data on. Some things require multiple databases, like ER [emergency room] measures where we need to integrate outpatient and inpatient EHRs [electronic health records] and assume no one went to other another ER. I thought that the set of 8 so far are all reportable. But the 24 are all good goals.”
	Education of providers on coding and billing for services targeted by quality measures	“We worked with the folks at the state level to train all of our Qis [quality improvement specialists] to provide dental varnishing training to practices. It’s one of the easiest sells. It reimburses at $52 per varnish and the provider doesn’t have to do it themselves…The fact that it reimburses so well is a helpful point in talking to practices.”
Barriers to engaging providers in quality measurement and reporting efforts	Resistance to perceived external intrusion	“Practicing folks assume that you are dictating from above. Unfortunately it’s hard to convince people that you had practicing providers on the panel even when you did."
	Concerns about implications of providing new services	“The concern of trying to manage a problem that they can’t treat…If you identify someone with maternal depression then the follow through is huge to ensure that all the needs of that patient are met. And so there were some logistical, medical, and legal concerns related to that.”
	Mismatch between measure specifications and practice reporting systems	“Just little differences exist, like the BMI measure for CHIPRA is for kids aged 3–17 and meaningful use is for kids aged 2–17. Just matching up the measures so that when you’re working on reporting you can report as one [would reduce the burden].” “The BMI measure is all about reporting the BMI percentile, not the BMI. Some of the systems might show the percentile while the doctor has the patient in the room, but the percentile is not stored. So when the quality measure is calculated, the doctor will score poorly.”
Changes made in response to quality reporting	Improved attention to service provision	“Because it was addressed with everybody and it was pushed it’s happening more…The physicians are taking that more seriously… I think that makes a huge difference. You could look at dental varnish and say big deal but they are looking at it as this is part of our treatment now for these children. “The autism screenings – making sure we changed policies and that we knew that we continuously follow up and wouldn’t let kids fall off the grid. That was a big thing for our practice. We learned to help these children that needed more special attention to make sure they had more individual nursing time.”
	Attention to documenting and reporting	“The rate [at which we are documenting BMI] has gone up to 100% from a much lower rate than that - probably less than 50%.”