Integrated care: what it really means

August 3, 2016

Dr. Carl W. Nohr, AMA President

Dear Member:

Last week I wrote to you about our ongoing discussions with government around stewardship of the health care system. I have written several times this year on the subject of stewardship, but in the context of negotiations, members might ask: Why does it matter? Why should we try? What will we achieve?

My answer is that it is not only our professional responsibility to be stewards and to make sound choices about the resources we use on behalf of our patients, it is also our greatest opportunity for happiness in our work.

The value of effective stewardship has two dimensions: fiscal efficiency and quality care. In a sustainable health care system, both these things must be present – and that can only happen in the context of a transformed health care system. As part of the call for transformation, we often hear about “patient-centered, integrated, high-value care.” These are my thoughts on what this means.

Why do we need change?

The need for transformation of the health care system is based on changing patient attitudes and demographics, advances in technology, the increased need for chronic illness management and, importantly, on the failure over recent years to improve health outcomes by simply doing more of the same. Among Commonwealth countries, Canada ranks 5th of 11 in expenditures and 10th in performance. While the introduction of Medicare was a significant social event that has become a pillar of Canadian society, we cannot continue in the belief that yesterday’s success is sufficient to meet tomorrow’s challenges.

Integration is an approach to health care that involves a high degree of communication, collaboration and coordination among providers and patients to meet the needs of the whole person. Integration around the individual patient or a defined population creates a seamless patient experience. This is the most effective approach to prevention, acute care and chronic illness management. It also affords opportunity to address social determinants of health.

Instead of regarding the patient as a consumer of health services produced by providers in a system managed by the providers, we must shift our thinking. We should change from viewing health care as a commodity to seeing it as a collection of services, co-produced by patients and providers – and based on the values of patients in a co-managed system. This will lead to patient-centered integration.

There are several global trends that require these changes. They include:

  • Cost. Health services generated by the system must have a justifiable value to patients, be affordable by the payer and be cost effective.
  • Shift from acute care to health maintenance and prevention. The system must continue to provide “fixes” when health is damaged, but must do more to develop and maintain health of individuals and populations.
  • Technological innovation. Using self-monitoring devices and apps, patients can now generate their own value for some health services. The role of providers will need to evolve to co-manager of such services.
  • Generational changes in needs and expectations. There is an evolution in generational thinking regarding connectedness, convenience, choice, value, access to information and use of time.

To serve today’s patients the system must focus on what they value by providing connectedness, convenience and choice while maintaining acceptable cost. The traditional quadruple aim of health care (patient experience, population health, per capita cost and provider experience) is system-focused, and should evolve to a model where patient and provider co-produce health outcomes that the patient values. This new model would be meet the definition of the oft-repeated motto of “patient-centered” care.

The “Medical Home” or “Health Home” is the conceptual structure that will facilitate integration of care around the patient. Timely and continuous care can be achieved using the principles of: rostering and identification of a personal physician; comprehensive team-based care; shared electronic health records; and strong linkages to specialist care. Appropriate physician compensation can facilitate the development of this structure. In Alberta, primary care networks are working toward this model.

How are physicians involved in integrated health care?

The principles of integrated care that relate to physicians are stewardship, professionalism and co-management. I have written before about stewardship in my February 17 President’s Letter as part of the social contract between the medical profession and society. For these principles to be realized, the role of providers in several areas needs to evolve. They include:

  • Information management
  • Communication
  • Physician compensation and equity
  • Definition of value
  • Definition of autonomy
  • Precision self-regulation

The traditional role of physicians as medical experts will continue. How we exercise that role will change based on evolution in patient expectations, value systems and fiscal realities. Information management, particularly patient access to their information, will change. The traditional view of comprehensive autonomy in all aspects of physician life, including clinical work, business arrangements and compensation models will adapt to the population and payer requirements of convenience, value and fiscal realities. Regulatory bodies will move to data-enhanced, precision education and regulation of members.

Do we have integrated health care in Alberta?

We have facility integration through a single health authority, but we do not have complete integration of the patient’s path. Primary care networks and strategic clinical networks have done pioneering work to link pieces of the continuum of care, but more is needed.

Attachment to a primary care provider is the entry level of integration. Beyond that, we must address many challenges. Today, patients experience episodic, poorly coordinated care in multiple locations. We have fragmented care pathways, with a blend of traditional referral patterns. There are inconsistent protocols, isolated triage tools, some common intake approaches blended with specialty clinics and clinicians practicing independently at multiple sites that the patient must visit in sequence. We have patient information in multiple locations, often inaccessible to providers and likely leading to error, inefficiency, repetition and redundancy. We move patients around from site to site rather than moving their information. We have weak linkages between community and facility-based care, and between primary and specialist providers. We have complicated branching pathways with built in delays that require the use of navigators to get a patient through the system.

How will we know when we have an integrated system?

From the physician’s perspective, integration will provide:

  • Easy access to needed medical information, clinical decision support tools, documentation that creates context for decision-making, clinical reminders, access to care pathways (into secondary care and back) and effective provider-to-provider communications.
  • Access by physicians to data about their own patterns of practice that can identify if they are trending away from best practice, revealing opportunities to improve service to defined patient populations.
  • Ability to communicate with patients through several means, reducing the need for short in-person visits to provide services that could be provided through more modern methods.
  • Assistance from patients to monitor their own health conditions through the use of technology.

From the government’s perspective, integration will provide better measures of accessibility and quality. Tracking and studying population health needs through secondary usage of data will facilitate budgeting. Resource planning with provider associations will support geographically equitable access.

What about the patient perspective?

This is a description of what I imagine my experience would be like as a patient in an integrated system. All my providers and I have convenient access to my health information. I am no longer the medium through which information is exchanged between multiple providers: I do not have to repeat myself. My medication information is updated in real time and available to all providers and me. My diagnostic tests are not unnecessarily repeated. I have convenient access to information to help me make informed choices, so I am a member of my own health care team. I can choose among providers, accessing care simply, effectively and in a relevant time frame. I can make, confirm and change appointments with multiple providers with a single call, website or app. Members of my health team and I communicate in a variety of ways that meet the clinical need and respect my time. I can find my way through the system without navigators. I can help to monitor my own conditions with technology and my providers have access to that information.

Historically, health care was something that was done to patients. Currently, it is something we do for patients. We need to move to an era where health care is something we do with patients. When this happens, we will have achieved integration around the patient.

What’s next?

Abraham Lincoln once said that if he was given six hours to chop down a tree, he would spend the first four hours sharpening the axe.

For decades we have planned to reform the system, producing endless designs and redesigns. We have engaged in pilot projects, but failed to upscale success. There are several reasons for this: lack of alignment of authority and accountability; a desire for a single solution with agreement by all stakeholders; and disjointed leadership are among them.

It is time to act definitively. Building consensus is useful, but when agreement on a direction is not achievable, leadership is required to move forward. There will be failures; the appropriate response to this is not fear. Instead we should expect setbacks, recover from them quickly and learn from the experience. All health care system designs are imperfect, but some are good enough to get started on the path to integrated care.

There are some positive indicators. The three pillars of integrated health care are information, innovation and interest. The Government of Alberta is investing significantly in an integrated health information management system. The need for innovation is increasingly obvious and is inevitable. When I say interest is the third component, I refer to the interest of the physicians and society in meeting the terms of the social contract that exists between us. There is an increased emphasis on medical professionalism, which I applaud.

I know I live in a world of imagination and hope. These things sustain me as I seek to make a little difference in the lives of a few patients. I ask you to be thoughtful in your day-to-day work; if you make some small progressive changes toward an integrated approach to care, I know we will have better patient outcomes and achieve fiscal sustainability, while also gaining greater personal and professional satisfaction, and a happier life.

This letter has brought together a number of themes that I have addressed through the past year. As a result, it is longer than I prefer. I appreciate your consideration and look forward to learning what you think.

Please email president@albertadoctors.org or leave a comment below.

Kind regards,

Carl W. Nohr, MDCM, PhD, FRCSC, FACS
President

7 comments

Commenting on this page is closed.

  • #1

    bill gould

    Member of the public

    4:02 PM on August 03, 2016

    I am not sure if I understand what it is the AMA is trying to do.

  • #2

    This comment has been deleted.

  • #3

    Dennis Kendel

    Physician

    4:47 PM on August 03, 2016

    Thanks for your thoughtful reflections on health resource stewardship. integrated care, and the leadership opportunities open to physicians in shaping our future healthcare system.

  • #4

    David Climenhaga

    Physician

    8:53 PM on August 03, 2016

    The letter sure looks like stringing together a bunch of catch phrases with a pile of bs mixed in. There are some facts, there are increasing elderly, the elderly will die, they will have diseases that lead to their death and preventing one type of illness will only mean the elderly live longer and consuming more chronic healthcare. Prevention is not wrong it only increases the consumption of care for degenerative diseases. Instead of the AMA focusing the discussion on the gross excess management costs you are focusing on cutting and transferring the 18-20% in physician billings. The fix to the healthcare system is in the 80% that includes all the redundant over the top administrative expenses that produce rampant cost over runs. As an operator of an NHSF I have seen stupid rules pushed through by the College and AHS without the AMA raising the slightest objection. Physicians need to be allowed to deliver care to patients and not spend countless resources producing metrics for endless garbage meetings. I for one think its time to shake up the AMA, clear out the AHS syncopates and replace them with people that actually want to deliver patient care.

  • #5

    Karenn Chan

    Physician

    11:49 PM on August 03, 2016

    Dear Dr. Nohr,
    Thank you for your thoughtful and well composed letter this week. I feel deeply these issues in my day to day work. I feel that over the years I have heard many of the same themes, particularly the fact that we simply need to change where the health care dollars are spent but it seems no one in control of those dollars is willing to do this. How will we change this? How do we enforce accountability of all parties involved to move things forward?
    I have great hope in the patient medical home model and feel that one area that may get left behind is connections with Home Care. I see a huge gap in the current communications between all medical professionals outside and those inside of Home Care. Let's sharpen some axes.

  • #6

    Judith Brooke

    Member of the public

    5:40 AM on August 04, 2016

    I applaud your approaches. I want to have my family doctor to have access to my other health care providers (chiropractor, massage therapist, naturopath, dentist) and visa versa. In my frustration of repeating myself, I have created a paper that lists all my symptoms, surgeries, illnesses from as far back as I can remember. I then give it to my health care provider (although my former family doctor didn't read it). This I should not have to do. With modern technology all this could be available to all health care providers, with the patients consent of course. I want my health care to be a team effort where my thoughts are important on why I am unwell. Thank you for your forward thinking. I do hope that the future generations can enjoy a more integrated health care system that you envision.

  • #7

    Dr. Dinesh Witharana

    Physician

    11:10 AM on August 04, 2016

    Hi Dr. Nohr,

    Thank you for sharing your thoughts. As a family physician and palliative care specialist, I see disintegration at its worst for patients suffering from severe life-threatening, progressive illnesses. Patients bounce between family doctors, specialists, oncologists, home care, and emergency rooms without any clear coordination in their care. They often do not know who to call with concerns. We need to do a better job at integrating the journey that these patients take from diagnosis to life-prolonging treatment to palliative care.

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