Overview

Clinical integration has many definitions, including those driven by legal guidelines. The American Medical Association (AMA) describes clinical integration as “the means to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused.”¹

The Affordable Care Act (ACA) of 2011 includes provisions to promote clinical integration. That means hospitals and health care organizations are expected to participate in efforts to improve clinical integration — or the coordination of care across settings — and to expand coverage, boost the effectiveness and efficiency of care, promote innovation, and control costs.

Why is clinical integration important? Because many health care providers and organizations practice "in silos," meaning that they lack meaningful connections and information exchange with other health care entities:

• Many office-based physicians practice alone, in small groups or in single-specialty groups. They may not have access to peer benchmarking and best practices, or tools that can enhance communication across settings and enable clinical integration (such as an electronic health records [EHRs]).
• Many hospitals cannot ensure true clinical integration because they have limited tools for positively influencing the behavior and decisions of the staff and partners involved in patient care.
• Patients, especially those with chronic conditions, receive care in hospitals, ambulatory settings, clinics and at home. These facilities may not have mechanisms in place to track patient care across different health care settings.

Without coordination across multiple settings, patients are more likely to receive duplicative diagnostic tests, have adverse prescription drug interactions and get conflicting care plans.

As mentioned above, clinical integration tends to have many definitions, and is not a firm set of principles or practices. It does not require a “closed” system of information, where one hospital or health care organization monitors and influences patient care within that system. Clinical integration is a continuous process of alignment across the care continuum that supports the triple aim of health care:

• Improving quality of care
• Reducing or controlling the cost of care
• Improving access to care and the overall patient experience

In reality, clinical integration spans a range of settings and efforts, from multi-setting care coordination initiatives focused on a single condition, to networks of caregivers accessing and exchanging a variety of clinical and financial information to deliver quality care.

Legal Considerations

There may not be a firm definition for clinical integration among caregivers and health care leaders, but it has been officially defined by the Federal Trade Commission (FTC) and the U.S. Department of Justice. The need stems from providers and organizations often using joint ventures, with contractual agreements, to help achieve clinical integration, leaving them open to scrutiny for possible anti-competitive practices under antitrust law. While any group should obtain legal advice during the process of integration, the FTC has indicated that clinical integration is acceptable as long as a group comes together with the goal of improving care—and not simply to bargain for better rates.²