Few would dispute that health care should move from the traditional silo system of practice with single-specialty providers to a seamless, well-integrated clinical care environment that brings together the various disciplines needed to provide patient-centered care, to educate trainees, and to conduct research into a particular disease or episode of care. Yet there are relatively few examples of such seamless clinical integration, either in the community setting or in academic health centers (AHCs). It is easy to see why such seamless integration might be difficult to achieve among community-based providers, where solo and small single-specialty groups are mostly autonomous economic and legal units. It is harder to explain the lack of progress toward clinical integration within most AHCs. Whereas AHC faculties traditionally have been organized within relatively autonomous academic and clinical departments, they practice, investigate, and teach within group practice plans and in university health system environments that, for at least two decades, have seen growing demands and incentives for clinical integration. Why has progress been so slow? What can be done to foster seamless clinical integration in the AHC?
The Case for Integration
It is hard to argue against clinical integration. From almost any stakeholder's perspective, integration is a good thing.
▪ Patients. Patients and their families want a well-organized team of providers within an organization that is focused on quality, safety, and service. They want easy access to all the specialties needed to diagnose and treat their disease. And most value access to providers who develop new knowledge and treatment approaches.1
▪ Payors. Payors value efficient, high quality, cost-effective care. Multidisciplinary care teams have the potential to deliver higher-quality and greater cost-effectiveness through a comprehensive, team approach that can define the optimal diagnostic and treatment regimen.
▪ Providers. Professional satisfaction should be improved by better access to needed specialists, greater sharing of patient care assignments across specialties, greater critical mass to enable dedicated diagnostic services, better coordination and integration of patient services according to patient needs, and improved outcomes. This is especially true for the AHC, where complex cases abound, and patients exhibit numerous comorbidities requiring specialized consults.
▪ Policy makers and the public. Public policy increasingly is valuing integration. The National Academy of Sciences has called for academic institutions to explore new models that foster and reward interdisciplinary programs.2 The recent Roadmap for Medical Research of the National Institutes of Health (NIH) promotes the need for medical schools and universities to develop collaborative teams of scientists.3 The NIH itself is organized around disease-related groupings rather than medical specialties. It is difficult to imagine the NIH with a cardiology institute that is separate and distinct from a cardiac surgery institute or a pulmonary medicine institute instead of the Heart, Lung and Blood Institute.
Two Forms of Clinical Integration at AHCs
AHC faculty members have long worked with one another and with other professionals and staff in patient care, research, and teaching. In patient care, physicians routinely consult with other specialists and refer patients for diagnostic tests and treatment (including rehabilitation). In some instances, such collaboration has evolved into more structured forms of clinical integration and the formation of clinical centers. Most often, clinical centers in the AHC are composed of professionals who are relatively closely aligned in clinical approach-or, perhaps, they overlap (i.e., compete for patients)-in clinical practice. Such clinical integration among similarly situated professionals is what we call lateral clinical integration. Clinical integration that includes a broader range of professionals who play different roles in the diagnosis and treatment of medical conditions and health problems is what we call vertical clinical integration. Vertical clinical integration is rarer and seems to be much harder to accomplish, because it requires integrating professionals who are less similarly situated. Comprehensive cancer centers are perhaps the best-known examples of vertical integration within AHCs.
A limiting factor in the vast majority of examples of clinical integration, whether lateral or vertical, is that they fail to integrate essential administrative and financial functions. This lack of administrative and financial integration has significant consequences for the ability of either laterally or vertically integrated centers to provide seamless, patient-centered care.
Lateral clinical integration: Easier to achieve but with limitations
On the basis of our experiences with several different AHCs, we postulate that lateral integration occurs more often than vertical integration because of similarities among the physicians (even where they are in different departments) along four dimensions:
▪ Levels of reimbursement for services provided are the same or similar.
▪ Different specialties are converging on the same or similar diagnostic or therapeutic approaches.
▪ Similar cultures or personalities exist among different specialists.
▪ There is a pressing need to share expensive institutional resources, such as interventional labs, surgical instruments, and unique diagnostic facilities (e.g., sleep labs).
Below, we briefly describe some common examples of this sort of lateral integration in AHCs.
Sleep disorder clinics/centers.
In many institutions, a patient or referring physician can schedule a sleep study through either a neurologist, a pulmonologist, or, in some AHCs, a psychiatrist. A number of AHCs have been able to get these specialties to work together to share the sleep lab and, in some cases, to coordinate their diagnosis, treatment approach, and research. This type of lateral integration works because these specialties are paid the same for the sleep study, they are both primarily noninterventional medical specialties, and they need to share a dedicated resource, that is, the sleep lab.
Spine centers.
A number of AHCs and some community practices have developed spine centers that use both orthopedists and neurosurgeons to do spine surgery. The surgeons are generally paid the same amounts for spine surgery or other spine treatment. Both orthopedists and neurosurgeons are surgical specialists, and they share unique surgical tools and implantable devices and instruments.
Neurovascular/stroke centers.
A number of AHCs have brought into a single practice neurosurgeons and interventional neuroradiologists who treat cerebral aneurysms and hemorrhagic stroke.
Carotid and aortic stenting.
A number of AHCs have established coordinated programs in each of these areas, where faculty members in several specialties are trained to do these procedures. In the field of carotid stenting, coordination has been aided by the Centers for Medicare and Medicaid Services requirement that a hospital have a unified approach to credentialing the different specialists (cardiologists, interventional radiologists, vascular surgeons, and possibly interventional neurologists) that perform these procedures.
These examples show that clinical coordination among similarly situated specialists is often beneficial to the providers. Coordination can
▪ help rationalize the provision of care, often improving both interprofessional relations and patient service;
▪ help coordinate practice management and pooling and apportioning of practice costs, revenues, and dedicated facilities or equipment;
▪ enable certain specialists within a clinical system to cooperate to market their programs rather than engaging in potentially acrimonious competition in the provision of care to patients;
▪ help establish and monitor uniform standards of care based on evidence-based medicine that yields superior outcomes for patients; and
▪ help establish interdisciplinary curricula and common credentialing criteria.
The opportunities for this type of integration will likely become increasingly common with the growth of minimally invasive treatments that can be done by multiple specialties (e.g., surgical, medical, and radiology faculty trained in interventional techniques and management of high-acuity patients during and after interventional treatment), and as the volume of certain surgical procedures declines (e.g., in cardiac surgery, some cardiac surgeons are focusing on vascular and other procedures previously done only by vascular surgeons, cardiologists, or other specialists).
At the same time, many of these examples also display limitations inherent in the lateral integration model. Coordination of competing or similarly situated medical professionals tends to be provider centric rather than patient centered. Such practices and centers tend to form in order to address provider, institutional, or marketplace issues. They almost always simply replicate or extend traditional academic or clinical structures rather than integrate them administratively and financially into new, more efficient, and patient-centered models of care. Problems persist with coordination of provider and patient scheduling, multiple billing centers, the location of diagnostics facilities, and other patient service and access issues.
And, an important question arises from the patient's point of view: are some patients deprived of the option of having the diagnostic and treatment input of specialists who might approach the patient from other clinically viable perspectives? For example, if a spine center consists only of providers who specialize in invasive procedures, a patient might never have the input of a neurologist or physiatrist, who would quite possibly have a different approach to spine care than a neurosurgeon or orthopedist would. In the lateral integration typical of many spine centers, the neurologists are not participants. Thus, the formation of some laterally integrated centers may, in fact, limit the approaches to care available to patients.
Vertical clinical integration: More patient-centered but more difficult
Unlike lateral integration, vertical integration involves bringing together the multiple clinical specialists who have either a primary or other important relation to a particular patient population or disease state, regardless of whether they are similarly situated. Such vertical integration tends to be more difficult to achieve because of financial, organizational, and cultural issues not encountered (or purposely avoided) by lateral integration. Nevertheless, growing evidence suggests that vertical integration within the AHC is both achievable and highly desirable.
The comprehensive cancer centers at AHCs are often held out as the most advanced example of an integrated clinical center within an AHC. These centers are enabled in large part by the fact that one of the biggest challenges to integration-financing-is addressed to a significant degree by substantial grant funding from the National Cancer Institute (NCI). The competitive process for achieving NCI support and designation requires demonstration of significant interprofessional and multidisciplinary care and research. Coordination of care, research, and training can be quite extensive within these centers.
Nevertheless, it is also the case that these centers generally do not fully integrate care. The prevailing model will often bring together various professionals, specialists, and investigators through case conferences or tumor boards. But, as with other forms of collaboration within AHCs, this does not substantially affect the segregation of providers within home departments or the traditional organization of physician roles in patient service. Scheduling of patients and coordination of provider services, funds flow, management, and other critical functions generally remain within traditional clinical sections or departments and are neither centralized nor centrally coordinated. A recent Kaiser Family Foundation and Harvard School of Public Health survey of cancer patients and their families found extremely high levels of patient dissatisfaction attributable to the poor coordination of their care.4
Along these same lines, numerous organizations have attempted to establish tumor- or cancer-specific multidisciplinary clinics, including, for example, breast clinics, but they have found that this type of voluntary coordination of schedules and care is too difficult and too costly, given that not all patients require the services of each specialist at each visit. As a result, some departments/divisions will complain that their faculty members who participate in these multidisciplinary clinics have poor productivity because there are insufficient patients during each clinic session. Further, the challenges of coordinating faculty schedules, billing, assignment of overhead costs, and other issues across different departments and specialties (such as medical oncology/medicine, surgery, and radiation oncology) are often considered too difficult to justify the benefits. We have identified very few AHC cancer centers that have integrated their finances so that, for instance, the breast center collects the professional fees for the diagnosis and treatment work done by the faculty and staff, or where all faculty and staff whose practices primarily relate to diagnosis and treatment of breast cancer work for the breast program.
The failure to truly integrate is by no means limited to many of the cancer centers. Almost all fields are missing opportunities for vertical integration, including the management of heart disease, solid organ transplantation, the neurosciences, and digestive health.
Characteristics of vertical clinical integration.
Despite the obstacles, vertical clinical (along with administrative and financial) integration is both achievable and in the best interest of all stakeholders. We propose that a vertically integrated clinical practice or center within an AHC should be characterized by the following minimum features:
▪ The practice/center enables participation and coordination among all essential care/research professionals and staff necessary to the center's clinical focus. In most cases, this will entail interdisciplinary and interprofessional coordination.
▪ The center or practice conducts clinical care and research at least, and, if possible, also conducts education and training.
▪ The center's financial structure is a pooled or similar arrangement, rather than administered separately by participating school and clinical departments.
▪ The center serves as the clinical home for a critical threshold of faculty participants who spend most of their time in care or research related to the disease that is the center's focus.
▪ Administrative processes, especially registration, billing, and scheduling, are facilitated through a single point of contact for all participating providers, regardless of their specialties or departmental affiliations.
▪ There is a center director with authority and responsibility for the activities of those faculty and staff who are active members of the center. The center director also has authority and responsibility for space, financial, and related resources that the director can manage, to achieve the center's goals (understanding that some of these responsibilities may be shared with other senior leadership).
Examples of successful vertical clinical integration.
Several examples will serve to illustrate the potential and the possibilities for centers organized according to these principles.
Although examples of true clinical integration are still relatively rare, some have been developed and can serve as models.
The Mayo Clinic in Jacksonville (MCJ) has created a department of transplantation that includes the liver, renal, and pancreas transplant surgeons as well as the transplant nephrologists, all hepatologists, the lung failure pulmonologists, the heart failure cardiologists, and two critical care medicine specialists. This new model has been in place for five years and has been a major contributor to the program's success on a number of measures. For example, the number of liver transplants has increased from 150 each year to approximately 250 each year, making Mayo/St. Luke's one of the nation's largest liver transplant programs.
MCJ's integrated model has enabled the department to deploy its faculty using a team approach. That is, the surgeons are able to spend the vast majority of their time in the operating rooms conducting organ recovery and transplantation while the medical faculty are able to spend their time consulting with patients and families in the clinic setting and managing postoperative care. The current department chair is a transplant nephrologist, even though many of the department's faculty are surgeons. Academic appointments for the faculty remain within the departments of medicine and surgery; all clinical activity for the participating physicians is managed through the transplantation department. Whereas implementation of this interdisciplinary model experienced many of the challenges typical of clinical integration efforts at other academic centers, the new model was enabled by the Mayo Clinic's group practice culture and because many clinic departments at Mayo are not profit centers as they are in most academic centers.
The integrated model enables the faculty and leadership to focus on optimizing the program's performance on quality, service, satisfaction and economic measures across all specialties and venues of care, including the hospital. Programs without this type of integrated model typically focus on optimizing specific elements of the program, often at the expense of optimizing overall program performance.5
Penn State Hershey Medical Center has organized its heart and vascular institute to combine the practices of the faculty cardiologists, interventional radiologists, cardiac surgeons, and vascular surgeons. The institute is led by a well-respected cardiologist and has been successful in strengthening the program's performance on all missions. This institute blends horizontal collaboration within a vertically integrated model. For example, the institute has organized its faculty into six areas, several of which include physicians in different specialties that provide the same services. This model enables the physicians to work as a team regardless of their specialty training, rather than competing for patients and large capital investments. The six areas are
▪ imaging-which consists of vascular surgery, cardiology, and interventional radiology (includes diagnostic caths, angiograms, and vascular studies);
▪ interventional (interventional cardiology, carotid intervention, and aortic stent procedures)-which consists of cardiology, interventional radiology, vascular surgery, and one computed tomography (CT) surgeon being trained in selected interventional procedures;
▪ general cardiology-which consists of the cardiology consult service, the heart failure program, and the congenital heart disease program;
▪ electrophysiology (EP)-which has grown to include five EP specialists;
▪ cardiac surgery-which consists of the CT surgeons; and
▪ vascular-which now consists of the vascular surgeons, but the institute is recruiting a vascular medicine specialist who will be part of this group.
Academic appointments remain within the legacy departments (medicine, surgery, and radiology), but the practices operate through the institute. Faculty compensation, recruitment, and research grants for participating faculty are managed by the institute. The medical center shares research indirect payments with the principal investigator's (PI)'s home department; in this area, the shared indirects are split between the PI's department and the institute. There is an executive oversight board composed of the chairs of medicine, surgery, radiology, and neurosurgery, as well as key executives from the medical center such as the COO, CFO, and others. The director of the institute also meets regularly with the dean/CEO of the medical center.
This unique model is partially enabled by the Penn State culture developed over the past several years,6 which emphasizes collaboration across the departments and was the subject of a University HealthSystem Consortium case study in 2004.7 New department chairs have been selected, in part, on the basis of their ability to work in a collaborative model. A number of incentive and management mechanisms were implemented to encourage faculty and chairs to focus on optimizing the medical center's overall performance rather than optimizing departmental performance.7
Beth Israel Deaconess Medical Center Cardiovascular Institute (CVI) is a new, integrated patient care model that integrates three services specializing in the delivery of cardiovascular care: cardiology, vascular surgery, and cardiac surgery.8 All of the physicians involved are integrated into one reporting and financial structure. Nursing and hospital services involved are integrated as well, meaning that all of the physician and hospital components are consolidated into a linked reporting, financial, and care delivery structure. The CVI is being led by the current chief of cardiac surgery of Beth Israel Deaconess and has its own board of directors.
The CVI is being implemented and is described as designed to
be an organization that is nimble and flexible, with the ability to make needed changes quickly meeting the demands of a rapidly changing health care environment. It will also allow us to tailor the patient experience for specific patient types as well as specific patients. A critical feature of the model is that it is very dynamic. Its lean infrastructure and multidisciplinary board will enable it to quickly meet new challenges and adapt to overcome them.8
The CVI describes the ideal patient experience that it is being designed to achieve:
Once fully operational, the CVI will be seamless and transparent. A patient will enter the system, often at a community location, and move through the CVI without having to be concerned with the organization around them. Medical records will be shared. Appointments will be made in a manner convenient for the patient. The patient will make a single trip for all tests and then a single trip to see consultants. Specialties will consult with each other, having already preestablished a consensus regarding what needs to be done, in what order, and by whom. The complete outpatient and inpatient experience will be organized around a multidisciplinary approach that involves all care givers-including nurses, case managers, social workers, physical therapists, and even housekeepers-coordinated to achieve the best level of comfort and care. All of this will be visible only to the most discerning patient, but it will distinguish the CVI at BIDMC as the place to go for the highest quality care provided in the most humane way.8
The Emory Transplant Center (ETC) of Emory's Robert W. Woodruff Health Sciences Center (WHSC) is one of four centers that have been chosen to become Emory's first fully vertically integrated centers. Having been involved in the conception, design, and implementation of this center, we can provide greater detail concerning some of the key characteristics of the new ETC model that are likely germane to the creation of all such centers.
To develop a new model, a systematic and inclusive process was undertaken during many months, starting early in 2006, involving all key players in the ETC as well as the relevant departments, deans, and staff. This model draws on traditional structures and functions of AHC organizations by establishing the ETC as a new clinical section. Yet, at the same time, this traditional vehicle is imbued with new features that enable it to expand and, in certain ways, redefine the nature of a clinical section or center. It also asks medical school departments to realign and/or share certain governance, funds flow, professional development, and other core responsibilities to enable unprecedented levels of coordination and integration. The result is a new model for integrated clinical practice within the overall AHC administrative and governance structure. The following paragraphs describe some of the key characteristics of this center.
* ▪ The center director has the authority and responsibility for the activities of those faculty and staff who are active members of the ETC. Faculty and staff who spend significant time (more than 50%) in solid organ transplantation, or are essential to the mission of the ETC, will have appointments in both the ETC and their departments. These faculty and staff members will be managed by the ETC leadership. Performance reviews and development plans for faculty with ETC appointments will be done by ETC leadership with recommendations made to the schools/units/department of appointment as appropriate.
* ▪ The ETC director will also have dedicated resources, including clinical and research space, essential to achieving success. Research grants will be tracked both by schools/units/departments and for ETC. The ETC must fulfill traditional educational responsibilities of the schools and departments and take a lead in the pursuit of educational programs that build interprofessional teams.
* ▪ The ETC will be integrated into the governance structure. A new senior position has been established within the WHSC, with responsibility for oversight and successful development of vertically integrated centers. The center director will report to the CEO of Emory Health Care, the dean of the school of medicine, and the director of The Emory Clinic. A transplantation section (i.e., a transplant practice) will be established in The Emory Clinic to include the medical and surgical transplant faculty essential to the core mission of the program. All clinical activities and revenues of these faculty will be assigned to this new Emory Clinic section. This includes transplant-related activities as well as dialysis coverage, endoscopies, and so forth, to avoid splitting clinical income for these faculty between multiple Emory Clinic sections. An advisory board has been established to bring together the key stakeholders that have a role in the success of ETC. Participants include the chairs of medicine and surgery, the COO of Emory University Hospital, the COO (or CEO) of The Emory Clinic, a representative from the school of medicine research administration, and a WHSC executive staff representative. Information transparency will ensure that leadership can assess performance and make informed decisions about ETC's program and its impact across WHSC entities.
Although this model, finalized in the summer of 2007, is still in the process of being implemented, there is reasonable optimism that it can be very successful both in this center and in several additional integrated centers within the next two years. And, although not all AHCs could adopt this exact model, it is likely that many of its features could be transferred and adapted by most AHCs.
Seven Lessons Learned
The examples discussed above from Mayo, Penn State, Beth Israel Deaconess Medical Center, and Emory are robust models of vertical integration, but achieving such integration has been no easy task. One senior executive in an AHC recently commented wryly when discussing approaches to integrating clinical practice, We're just talking about people's money and power, so this shouldn't be a problem!
Nevertheless, AHCs can and should move more aggressively to create integrated, disease-specific centers that cross clinical, research, and training missions and, thereby, leverage the inherent strengths of the AHC. Moving in this direction requires the AHC to address underlying financing and governance issues. Though not simple, lessons learned indicate that success is possible and highly rewarding for all stake holders:
Lesson one: Start with centers that are most likely to succeed.
Any AHC wanting to create one or more centers should start with programs that have strong leadership and in which the AHC plans to invest. Finding the right leadership is critical. Where a single director candidate is not obvious, consider creating coheads with leaders from participating specialties working as an executive team. Inserting strong administrative staff into the center can also help maintain balance among the participating specialties and protect the interests of the departments and other constituencies whose cooperation is needed for success
Lesson two: Work closely with all department chairs whose faculty or department will participate or be affected by the formation of a new center.
Clearly define the role, responsibilities, and expectations of the department chair (or division chiefs) and the center director in managing key elements of faculty performance and career development-and then hold them accountable. In this regard, link chair performance reviews and incentive compensation to the success of the centers. That is, make it clear that helping an integrated center to succeed is important to the overall organization and that efforts to constrain its success are not desired or rewarded. Departments can share in the profits of an integrated center if they are moving into this center faculty members who previously made a significant financial contribution to the department. Additionally, chairs should be rewarded through their performance reviews and their incentive compensation if the centers that include their faculty are successful.
Going forward, the types of individuals who will be successful chairs may need to be reevaluated. Future success will require chairs to work collaboratively with their peers to build, fund, and govern these types of centers, as well as building their departments. Individuals who are focused exclusively on optimizing the performance of their own departments would not succeed in an AHC that is developing numerous interdisciplinary programs. Recent recommendations for systematic investment in chair development should be adopted in all AHCs.9
Lesson three: Understand and manage faculty needs.
The AHC must clarify which individuals will have primary and secondary responsibility for management of the faculty participating in a center. Faculty members will rightfully fear participating in these centers if these issues are not fully addressed and clarified. Especially important is to determine who will
▪ define faculty performance expectations,
▪ determine work hours and time allocations,
▪ conduct performance reviews,
▪ determine faculty raises and bonuses,
▪ recommend promotion and tenure, and
▪ make hire and fire decisions.
Lesson four: Fashion and experiment with governance models that bring chairmen, faculty, and other leadership together to provide direction and oversight for new centers. Be very clear about the authority and reporting relationships of the center director.
This area is ripe for new ideas and experimentation, with opportunities for faculty within the AHC as well as from other parts of a university, such as business schools, to provide input and training for chairs and others. Some AHCs may want to have community leaders or their own board members participate in center governance to help convey the importance of these programs to the organization's future and to help provide board members with insight into the organization's opportunities and challenges. Emory has decided to appoint a vice president for clinical and academic integration, whose role it is to work with the center directors and help them succeed. With respect to the reporting relationship for center directors, options include having the center directors report to the AHC senior executive and/or, as in the Emory model, have a main reporting relationship to, for instance, the dean of the school of medicine, with dotted lines to one or two other key members of the leadership team (e.g., clinic director and/or hospital CEO).
Lesson five: Information transparency is vitally important.
It is important to gain agreement that all information across the AHC will be transparent, especially as it relates to any integrated center. In general, the information needed to develop and manage centers is available, but scattered, across the AHC. The challenge is to bring together and share that information effectively.
Lesson six: Develop an internal investment strategy.
Although there are numerous examples of practice plans or departments investing in outside ventures, such as surgi-centers, imaging centers, and other ambulatory care initiatives, there are few examples of departments jointly investing in and governing their core programs. These investments typically have some type of shared governance structure based on each department's proportion of the investment in the endeavor.
For example, in many AHCs, diagnosis, treatment, education, and research related to heart disease are a core business of the AHC and typically the source of a high percentage of hospital and professional fee surpluses. Yet, AHCs haven't created economically integrated heart centers that have the departments of medicine and surgery as the primary investors and with key roles in governance. AHCs have the opportunity to organize their resources to manage this and other business for success internally, just as they do with outside ventures.
Similarly, traditional departments and new centers can face challenges in accounting for both research awards and other receipts. Schools of medicine can agree to structure their accounting systems to enable dual counting of research grants so that the departments and centers both take credit for research awards. This mechanism works as long as the school does not share the indirect cost payments (IDCs) with the department. If IDCs are shared with departments, then a mechanism for sharing IDC revenues and expenses between departments and centers will need to be established. At one AHC, for example, the practice plan agreed they would create a new practice entity within their systems to capture the data for the center. The development of electronic health records should mitigate some of the challenges of managing patient-specific information and other clinical information.
Documentation of performance should be formalized so that the AHC can demonstrate center success both internally and externally. This requires clear definition of performance goals, documentation of current state performance, and monitoring mechanisms to track progress.
Lesson seven: Departments organized as stand-alone profit centers may not be the best model for the AHC going forward.
As long as departments are expected to operate as essentially stand-alone profit centers (which is the prevailing AHC model), creating and supporting vertically integrated centers will encounter stiff resistance from department chairs and other department-based faculty, who will fear the implications of center development on their revenues, autonomy, and authority. Although difficult to reengineer, the development of integrated care would be vastly aided by transitioning the financial model from one where the departments are profit centers to one where departments and other clinical units are cost centers where revenues are centralized and distributions rationalized. There are many accountability and incentive mechanisms through which such models can be successful, as is the case at the Mayo Clinic.
The Challenge and Promise of True Clinical Integration
True clinical integration presents a classic case of disruptive innovation that will affect the roles of traditional academic departments and clinical programs. Yet, our experience is that faculty members and leaders will support moving in this direction when they are brought into the process, when the organizational and funds flow processes are made transparent, and when they are able to consider the opportunities for overcoming the impediments that they experience every day to increasing the organization's-and their own-success and overall performance. A leader who wants to spur integration must be willing and able to invest a great deal of management effort and financial resources. It is clear that issues and solutions will be particular to each institution.
One AHC leader faced with resistance to change was heard to comment that the battles in academic medicine are so fierce because there is so little at stake. Yet, however well that might characterize certain battles within academic medicine, we believe that there is, in fact, a great deal at stake around the issue of integration. If our AHCs can develop new, integrated models of effective education, discovery, and patient care, the benefits to all stakeholders will be high. We believe solutions exist and that the successful creation of new model centers provides data and experience with which many more AHCs can move forward with the goal of patient-centered clinical integration.
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