While the current study has elucidated important lessons learned for adoption of health IT among health center and health center networks, we identify a number of areas that merit further investigation to assist policy development moving forward.
- Feasibility and sustainability of promoting a network model. While networks represent an important opportunity for health centers, we found evidence that not all health centers are bought-in to an integrated network approach. For their part, we found that even the most successful networks are not self-sustaining financially and may not be for a significant period of time. Additional work may be required to understand the level of access health centers currently have to health center networks, the issues around health center buy-in for an integrated network model, opportunities for networks to obtain sustainable funding through non-grant sources and the potential role of incentives created by changes in Federal policy.
- Health center network gap and overlap analysis. Health centers around the country currently have different access to networked services depending on geographic location and resources available. While some geographic areas may not have any network activity, in the areas we visited for their study we often found three or more Federally funded health center networks. Although their activities were usually complimentary (and in some cases overlapping), we observed limited coordination and collaboration among networks in the same geographic area. Additional analysis may systematically catalog overlap and gaps in network access for health centers around the nation in an effort to facilitate broader access to networks and optimize future investments.
- Value relative to cost. As in other health care provider settings, health centers implementing health IT, and EHR in particular, struggle with the task of understanding the value of these investments relative to their costs. While health centers, as mission driven organizations may be less concerned with the bottom line for their institution, they are required to make responsible decisions with public resources. Also, understanding value of health IT relative to cost in health centers (where health IT purchases may be subsidized) offers a valuable opportunity to learn about the cost effectiveness of these tools in other ambulatory care settings. As most health centers do not have the resources or expertise to conduct rigorous internal evaluations incorporating initiative costs and comprehensive benefits, external research can play an important role.
- How to foster sustainability. While several health center networks have exhibited important successes in encouraging health center IT adoption, none indicated that they were moving comfortably toward self-sustainability under their current course. Even the most successful networks investigated struggled with the question of how to maintain an adequate level of resources as well as an exclusive focus on health centers while moving towards a self-sustaining financial model. The vision for some has been to expand to include non-health center providers as customers. Future analysis may focus specifically on options for achieving self-sufficiency working within market conditions. Pay for performance or other payer driven incentives specific to the use of EHRs may offer opportunity for these analyses.
- Considerations for future research. Because efforts were made to identify “leading edge” networks for this study, findings presented here do not reflect the state of the “average” health center. However, as the first study focused on health center use of IT generally, we have identified important methodological and substantive considerations. Methodologically, it is clear that any future efforts to assess IT use among health centers should consider an array of relevant respondents, from network leadership and staff, to administrative and clinical leadership at health centers. Because we found that health centers use a variety of models for staffing in IT, with relatively few employing a CIO, identifying appropriate respondents who can speak to how day to day technology decisions are managed will continue to pose a challenge that will need to be addressed on a individual basis with each health center.
Our study also highlights the important issues for focus in future studies of IT use among a representative sample of health centers (e.g., future efforts to survey health centers). For example, it will be critical that any such study consider a wide range of the structural barriers and enablers identified here such as history of network participation and collaboration with other health centers and access to executive level IT management staff. In addition to staffing and capacity, it is clear that gaining clinical benefits from health IT implementation requires sustained investment at multiple stages, from planning, to workflow and culture re-design among clinicians, implementation and ongoing improvement. As such, it will be critical to understand health centers’ plans for financing IT implementation and determining the scope of necessary outside investment. Finally, future research should ask how health centers make IT investment decisions to identify the extent to which health centers are equipped to assess the value of these investments relative to their mission.