Historically, hospital systems were based on affiliations with physician practices, ancillary and other clinical services. However, as a renewed focus on “Wellness Care” took root in the mid-1900’s, hospitals began bringing those practices inside the provider organization; this was the first wave of clinical integration. While ‘clinical integration’ is a dynamic term, for the purposes of this article we will define it as the move from stand-alone hospitals to more robust healthcare provider organizations, health systems and IDN’s.
Studies had indicated for years that clinical integration was the best way to manage costs because hospitals could be proactive: continuing education among providers and patients and encouraging patients to get regular check-ups rather than waiting until a serious condition arises. These initiatives, while based on a solid premise, didn’t go far enough to include true financial integration, resulting in a short-lived boom of reorganization. Healthcare payers were not structured to work well with physician practices in this manner and providers found it difficult to manage.
Today, the next step in healthcare reform is the development of heath information exchanges (HIE’s) as part of the American Reinvestment and Recovery Act (ARRA). The primary use of HIE’s is to distribute Personal Health Records (PHR’s) but this is just the beginning of its functionality. We have already seen significant changes in the market with the development of ‘ACO’ or ‘accountable care organizations.’ These are new alliances by health systems, physician practices and other providers at the HIE level to help lower healthcare costs.
Keep in mind that Medicare’s traditional payment structure inherently incentivizes providers to order more tests and services because reimbursement is tied to volume. Under the Patient Protection and Affordable Care Act (PPACA) of 2010, the government intends to reward ACO’s that can demonstrate reductions in Medicare costs across a group of patients through new models of care. What this means is that organizations will now be able to operate as affiliates but still use the clinical integration that allows and encourages better patient care. Add to that the improved diagnostic tools, better clinical procedures, increasing levels of clinical review and clinical decisions support and healthcare is set to take the next step in clinical integration.
While the long-term consequences and benefits of HIE’s are still to be determined, we have seen a few significant trends in the last few years. First, healthcare organizations have started to separate diagnostic medicine and its remediation into two separate processes. This method provides a second review of and alternate opinions to the diagnosis as well as the treatment. Therefore, it makes sense to develop a practice where hospitals use specialists in diagnostic medicine to determine the issues and then pharmaceutical specialists for the ordering and administration of remedies and therapies. We currently see this in CPOE with the use of Clinical Pharmacists in the ordering of pain and medicine therapies.
HIE’s are also leading the development of ‘Care Plans’ that will take medical information and data from HIE’s across the country in order to create patient-specific care strategies. While it is easy to imagine the benefits of such care plans, interfaces, platforms and effective two-way communication for EHR systems still need to be developed and implemented in every organization. These will not be built overnight, even with the incentives to become ‘meaningful users’ of EHR’s; until then, physician practices will face significant challenges trying to operate their clinical and financial systems efficiently.
Ironically, these are the same challenges that slowed the clinical integration push in the 1990’s. This time around however, we are better poised to achieve success if we keep pushing forward with reform and stay focused on lowering costs and improving physician tools. Healthcare reform has forced organizations to develop standards and interconnectivity that will in turn drive the creation of innovate methods to improve patient care. The next wave of incentives is designed to do just that: improve interoperability, knowledge and information to empower our providers to better their care.