Clinical Integration Definitions

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What are the characteristics of effective clinical integration initiatives? 

An effective Clinical Integration Program contains initiatives that (1) provide measurable results, (2) are used to evaluate physician performance and (3) result in concrete improvements in quality, cost, and patient satisfaction. Clinical integration fosters interdependence among providers and, by working together on the quality initiatives selected for the program, enables them to achieve higher quality and demonstrate greater cost-effectiveness than likely accomplished on their own.

In "real life,” what does a clinically–integrated network of independent physicians look like?

In most instances, clinical integration involves a hospital or health system and physicians on its medical staff who create committees and management capabilities to: (1) identify and adopt clinical protocols for the treatment of particular disease states; (2) develop systems to monitor compliance with the adopted protocols on an inpatient, outpatient, and ambulatory basis; (3) collaborate with the hospital or health system to encourage compliance with hospital performance improvement processes and protocols; and (4) enter into contractual arrangements with fee-for-service health plans in a manner that financially recognizes the physicians’ demonstrated improvement of health care quality and efficiency.

Are physicians involved in the development of clinical integration and leadership of the St. Rose Quality Care Network?

Yes. Physician leaders, along with the Hospital’s leadership, are working to create a new, independent physician network. This physician network will be governed by a board composed of physicians and will operate for the explicit purpose of developing and implementing a Clinical Integration Program. Physicians are leading and actively participating in developing the key components of the Program.

What clinical initiatives will the St. Rose Quality Care Network include?

Quality initiatives are designed to facilitate and improve:

  • Inpatient EMR and CPOE adoption
  • Ambulatory EMR adoption
  • Chronic disease management
  • Care episode management
  • PQRI reporting
  • Communication among primary care physicians and specialists
  • Community case management
  • Quality-based credentialing

The goal for the St. Rose Quality Care Network is to enhance the value of services that physicians provide to patient, employer, and payer communities by measuring compliance with initiatives based on data from various sources, including systems associated with claims processing and adjudication, practice management and scheduling, disease registries, pharmacy benefits, and hospital and ambulatory EMR.

Why are physicians across the country engaging in clinical integration?

Physicians have numerous and overlapping motivations for joining together in clinically-integrated networks, including: (1) to enhance the quality of the care provided to patients, (2) to legitimately negotiate with payers as a network, (3) to develop their own alternatives to heath plan "report cards” and other initiatives that may not accurately assess physicians, (4) to provide access to technological and quality improvement infrastructure, and (5) to allow networks of physicians and hospitals to market themselves on the basis of quality.

What role does an Electronic Medical Record (EMR) system play in clinical integration?

An ambulatory EMR is not a prerequisite to participate in the St. Rose Quality Care Network. While a common EMR across all participating physician practices can certainly accelerate and strengthen a Clinical Integration Program, most (if not all) successful models of clinical integration nationwide do not depend on an ambulatory EMR for data on physician performance. The St. Rose Quality Care Network will utilize a technology system, Intelligent Healthcare, to measure, analyze, and evaluate physician performance through claims data, existing hospital data, disease registries, and chart audits.

Why do a growing number of physicians and hospitals believe clinical integration to be a good business and health care strategy?

Doctors and hospitals in multiple states are implementing Clinical Integration Programs not merely for reasons of antitrust compliance, but rather because they believe in its value proposition:

  1. Clinical integration allows physicians to: (a) demonstrate their quality to current and future patients; (b) choose the clinical measures against which they will be evaluated; (c) pursue enhanced revenue through better management of chronic patients; (d) gather collective support for building necessary infrastructure; and (e) seek greater reimbursement that reflects the higher demonstrated value furnished to patients and health plans.
  2. Clinical integration gives hospitals the ability to: (a) demonstrate quality to current and future patients; (b) enlist physician support for hospital initiatives, including compliance with "core measures,” clinical pathways, standardized order sets, and supply chain management initiatives; (c) develop a better, more collaborative relationship with the medical staff; (d) improve performance on hospital pay-for-performance measures; and (e) create an advantageous position for themselves in the market on the basis of quality.
  3. Clinical integration provides patients with: (a) a better value for their health care dollar; (b) more effective care management and outreach from a trusted source, their physician; (c) more reliable information to support their choice of health plans, physicians and hospitals; (d) more accurate and meaningful provider ratings; and (e) greater stability in their relationship with their doctor and hospital.
  4. Clinical integration gives employers: (a) the ability to more effectively manage the health care costs of employees and their dependents through the purchase of better, more efficient health care services; (b) increased employee productivity and reduced absenteeism through better management of chronic disease; (c) lower health care costs over the long term through the reduction of variation in physician practice patterns; and (d) more reliable information to support the conversion to consumer-driven health insurance products.