Clinical Integration: Healthcare

Healthcare: Clinical Integration Item Page What is clinical integration History of clinical integration Goals of clinical integration Importance of clinical integration Health reform New payment models IT advancement Barriers to clinical integration Legal barriers Lack of practitioner alignment Lack of interoperability How to achieve success in clinical integration Incentive alignment Knowledge alignment Behavioral alignment The future of health care systems Physician acquisitions vs.

clinical integration HIEs -- solution to clinical integration? Policy makers are beginning to appreciate the fact that only systemic change can effectively change, for the better, the manner of health care delivery in the U.S.; and that anything less would only alter the system's edges - with little or no substantial effect on cost-control, innovation-promotion, effectiveness of reward incentive schemes, coordination and coverage (AHA, 2010). Clinical integration has been found to be crucial to the change needed for the achievement of the aforementioned goals (AHA, 2010).

Despite the challenges (legal and otherwise) clinical integration faces, it still is key to health sector reforms. What is Clinical Integration? Clinical integration refers to "the coordination of patient care across conditions, providers, settings, and time to achieve care that is safe, effective, efficient and patient-focused" (URAC, n.d.). It mainly focuses on collaborating the operations of different providers to ensure consistency and coordination, hence cost-effectiveness and quality in the delivery of health services (URAC, n.d.).

History of Clinical Integration Clinical integration efforts were in place even before the term was first defined by the Federal Trade Commission (FTC) in 1996 (Athena Health, 2014). Today's model, however, differs from that which was in place then. The models in the past sought to create integrated delivery networks (IDNs) and physician-hospital organizations (PHOs) with the aim of ensuring greater cost and admission control, facilitating contracts with payers, and improving negotiations (Athena Health, 2014). The models were, however, ineffective and hardly had the infrastructure needed in risk management (Athena Health, 2014).

Moreover, there is very little proof that the models achieved their intended objective - providing quality care while containing operational costs; a factor that led to their abandonment (Athena Health, 2014). The present day's models differ from those of the past in three fundamental ways; The concept of purchasing and acquiring practices is not relevant to today's strategy; integration is achieved when individual practitioners align with provider networks (Athena Health, 2014). Today's hospital-physician groups are not open, and demand "that providers maintain a more uniform, high standard of care" (Athena Health, 2014).

Health information technology (HIT) "has evolved to meet new standards of secure, interoperable and comprehensive exchanges" making it easier and cheaper for health care leaders to share information (Athena Health, 2014). They can make use of data aggregation solutions, HIEs and EMRs for faster and more affordable information sharing (Athena Health, 2014). Goals of Clinical Integration Clinical integration focuses on expanding the coverage of health services, improving care and quality coordination, rewarding efficient and effective care, fostering innovation within the health sector, and controlling operational costs (AHA, 2010).

Importance of Clinical Integration Clinical Integration and Health Care Reform Three fundamental fragmentation scenarios synonymous to the health sector make it extremely challenging for patients to navigate "the health care delivery system at a time when they are most vulnerable" (AHA, 2010, p.2). To begin with, the common physician-hospital relationship model does not ensure optimality in care coordination between the two parties (AHA, 2010). According to the model, practitioners (physicians) rely on hospital staff who are not employed by the hospital for service provision (AHA, 2010).

The Civil Money Penalty, anti-kickback and Antitrust Stark laws limit the extent to which hospitals and physicians can interact and influence each other's patterns in cases such as these (AHA, 2010). Secondly, "most office-based practitioners continue to practice in solo or small" single-specialty groups, which have limited ability to support quality coordination (AHA, 2010, p. 1). This gives rise to a situation where "for every 100 Medicare patients treated, each primary care physician would typically have to communicate with 99 physicians in 53 practices" to achieve coordination (AHA, 2010, p. 2).

Third, patients can readily access health services from post-acute settings and freestanding ambulances, which are either in competition or working complementarily with hospitals (AHA, 2010). Such situations, especially those that involve competition, fragment care and expose patients to substantial risks of duplicative diagnosis and adverse drug interactions (AHA, 2010). Clinical Integration and New Payment Models Payment reforms could provide significant boost to the ongoing clinical integration promotion efforts.

There have been attempts to replace the fee-for-service system with one that cuts across different types of providers and holds "providers accountable for the quality of care and the resources used to provide it" (AHA, 2010, p. 4). Such a system would promote integration as it would allow for the creation of provider incentives and reward benefits as well as the use of resource management and pay-for-performance tools (AHA, 2010). Clinical Integration and Advancement in IT Information sharing is a vital component of clinical integration (AHA, 2010).

Congress, in 2009, in passing the HITECH Act, made an authorization for a $36 billion funding for "an electronic health information infrastructure" (AHA, 2010, p. 3). HITECH, moreover, sought to advance additional funding to providers who made 'meaningful use' of electronic health records (AHA, 2010). The Internal Revenue Service (IRS) guides hospitals to "assist physicians in developing electronic health records" (AHA, 2010, p. 3).

Although the limited relief from anti-kickback and Antitrust Stark laws does not allow for complete information sharing and subsidization of software and connectivity by hospitals, a number of systems have successfully managed to increase their use of IT (AHA, 2010). There is room, however, for facilities to "establish the type of information sharing that will support greater clinical integration" (AHA, 2010, p. 4). The development of guidelines, through which physicians can assess their effectiveness in service delivery, could go a long way in facilitating information sharing (AHA, 2010).

Barriers to Clinical Integration Health facilities face a host of regulatory barriers in their attempt to enhance clinical integration with their physicians (AHA, 2010). The gain sharing-prohibiting provisions of the Civil Monetary Penalty Statute, the anti-kickback and the stark laws are the most significant legal barriers to clinical integration (AHA, 2010, Gosfield & Reinertsen, 2010). Lack of i) practitioner alignment and ii) integration interoperability also pose as serious hindrances to integration (Gosfield & Reinertsen, 2010). Table 1 summarizes the effect of the legal barriers on clinical integration.

i) Legal Barriers to Clinical Integration Table 1: What is Prohibited Concern Antitrust (Sherman Act) Non-financial and non-integration ancillary agreements, which would give physicians market power. Hinders physicians from "entering into pro-competitive innovative arrangements because they are uncertain about antitrust consequences" (AHS, 2010, p. 11). Stark Law (Ethics in Referral Act) Referral of patients to facilities to which the referrer is financially-linked.

Bans certain arrangements that could improve health care delivery to patients by tying payment to services offered rather than to hours worked Anti-kickback laws Medicaid and Medicare-induced patient referrals Brings about "uncertainty concerning arrangements where physicians are rewarded for treating patients using evidence-based clinical protocols" (AHS, 2010, p. 11).

Civil Monetary Penalty Payments from a facility that induces a practitioner to reduce the services extended to a Medicare/Medicaid patient Bans any incentive whose result is reduced care, even if such a result improves the quality of care; for instance, low-priced products Source (AHA, 2010, p. 11) ii) Lack of Practitioner Alignment Practitioner alignment, the efficient coordination between physicians and hospitals, is a vital element of successful integration (Kaufman, Hall & Associates, 2012).

Clinical integration entails a shift from the current to a new environment, in which case providers are compensated on the basis of results for efficiency, access and quality (Kaufman, Hall & Associates, 2012). This implies that if physicians meet the baseline performance standards, they, together with their facilities (groups), get to enjoy the benefits of shared savings (Kaufman, Hall & Associates, 2012). This is, however, only possible if the actions of physicians are properly-aligned to those of their provider groups (Kaufman, Hall & Associates, 2012).

Entities wishing to pursue physician alignment have three alignment options to choose from; independent physician programs, employed physician programs and clinical integration models - each with its share of advantages and disadvantages (Kaufman, Hall & Associates, 2012) The Independent Physician Approach: facilities have to formulate options that would enable them to not only support, but align with care providers who prefer being independent (Kaufman, Hall & Associates, 2012).

This would involve a hospital contracting with a physician group in an agreement in which both parties define their performance levels and deliverables (Kaufman, Hall & Associates, 2012). Although such an arrangement would be easy to form, and would also be highly flexible to adjustments, it limits the extent to which the hospital can influence the behavior of physicians, control costs, and keep quality in check (Kaufman, Hall & Associates, 2012). Employed Physician Approach: in this approach, a hospital acquires a private practice and then recruits physicians (Kaufman, Hall & Associates, 2012).

Unlike the independent physician approach, this approach grants hospitals the ability to influence care outcomes and control costs (Kaufman, Hall & Associates, 2012). Huge sums of initial capital would, however, be required to take care of the acquisitions, salaries and recruitments (Kaufman, Hall & Associates, 2012). Moreover, it does not guarantee efficiency in physician alignment and also needs to be structured in a manner that offers long-term sustainability (Kaufman, Hall & Associates, 2012).

Clinically Integrated Approach: this approach aligns physicians, both independent and employed, with formal integration programs such as the Medicare Shared Savings Program (Kaufman, Hall & Associates, 2012). It allows for collective negotiations, aimed at formulating health plans that can better the efficiency and quality of care between physician networks and hospitals and managed care companies (Kaufman, Hall & Associates, 2012).

Regardless of the approach adopted, it is essential that both the physician and hospital administrative leaders engage constructively right from the onset because effective physician alignment can only be achieved through the engagement of physician leadership (Kaufman, Hall & Associates, 2012). iii) Lack of Interoperability This as Fredsma points out essentially denotes that ability of multiple systems to not only engage in information exchange, but to also make use the exchanged information (Fridsma 2013).

The term interoperability is used in health care to refer to the ability of a system to integrate patient data from multiple systems (Fridsma 2013). In as much as interoperability is a valuable integration asset, it could pose as a barrier if an organization lacks the mechanism to effectuate information exchange (Fridsma 2013). Interoperability ensures better delivery of health care services by facilitating the flow of patient information across different systems (Fridsma 2013).

As long as patient data is flowing effectively across linked systems, physicians have high chances of gaining access to the right information at the right time and can, hence, easily deliver (Fridsma 2013). The Internal Hospital Systems (HIS): in an attempt to address the barrier posed by lack of interoperability, many organizations have, in recent years, adopted the internal hospital information systems (HIS), incorporating all infrastructural elements, from servers to IT personnel, into a single closed network (McKinney & Hess, 2012).

The main advantage of the HIS approach is consistency; it ensures that all users of a system have access to the same patient information (McKinney & Hess, 2012). However, the HIS approach is not supportive of true interoperability since it bars providers who are not part of the system from accessing and sharing information with their in-system counterparts (McKinney & Hess, 2012). This means that rehab facilities, radiology centers, pharmacies and laboratories in different locations are in no position to exchange information through a closed HIS.

In this way, the HIS fails to regulate costs, control care, and keep physician's behaviors in check (McKinney & Hess, 2012). Lack of true interoperability, moreover, brings about inefficiency especially in the retrieval of patient data because it does not typically integrate patient information within the provider EHS workflow (McKinney & Hess, 2012). True Interoperability: gives both in-system and out-of-system caregivers access to 'meaningful' patient data (Fridsma 2013). True interoperability is crucial to clinical integration because it enables coordination, connection and easy exchange of data among providers in different locations (Fridsma 2013).

True interoperability should be emphasized because health care systems can only serve patients effectively if they are designed in a manner that allows for the sharing of clinical data across multiple providers, without boundaries (Fridsma 2013). How to Achieve Success in Clinical Integration Getting physicians involved in the hospital's decision-making processes is crucial to clinical integration (AHA, 2010). It gives them an opportunity to work with the administration in establishing the shared goals of the organization and formulating strategies relevant to the achievement of those shared goals (AHA, 2010).

It is evident, from the rules of clinical integration discussed earlier on in this text, that a successful process of clinical integration is one that achieves i) behavioral alignment, ii) knowledge alignment at the point of care, and iii) incentive alignment across the care spectrum (AHA 2010). Achieving Incentive Alignment Clinical integration can only be successful if it aligns physicians across the care spectrum financially, culturally, technically and clinically (AHA, 2010). This is only possible if the strategy adopted incorporates the best interests of all participants.

This can be achieved through formalized contracts, financial incentives, to mention but a few (AHA, 2010). Aligned incentives would, more often than not, translate to aligned physician actions (AHA, 2010). In order to effectively align incentives, groups ought to formulate a measurable image of success that is shared by all participants and delineates clear-cut financial benefits to all the continuum stakeholders (AHA, 2010). Salaries and bonuses have been found to be a more holistic approach of building incentives, compared to the traditional productivity-based reward system (AHA, 2010).

The former are more representative of the clinical integration values of team collaboration, effective ancillary personnel use, and evidence-base adherence (AHA, 2010). Achieving Knowledge Alignment The need behind any clinically integrated system is accessing the right data at the right time (AHA, 2010). This, together with the aspect of interoperability, is vital and should be accompanied by allowance for provider independence and choice (AHA, 2010). In order to achieve care management, caregivers require access to tools that have the ability to surface meaningful data at the right time (McKinney & Hess, 2012).

To this end, organizations have to keep updating their systems and aligning them with the prevailing levels of technology (McKinney & Hess, 2012). A number of solutions have proved effective in system integration and the achievement of true interoperability (McKinney & Hess, 2012). Cloud-based platforms are one such solution (McKinney & Hess, 2012). Cloud-based HIT makes it possible for providers to access complete patient information and to consequently make confident decisions at the point of care (McKinney & Hess, 2012). Cloud-based platforms have a number of associated benefits.

First, they allow for secure storage of information and accessibility of the same via the internet (McKinney & Hess, 2012). Secondly, they can be designed as to integrate (harmonize) information from a variety of sources (McKinney & Hess, 2012). Finally, cloud-based platforms are cost-effective, especially because electronic communication from the architecture to individual participants is built only once (McKinney & Hess, 2012).

If providers are in a position to access valuable information at the right time at the point of care, they are likely to be empowered to making decisions that are in support of cost-effective, quality outcomes (McKinney & Hess, 2012). Achieving Behavioral Alignment Behavioral alignment entails getting stakeholders to respond to data in a unified manner (Gosfield & Reinertsen, 2010). It is heavily dependent upon the level of standardization displayed in the creation, storage, use, and exchange of clinical information within a network (Gosfield & Reinertsen, 2010).

Most organizations seek to achieve behavioral alignment through the adoption of tools that ensure the delivery of the right patient information to the right recipients (Gosfield & Reinertsen, 2010).

Behavioral alignment, therefore, has to do with process standardization, and entails ensuring that all providers within a network i) act in adherence to the common benchmarks, ii) practice to the maximum levels of their knowledge, skill and license, iii) have the ability to identify and establish efficient outreach protocols for high-risk patients, iv) take the most appropriate action always, and v) have the appropriate technology, equipment and supplies (Gosfield & Reinertsen, 2010). Standardization is always difficult to achieve.

Effective physician relationships and leadership could go a long way in ensuring standardization, as they would build consensus for uniformity in the design and implementation of shared goals, and consequently, of the information systems through which those goals could best be realized (Gosfield & Reinertsen, 2010). The Future of Health Systems Physician Acquisitions vs. Clinical Integration Recent years have seen most organizations embrace the strategies of physician acquisition and practice consolidation in their operations (Kocher & Sahni, 2011). In as much as this approach gives hospitals the ability.