A clinically integrated network may seem just the thing to bring health care organizations into the age of value-conscious outcomes and payment, but many clinicians still regard the concept with suspicion because of its incursions on their autonomy and the costs in network-building and technology they have to share.

To counter the pushback, CIN leaders first have to explain and demonstrate the gains for physicians and other professionals. Properly designed, such a network can integrate primary and specialty care to each other's benefit, free physicians from the grunt work they think is part of the job but doesn't have to be, and use technology to fully include doctors in the decision-making process without requiring them to attend meetings outside their practices.

Secondly, the CIN will have to make evident that one of the assumptions behind its formation is that significant aspects of health care quality, access and utilization need fixing, and providers must agree, says Thomas Enders, a senior managing director of Manatt Health Solutions. "A CIN has to be very clear about, 'Here's where we have to improve,' and the people in it have to say, 'It's true, we need to improve, we're going to improve together, and we're going to benefit from it.' "

It may be awkward or irksome, for example, for doctors to work with embedded care managers in their practices, says Deb Smith, R.N., an expert in CIN development with URAC, the accreditation organization. But all highly trained physicians should be practicing at the top of their license, leaving much of patient management to others. A former oncology nurse herself, Smith remembers working with a gynecological oncologist in the 1970s. "He said to me one day, 'I used to think I had to do this alone.' And he didn't." As an advanced-practice nurse, she did what she was well-qualified to do, "and freed him up to do what he does best."

Physicians are just as overwhelmed with duties today, she explains. "The doctor who sees 40 patients a day and delivers three babies is exhausted, and therefore at risk, personally and professionally." There are easier, more satisfying ways to work, Smith says, through known models for transforming practice.

Open Communication

Doctors also have to work with one another in a continuum of care, and moves such as adding hospitalists haven't helped, says Smith. Primary care physicians stay in their offices while specialists and hospitalists do rounds at hospitals, creating "myopia on both ends" about their respective roles.

Reading (Pa.) Health System's nascent CIN felt this tension palpably, says George Jenckes, M.D., CEO of Reading Health Partners. "Like most institutions, once hospitalists came into the system, internists went out, and the practice went out to a purely ambulatory setting. There was a loss of communication. … So one of the things we tried to do in the beginning with the specialists and also the PCPs was to say, 'This is a chance for us to re-communicate.' "  

In the course of setting up for a pilot program on care for heart failure patients, cardiologists complained that many of the referrals from primary care physicians were inappropriate — either patients didn't need to be seen, or they should have been seen sooner. Primary care doctors countered that specialists hadn't told them how to determine what was appropriate. So they met and cardiologists explained that heart failure has four stages, the first two of which don't require a cardiologist's care. Stage three is where the most referral and communication activity should occur, while stage four patients should go straight to the specialist alone.

The process went well enough that it was repeated six months later with pulmonologists for care of chronic obstructive pulmonary disease, with the same initial issues over referrals. "That's been very positive for our system, getting the PCPs and the specialists to start communicating and better," Jenckes says. "And that's been the fun part, seeing that evolve."

Better doc-to-doc communication is one way to improve case management, as distinguished from care management, says Smith. Case management, an established process, is used by health care professionals in medical care, while emerging care management and coordination is everyone's job in the CIN, or the network won't work, she says. One way to establish network-wide coordination is through a "playbook," such as the one created and followed by physicians who belong to St. Vincent's Health Partners, Bridgeport, Conn. For patient-care transitions, for example, more than 100 types of transitions are identified and the steps defined, and essential information to guide a transition accompanies the patient and informs each face-to-face clinician interaction.

Strategic Investments

When physicians adopt protocols they all agree on and can benefit from, they start to feel better about the other essential components of CIN success, such as paying for the IT system capabilities required for integration on a wide scale, says Enders. "You can do them on the cheap, but they're not going to deliver much value, and delivery of value is directly correlated with resource input." Besides IT, system essentials include a care management system, a set of care managers, some staff to lead efforts on protocol development and practice integration, possibly a management services organization, and keen abilities around contracting, he says.

One obstacle to marshalling sufficient resources is a differing view of investment between the hospital or health system and the physicians, particularly independents, Enders cautions. "What seems like a lot of money to a practicing physician joining a CIN may not seem like a lot of money to a hospital. So generating the necessary resources to be effective is a challenge, and can lead to the hospital investing more than the physicians, and then the perception by the physicians that it's kind of taking over."

Deft leadership can highlight the applications of IT and other investments of people and infrastructure that result in more physician control, not less, says Smith. One example is setting up more convenient ways for physicians to contribute to governance. Systemwide access to a web-based meeting application can conquer the difficulty in carving out physician time to lead protocol efforts or make business decisions. "You can get 20 minutes, or even more, out of a physician in their office if they don't have to leave," Smith says. "But getting them to leave and go somewhere is much harder. … And you need them. So you've got to find a way that is organic to that community to communicate." The particular vehicle will depend on what participants say would make it worth their time.

A CIN may have it all, just waiting for physicians to embrace the communication, contracting and data-analysis benefits available to them, but what if some still balk? For St. Vincent's, the answer comes down to one word. "Persistence," says Michael Hunt, D.O., chief medical officer and chief medical information officer. "We never take no for an answer."

That goes especially for breaking down wariness about having performance monitored and converted into monthly data reports. Within the St. Vincent's physician community, those complete evaluations were having a positive effect among doctors who took the information the right way, says Hunt, and "for those who were being stubborn, when they started hearing how well that was going, we seem to not have as many roadblocks."

For more on CINs, please see the November/December cover story, "Success Factors and Barriers on the Journey to Clinically Integrated Networks."

John Morrissey is a writer in Mount Prospect, Ill.