Originally published June 2013
As healthcare leaders strive to reform and improve the healthcare system, a growing area of focus is how to achieve an integrated system that meets the needs of patients and communities.
Integration is occurring in different ways across the country, including the evolution of regional health authorities and local health integration networks, as well as numerous primary care reform models. Given the rapidly evolving healthcare environment, it's fair for doctors to ask themselves what is their role within these organizational systems.
Physicians need to understand the goals of healthcare integration and their role in achieving these goals, in order to adapt their practice and become involved in the decision-making. Increased understanding of integration will enable physicians to consider the medico-legal aspects of this model of healthcare.
One of the classic definitions of integrated healthcare is a delivery system in which "networks of organizations provide or arrange to provide coordinated services to a defined population and are willing to be held clinically and fiscally accountable for the outcomes and the health status of the population being served." 1
Essentially, integration aims to improve the healthcare experience by creating a seamless system of care. Physician integration relates to the extent to which doctors are linked to the healthcare system, either functionally, clinically, economically, or otherwise.
The main objectives of integrated care are to improve the patient experience, enhance access and service coordination, strengthen the links between different levels of care and support services, reduce duplication, improve efficiency, and enhance clinical outcomes. An integrated healthcare system has a patient-centred approach, is structured around community health needs, with care coordinated across the continuum — meaning delivered over time, in different settings, and across various levels and types of care. Integrated healthcare also leverages key support functions such as information management, and uses the skills and experience of a variety of healthcare professionals.
The building blocks of integrated healthcare
In successfully integrated health systems, doctors work with other healthcare providers to plan and deliver care that is organized around patients. Within these healthcare delivery teams, 2 or more healthcare professionals utilize and share their skills and knowledge to assist patients. Examples include family doctors working as part of primary care teams, or even specialists involved in proactively managing wait-lists or working in teams in specialized clinics.
In some cases, healthcare integration has allowed patient care to shift from doctors to other healthcare professionals such as nurse practitioners, nutritionists, and psychologists, enabling physicians to focus more on diagnosis, intervention during acute episodes, and providing care to patients with more complex conditions. Healthcare integration has also resulted in more doctors working in community settings, including health centres, ambulatory sites, long-term care facilities, and walk-in clinics.
Effective strategies to help physicians mitigate risk when working in collaboration with other healthcare professionals include using good communication skills, understanding the scopes of practice, roles and responsibilities of different healthcare professionals, and complying with applicable policies and procedures. The importance of effective written communication cannot be underestimated, including appropriate documentation and review of what is increasingly an interdisciplinary clinical health record.
The notion of integrated healthcare can be challenging for family doctors, some of whom operate outside of local or regional health networks. The same can be said of some physicians working in public health, which is often managed by local municipalities. Healthcare integration can also affect different physicians in different ways depending on, for example, whether they practice in urban or rural settings. Given this, doctors should reflect on their responsibilities towards patients and the role they play in relation to other health system partners.
Within integrated health systems, doctors play an important role in easing patients' transitions to different levels of care, such as from primary to secondary care. Physicians also facilitate the movement of patients within different parts of the system, and make linkages with other sectors. Physicians involved in care handovers at any level or in any setting should focus on the transfer of key information such as the patient's diagnosis, test results, and treatment plan. The goal is to improve care transitions and communication with patients and other healthcare providers.
Changing the healthcare system means that doctors and other healthcare providers need to learn to work in new ways. Successful integration requires "big picture" thinking, such as analyzing the impact of service changes and new technologies. All of this demands the right set of skills — the ability to observe, listen, analyze, and organize — to power transformational work.2 Physicians should reflect on how they work with other doctors and healthcare professionals across the continuum of care. Doctors should communicate and exchange ideas about providing coordinated care to achieve desirable outcomes for patients.
Information sharing and appropriate technological support are enablers of healthcare integration. Electronic medical records can be very helpful, as are other information systems to monitor patients within the care delivery organization and among various healthcare organizations and levels of care. Integration requires appropriate and secure sharing of information. Increasingly, physician use of electronic records is seen as necessary in integrated health systems. While electronic records and other emerging technologies may facilitate the management of patient health information, doctors continue to have an important professional responsibility and legal obligation to protect the confidentiality of patient information.
Physician involvement in monitoring and evaluating quality is also required in integrated systems. Valid, useful indicators and standardized reporting allow for performance comparisons among individual organizations and groups of healthcare providers. Due to their unique understanding of medical and safety issues, doctors should be involved in quality monitoring and improvement in areas such as surgical wait times, access to cancer care services, length of stay, and patient satisfaction, for example. In terms of adverse events (accidents in Québec) and near misses, physicians should understand the differences between quality improvement (QI) and accountability reviews, and actively participate in appropriately constituted QI reviews.
Since healthcare integration favours an interdisciplinary approach to care, questions may arise concerning the coordination of care and team leadership. Team members must have clear roles, responsibilities, and accountabilities, and these should be supported by a policy and procedural framework. This will not only reduce liability risk but also the likelihood of adverse medical events caused by confusion or ambiguity. It is also imperative that all health professionals carry adequate professional liability protection.
Healthcare teams should also know and agree on the care provider with overall responsibility for directing and coordinating care of an individual patient. This doctor is generally referred to as the most responsible physician (MRP). Physicians should be aware of any organizational policies outlining the expectations of the MRP, as well as circumstances when the most responsible practitioner may not be a doctor.
Healthcare integration can also affect doctors' practice arrangements, for example through employment or contracts for service with hospitals and health authorities. While these new and evolving models can benefit doctors in many ways, physicians need to be familiar with the medico-legal aspects of these delivery arrangements. Different models carry different procedural safeguards and medico-legal risks. Doctors should carefully review these new arrangements and their implications.
Another potential area of concern for doctors in an integrated healthcare system relates to the appropriate reporting of other physicians. Recognizing the need to foster a just culture of safety, health authorities and hospitals should establish appropriate thresholds and pathways for reporting within the organization. Doctors should avoid forming or communicating partially informed opinions about the performance of colleagues or other care providers. When a physician has a legal obligation or an ethical duty to make a report to a regional health authority or College, the report should be made in a timely manner with the intent to support safer care.
Healthcare integration activities may also result in increased advocacy efforts by physicians at the patient or system level. Governments, health authorities, and hospitals should encourage reasonably voiced physician perspectives. For their part, doctors must advocate ethically and appropriately.
The critical role of physician leadership
Healthcare integration is generally most successful when doctors form part of governance structures that promote collaboration and integration, and when they play a part in shaping clinical services.3 This can include physicians who are involved with planning and implementing new care models. That said, many doctors face pressures that limit their ability to engage with the larger health system. Despite these challenges, doctors should strive to be included at all levels of the healthcare system and play a leadership role in the design, implementation, and operation of an integrated system.4 Participation in meetings or conferences promoting integration and implementation of provincial strategies, regional service planning, health system improvement initiatives, and medical advisory committees are just some ways doctors can be involved. Physicians should consider their roles as formal or informal leaders to help envision, champion, and support effective, integrated healthcare systems. Successful integration is dependent upon physician leadership and ongoing involvement in decision-making.
Integrated models of healthcare come in many different forms. While progress toward greater integration is being made across the country, healthcare integration is built around the needs of patients and communities. It requires enhanced collaboration and teamwork among all healthcare professionals. Meaningful improvements to our health system also require new ways of thinking and also learning from others. Experience has shown that successful healthcare integration requires the direct and meaningful involvement of physicians. Given their vested interest in healthcare integration, doctors should strive to engage in healthcare planning and priority setting, strategy development, and patient-centred care delivery in order to help achieve improved coordination across the system.
- Leatt, P., Pink, G., Guerriere, M., "Towards a Canadian model of integrated healthcare," HealthcarePapers (2000) Vol. 1, No. 2. Retrieved on December 4 2012 from: http://www.longwoods.com/content/17216
- MacLeod, H., Davidson, J., "Fragmentation vs collaboration" Longwoods.com (2013 Essays). Retrieved on January 23 2013 from: http://www.longwoods.com/content/23145/print
- Marsden, J., van Kijk, M., Doris, P., Krause, C., Cochrane, D., "Improving care for British Columbians: The critical role of physician engagement," Healthcare Quarterly (2012) Vol. 15 (special issue). Retrieved on January 14 2013 from: http://www.longwoods.com/content/23163
- Suter, E., Oelke, N., Adair, C., Armitage, G., "Ten key principles for successful health systems integration," Healthcare Quarterly (2009) Vol. 13 (Sp). Retrieved on January 14 2013 from: http://www.longwoods.com/content/21092