Table 1. Challenges and potential solutions to PBRN research mission in the changed practice environment of integrated delivery systems and EHRs.

IDS Supports	IDS Challenges	PBRN Solutions and Strategies
Provides consistent administrative policies for research participation across practices.	Presence of an additional bureaucratic layer that requires negotiation (e.g. need for subcontracts versus simple invoicing).	Develop standard governance agreements to share data across systems (e.g. business agreements).
Clinical initiatives can align with practice based research questions (e.g. meaningful use, patient centered home certification, maintenance of certification).	Practice interest is lessened due to pressure from the IDS to maximize their clinical output.	Build grant budget justification to compensate practice expenses incurred. Build in Continuing Medical Education (CME), Maintenance of Certification.
Priorities may support a philosophy of rapid dissemination and implementation.	Practices at the IDS geographic periphery suffer neglect regarding system integration, support of usual services and administrative consideration of projects not related to the system as a whole.	Package research with practice support services (e.g. EHR support, patient education, mHealth, practice facilitation, purchase and maintenance of data mapping/harmonization products).
Increased interest in research from the IDS, through the lens of a ‘learning health care organization’	Adjacent IDSs may compete with each other for clinical market share. This competition could potentially have the unintended effect of reducing collaboration on research projects. IDSs may be in direct competition with PBRNs; may not see the worth of PBRN work when they are already connected and have data.	Engage patients and other stakeholders with the idea of existing in a continuously learning health system and how all may benefit from this approach. Engage providers and staff in publications, presentations, and pursuit of better outcomes for patients based upon sound science. Initially avoid topics that might be ‘hot button’ for administrators. Look for win-win grants and contracts that require collaboration with multiple systems; PBRNs bring a primary care focus and insight, and IDSs bring a hospital focus
EHR and data warehouse
Allows data collection and analysis consistency.	Reduced presence of safety net practices, since community health centers may not be part of the IDS, and use a different EMR. This risks reducing the presence of low socioeconomic status and minority research participants. Fragmentation of safety net clinic PBRN's as unique entities that are not included in studies that include other practice types	Harmonize diagnostic, test, treatment and utilization variables and codes across IDSs, including community health centers. Standardization of interoperability methods (data transfer among EHR systems) across IDS's.
Provides an additional research tool for recruitment and quality improvement interventions.	Limited staff availability, even with funding, to program EMR modifications or extract data from CDW. Lack of responsiveness to providing requested data in a timely fashion.	Assure the ability of commercial EHR's to provide prompts to enroll patients in studies, as well as adjust the care process through order sets and targeted and evidence-based educational materials. Budget programmer time for all projects. Joint governance of data warehouse by care delivery and academic components of IDS.
Consistent roll out of quality improvement and regulatory practice enhancements	May be reactive to external forces, may inhibit innovative solutions	Can test novel interventions in practices that are early adopters External grant funds may partially support such innovation.