Clinical integration — standardizing clinical practices and processes across providers — can help hospitals and health systems improve quality of care while lowering costs. Rick Lopez, MD, CMO of Newton, Mass.-based Atrius Health, believes clinical integration is a critical strategy as healthcare moves from a fee-for-service model to pay-for performance. "[Improving] and sustaining quality is going to happen only if we eliminate the waste in practice. We can do that only through clinical integration," he says.
Atrius Health is an alliance of six medical practices and a home healthcare and hospice agency that clinically integrates in a variety of ways. Dr. Lopez shares five strategies the system uses to create an integrated network of care:
1. Share an electronic medical record. One of the most dramatic ways Atrius Health clinically integrates is through a shared EMR, according to Dr. Lopez. Five of its medical practices have the same kind of EMR, and one has a similar version, which allows providers to access patients' records across practices and facilitates communication between providers. While the home healthcare and hospice agency, VNA Care Network & Hospice, currently has a different EMR, Atrius Health is considering transitioning the agency to its EMR to enhance integration, Dr. Lopez says.
2. Collaborate on services. Combining clinical programs of different groups leads to clinical integration. For example, two of Atrius Health's practices — South Shore Medical Center and Harvard Vanguard Medical Associates — jointly created Atrius Health Women's Center in Weymouth, Mass. By collaborating on health services, physicians and staff can leverage the strengths of each organization to deliver higher quality care.
"Where we run into waste and duplicated efforts and failures in the delivery of care often is in interfaces between entities — between two medical groups, a hospital and physician office, a hospital and skilled nursing facility," Dr. Lopez says. "In those interfaces, there is a lack of transition of information, a lack of handoff, a lack of an ability to consolidate efforts because we're bounded by artificial structures we build around ourselves as separate entities." Clinical integration combats these barriers by sharing services and building on each other's strengths.
3. Centralize administrative roles. Reducing duplicate administrative offices also aids clinical integration. Atrius Health has one quality and safety department that oversees quality and safety across the system. Similarly, medical practices report adverse events through one program, which enables Atrius Health to more easily collect and analyze data on quality.
Centralizing data enhances clinical integration because it allows leaders to identify trends in processes and outcomes, which can reveal opportunities to reduce costs and improve quality. Atrius Health has a data warehouse that includes all claims data and clinical data from each of its affiliates. Atrius Health uses this data to identify and reduce practice variation, which reduces costs.
4. Standardize policies. "Another way we integrate is on an organizational basis," Dr. Lopez says. "The medical directors of all groups meet each month and adopt common policies, review common problems and share best practices."
For example, Atrius Health has a clinical pharmacy program at each of its practices that helps to standardize medication protocols, improve care and lower costs. Under the program, a system-wide pharmacy and therapeutics committee reviews evidence on clinical outcomes, costs and payor coverage to choose preferred medications for different conditions. The list of preferred medications is built into the EMR so when a physician prescribes medication, he or she can easily choose the most cost-effective option.
In addition, clinical pharmacists meet with physicians every quarter to provide updates on medications, discuss physicians' prescribing patterns and provide guidelines for ordering medications for different conditions. Standardizing prescribing protocols at each site ensures consistent quality across the system and reduces costs.
5. Reduce variation. In addition to standardizing protocols across each entity, Atrius Health is working to standardize clinical practices to improve quality and lower costs. Each year, leaders at Atrius Health choose several areas of practice variation to focus on. The clinical topics chosen are typically common, ideally have well established national guidelines, may require a significant amount of discretion in making decisions and have a potential to lower costs and improve quality. This year, Atrius Health is focusing on certain screening tests, such as electrocardiograms; opioid management; chronic kidney disease; chronic lung disease; bone density scans and referrals to orthopedics for spine surgery or spinal injections; and asthma.
Once leaders choose focus areas, they analyze the data to determine the variation at the physician level and share this data with physicians. Atrius Health evaluates guidelines for these practices to identify best practices that will become standard for all physicians in the system. Standardizing practices can eliminate waste from the system, improve quality and lower costs.
Atrius Health also standardizes practices as a Pioneer Accountable Care Organization and through its Alternative Quality Care with Blue Cross Blue Shield. Representatives from each physician group lead different projects to make best practices consistent across the system, according to Dr. Lopez.
Clinical integration is an opportunity for success
Clinical integration requires communication among providers and standardized practices and policies. By sharing best practices and reducing variation, clinical integration can help health systems meet healthcare reform goals. "The more you're separate, the less opportunity you give yourself to achieve the goals we want to achieve," Dr. Lopez says.
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Atrius Health is an alliance of six medical practices and a home healthcare and hospice agency that clinically integrates in a variety of ways. Dr. Lopez shares five strategies the system uses to create an integrated network of care:1. Share an electronic medical record. One of the most dramatic ways Atrius Health clinically integrates is through a shared EMR, according to Dr. Lopez. Five of its medical practices have the same kind of EMR, and one has a similar version, which allows providers to access patients' records across practices and facilitates communication between providers. While the home healthcare and hospice agency, VNA Care Network & Hospice, currently has a different EMR, Atrius Health is considering transitioning the agency to its EMR to enhance integration, Dr. Lopez says.
2. Collaborate on services. Combining clinical programs of different groups leads to clinical integration. For example, two of Atrius Health's practices — South Shore Medical Center and Harvard Vanguard Medical Associates — jointly created Atrius Health Women's Center in Weymouth, Mass. By collaborating on health services, physicians and staff can leverage the strengths of each organization to deliver higher quality care.
"Where we run into waste and duplicated efforts and failures in the delivery of care often is in interfaces between entities — between two medical groups, a hospital and physician office, a hospital and skilled nursing facility," Dr. Lopez says. "In those interfaces, there is a lack of transition of information, a lack of handoff, a lack of an ability to consolidate efforts because we're bounded by artificial structures we build around ourselves as separate entities." Clinical integration combats these barriers by sharing services and building on each other's strengths.
3. Centralize administrative roles. Reducing duplicate administrative offices also aids clinical integration. Atrius Health has one quality and safety department that oversees quality and safety across the system. Similarly, medical practices report adverse events through one program, which enables Atrius Health to more easily collect and analyze data on quality.
Centralizing data enhances clinical integration because it allows leaders to identify trends in processes and outcomes, which can reveal opportunities to reduce costs and improve quality. Atrius Health has a data warehouse that includes all claims data and clinical data from each of its affiliates. Atrius Health uses this data to identify and reduce practice variation, which reduces costs.
4. Standardize policies. "Another way we integrate is on an organizational basis," Dr. Lopez says. "The medical directors of all groups meet each month and adopt common policies, review common problems and share best practices."
For example, Atrius Health has a clinical pharmacy program at each of its practices that helps to standardize medication protocols, improve care and lower costs. Under the program, a system-wide pharmacy and therapeutics committee reviews evidence on clinical outcomes, costs and payor coverage to choose preferred medications for different conditions. The list of preferred medications is built into the EMR so when a physician prescribes medication, he or she can easily choose the most cost-effective option.
In addition, clinical pharmacists meet with physicians every quarter to provide updates on medications, discuss physicians' prescribing patterns and provide guidelines for ordering medications for different conditions. Standardizing prescribing protocols at each site ensures consistent quality across the system and reduces costs.
5. Reduce variation. In addition to standardizing protocols across each entity, Atrius Health is working to standardize clinical practices to improve quality and lower costs. Each year, leaders at Atrius Health choose several areas of practice variation to focus on. The clinical topics chosen are typically common, ideally have well established national guidelines, may require a significant amount of discretion in making decisions and have a potential to lower costs and improve quality. This year, Atrius Health is focusing on certain screening tests, such as electrocardiograms; opioid management; chronic kidney disease; chronic lung disease; bone density scans and referrals to orthopedics for spine surgery or spinal injections; and asthma.
Once leaders choose focus areas, they analyze the data to determine the variation at the physician level and share this data with physicians. Atrius Health evaluates guidelines for these practices to identify best practices that will become standard for all physicians in the system. Standardizing practices can eliminate waste from the system, improve quality and lower costs.
Atrius Health also standardizes practices as a Pioneer Accountable Care Organization and through its Alternative Quality Care with Blue Cross Blue Shield. Representatives from each physician group lead different projects to make best practices consistent across the system, according to Dr. Lopez.
Clinical integration is an opportunity for success
Clinical integration requires communication among providers and standardized practices and policies. By sharing best practices and reducing variation, clinical integration can help health systems meet healthcare reform goals. "The more you're separate, the less opportunity you give yourself to achieve the goals we want to achieve," Dr. Lopez says.
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