We end with a series of preliminary conclusions based on our discussion of findings above. We note that these conclusions are based only on the discussions conducted as part of the North Carolina site visit and that these observations will be consolidated with findings and conclusions from other site visits to establish findings and conclusions for the overall study.
Impact on productivity has been negative except in Greene County. Some EMR adopters anticipate short term reductions in productivity followed by a return to capacity and perhaps even improved productivity over time. Most respondents in North Carolina indicated that even when all providers are fully trained, the EMR still contributed to productivity losses because of increased documentation requirements facing providers.
Health center networks face competing priorities. In summarizing the enablers and challenges associated with health IT adoption in the health center network context, discussants highlighted the important differences in skill set required to support the varied functions that health center networks are expected to fulfill. They also pointed to the resulting need for a varied staffing model that includes individuals with IT infrastructure, support and training backgrounds as well as clinical quality improvement specialist, overall administrators and grant writers. While some individuals may have the skill set to allow them to meet more than one of these needs, it is rare to be able to adequately capture all of these skills in a small group of individuals. CPH’s current staffing model, which includes a total of four FTEs, may not be sufficient to adequately address all of these needs.
De-centralized approach to customization has advantages and disadvantages. We note in our findings that CPH has not been asked by health centers to standardize work flow, forms or templates to be used by health centers implementing the MicroMD EMR to meet regularly (see not above) Instead, it allows health centers and even individual providers to customize their own forms and views and establish a flow and documentation approach that works best for them. This philosophy has the obvious advantages of allowing individuals flexibility and not requiring the network itself to convene clinical leaders to achieve consensus on complex issues. At the same time, it does not allow for the establishment of a common approach to QI and collaboration across health centers and it can lead to problems with using reports of aggregate data from across health centers for the purpose of benchmarking.
For example, if each health center is using different forms to enter common data, developing aggregate reports would require complex queries where comparable data is drawn from different fields in the data warehouse. This level of complexity leads to the potential for error and raises the cost associated with use of the data warehouse for cross-center comparisons or aggregate estimates. Because health centers and individuals are free to create their own forms and use different fields in idiosyncratic ways, reports run out of the EMR or data warehouse must be reviewed thoroughly by the users and programmers to ensure that data are being pulled from appropriate fields for each health center and provider.
Sustainability approach uncertain and relies on keeping scope limited. CPH was up front in indicating that it did not have a clear sense of its long term sustainability beyond plans to leverage additional grant opportunities as they became available. Network leaders were clear that they were interested in seeing how grant opportunities evolve over the next several years given the change in administration. To date its approach to maintaining financial viability has been to keep staff relatively small and to generally stay focused on IT support, vendor contracting and infrastructure rather than employ the network in active, “hands on” quality and process improvement initiatives.