Chapter 3 Theoretic Framework
3.1 Healthcare System Integration Framework
Emerging models of health systems as complex adaptive systems are currently being explored and
examined (Begun, Zimmerman, & Dooley, 2003; Plsek & Greenhalgh, 2001), however Donabedian’s
structures, processes and outcomes remain dominant for analysis and evaluation (Atun, 2012; Begun
et al., 2003). Donabedian's (1988) model for quality measurement in health care identifies structures
(such as the settings and instrumentalities of care delivery), and processes (such as the procedures and
techniques of care delivery) that contribute to health care outcomes. Previous healthcare research has
used the Donabedian model to classify policy and service interventions in a causal chain that suggests
generic service interventions such as inter-organizational information exchange can be measured
using changes in targeted or clinical processes (Lilford et al., 2010).
Others have modeled integration frameworks (Fulop et al., 2005; Gillies, Shortell, et al., 1993;
Strandberg-Larsen & Krasnik, 2009), yet none has provided a comprehensive schema relating
interplay of components which theoretically contribute to outcomes in a successfully integrated
healthcare system. An explication of the components now follows. In this archetype, the performance
outcomes are drawn from the Ontario Health Quality Council’s “attributes of a high performing
healthcare system” (Ontario Health Quality Council, 2010, p.5).
Figure 4. Archetype of Successful Healthcare System Integration Measurement
Network of Organizations' Operational Domains •Strategy •People •Structure •Rewards •Processes •System •Clinical •Organizational
System
Performance
•Safe •Effective •Accessible •Patient-centred •Equitable •Efficient •Appropriately resourced •Focused on population health •Integrated System Integration Breadth •Horizontal •Vertical •Inter-Sectoral •Virtual System Integration Degree •Full segregation •Linkage •Cooperation •Coordination •Full integration System Integration Type •Functional •Organizational •Clinical •Professional System Integration ArchitectureInteracting Structures/Processes Outcomes
N or ma tiv e In te gr ati on Syste mi c In te gra tio n
A model of organizational structures and processes that contribute to integrated care is listed
under “Network of Organizations’ Operational Domains” after Galbraith's (2002) Star Model. One
small modification has been made to the Star Model’s domains; processes are broken out as system,
clinical or organizational according to Macadam's (2008, p.3) “levels of integrative activities”.
The Star model of organizational design originates in the business literature where increasingly
competitive and complex markets drive organizations to develop higher value, customized or
customer-centric offerings using what is referred to as customer “solution selling”. This philosophy of
organizational system-building to develop and deliver services in partnership with and valued by the
end user is entirely consistent with contemporary beliefs in the benefits of patient-centred over
provider-centred health care. The value of patient-centric care within health service organizations and
its role in improving outcomes underpins the current drive toward seamlessly integrated care. The
Star Model suggests that each organization’s “customer-centric solutions” involve the coordination
and linking of a number of components i.e. strategy, people, structures, rewards and process. The Star
Model has relevance to integrated healthcare systems which at their zenith should coordinate and
deliver seamless care; that is a network of organizations which act in unison towards common goals,
where patient-centric care delivers customer-centric “solutions” such as seamlessly integrated care.
However, the more units coordinating to deliver customer-centric solutions, the greater the number of
interfaces between providers and the greater the need for information and coordinating processes such
as health information exchange (as previously noted Section 2.3.1, p.51).
Further theoretical support for the appropriateness of this approach is provided by correlating
Suter et al.'s (2009) previously mentioned principles of integration, into the Star Model’s five
demonstrates how integrated healthcare systems might operationalize a patient-centric solution using
Table 4. Integration Structures and Processes by Operational Domain
Operational Domains (Galbraith, 2002)
Principles for Integration (Suter et al., 2009)
Integration Dimensions Category3
Strategy • Focus on wellness, health promotion & primary care • Patient-centred philosophy, focussing on patients needs
• Organizational support with strong demonstration of commitment
1 2 7
People
• Leaders with vision able to instill strong, cohesive culture • Physicians are gateway to integrated healthcare system • Physician support for EMR
• Physicians engaged in leadership role
7 8 8 8 Structure • State of the art information systems to collect, track & report activities • Strong, focused, diverse governance with representation for all stakeholders
• Organizational structure promotes coordination across settings & levels of care
6 9 9
Rewards
• Align service funding to ensure equitable funding distribution for different services or levels of services
• Funding mechanisms promote inter-professional teamwork & health promotion • Sufficient funding to ensure adequate resources for sustainable change
10 10 10 Processes: System Clinical Organizational
• Multiple access points
• Roster: resonsibility for identified poulation; right of patient to choose & exit • Population –based needs assessment, focus on defined population
• Patient engagement & participation
• Interprofessional teams across the care continuum
• Diagnostis, treatment & care interventions linked to clinical outcomes • Evidence-based care guidelines & protocols toendorace one standard of care,
regardless of where the patient is treated • Cooperation across the continuum
• Maximize patient accessibility & minimize duplication of services
• Commited to quality of services, evaluation & continuous care improvement
1 3 2 2 4 5 4 1 3 5 3
Legend for Table 4. Suter’s Principles by “Category” 1. Comprehensive services across the care continuum 2. Geographic coverage and rostering
3. Patient focus
4. Standardized care delivery through interprofessional teams 5. Performance management
6. Information systems
7. Organizational culture and leadership 8. Physician integration
9. Governance structure 10. Financial management
Of particular interest to this model is the Structure domain that relates information systems,
relationships between providers and coordination across settings and levels of care in health systems
integration. These structural dimensions at the organizational level, in the aggregate, contribute to
system level capacity for integration.
Integration architecture, as depicted in Figure 4, is a synthesis of the frameworks covered in
Section 2.2.2 (p.23). Here, integration architecture describes the foundational characteristics and
capabilities, structures and processes, upon which an integrated healthcare system is based. The
architecture of integration within a system is determined by its degree, breadth and type, in the
context of the systemic and normative integration structures and processes in the system itself. The
model was developed using Kodner's (2009) archetypal summary of integrated care literature with
some notable amendments. Kodner’s “degree” of integration, which is nominally used here, is
derived from Leutz's (1999) “levels” of integration subsequently named “intensity” by Shaw et al.
(2011), and describes a continuum from linkage and collaboration to full integration of health entities
within a network of care. Degree of integration is often determined by and descriptive of the type of
governance arrangement between the integrating entities in the system. Here the Luetz model is
augmented with two additional measures suggested by Ahgren & Axelsson (2005), a zero point called
full segregation, and cooperation, representing actions more oriented towards joint action than
coordination (see Figure 2.).
The likelihood of a closed, fully segregated network existing in a complex healthcare system is
unlikely. A fully integrated healthcare system is also unlikely given the challenges of merging social
service and clinical care goals, however it may be contemplated for care to a small subset of people
model. A complex health network, such as a regional healthcare system, will have a vast array of sub
systems, such as long term care or mental healthcare, in varying degrees of integration along this
continuum.
System integration “breadth” in the model, also referred to as “form” by (Macadam, 2008),
refers to the structural arrangement of entities within the integrating network. Macadam and others
recognize only two forms of integration (vertical and horizontal), however the literature reveals two
additional forms which additively provide a more comprehensive description of the spectrum.
Vertical integration affiliations between two or more providers generally refer to health entities
providing different types of services aligning along the care continuum. That is entities from, for
example, primary care, home care, acute care, and long term care aligning delivery of services. This
phenomenon is commonly associated with mergers or acquisitions of health entities, often with
common ownership (for example Kaiser Permanente and Inter Mountain Health Care in the United
States) and formal fiscal and clinical accountability or contractual obligations (Shortell et al., 1994).
Patients enter the vertically integrated system through corporate primary care facilities and are
directed to hospitals which are owned by the same corporation. Less so with Canada, however, where
public ownership of healthcare assets is the predominant model.
Horizontal integration does commonly occur in Canada, when health entities providing similar
services form an alliance, such as a network of physicians, or pharmacists or long term care facilities.
Inter-sectoral integration has been used by some researchers synonymously with horizontal
integration, however in the context of this model, inter-sectoral integration refers to alliances between
a health entity and organizations or networks outside the healthcare sector such as housing, social
services and the environment. Virtual integration, first introduced as a variant of vertical integration
governed by formal or informal contractual relationships (Goodwin et al., 2004) which can be
vertical, horizontal or inter-sectoral. None of these categories are mutually exclusive.
System integration “Types” generally refer to “buckets” of common activities in support of
healthcare service delivery. Kodner (2009, p.11) identifies the following:
1. Functional – shared or coordinated administrative and support activities such as
procurement, finance & information technology;
2. Organizational – relationships between organizations, governance systems, coordinating
structures;
3. Professional – provider relationships within and between organizations;
4. Service or clinical – coordination of services and care across time, place and discipline;
5. Normative – shared mission, vision, values and culture across organizations in the system;
and
6. Systemic – alignment of policies, rules and regulatory frameworks.
Contandriopoulos and colleagues' (2003) typology framework includes funding and
information systems, whereas in this model they have been subsumed under the functional category;
their location less important than the ability of the model to accommodate them logically in the
correct construct grouping. Conversely, normative and systemic integration, which are included in
various models’ “types” of integration (Contandriopoulos et al., 2003; Fulop et al., 2005; Kodner,
2009; Nolte & McKee, 2008), are not grouped with types of integration in this model.
Normative integration refers to the shared mission, values and culture in the system, systemic
integration architecture but have such a diffuse impact on the degree, type and breadth of integration
achieved that they are not assigned to any one construct but are separated to denote the pervasive
influence each has on the selection of an appropriate integration architecture. For example, the
governance and funding (systemic integration) of a network of primary care providers influences the
breadth of horizontal integration amongst the physicians and multi-disciplinary team members. A co-
governing troika representing physicians, the regional health authority and health ministry provides
oversight to the use of public funding for the network under examination in this study. It also
influences the degree of integration possible, the types of integration, and the breadth. All are inter-
related, though the literature quantifying that influence is scant.
Rather than nested, as suggested by Macadam and others, integrating mechanisms in health are
complex interventions which occur within a complex system characterized by “nonlinear dynamics
and emergent properties” (McDaniel & Driebe, 2001, p.12). Thus the integration archetype is not
layered or nested, but is non-hierarchical and adaptive, and may include many components of the
archetype simultaneously. There is no one optimal model but a matrix of constructs which can be
combined to build a representation of the integration architecture that facilitates care in any part of the
system. Seamless and integrated care arises from the right combination of organizational processes
and structures, and the integrating architecture. No one system has the same architecture, nor
operational domains or performance expectations; it is a reflection of the heterogeneity in
populations’ health status, expectations of wellbeing, the available resources, infrastructure and
policies to address healthcare needs.
Accordingly, there are no benchmarks, floors or ceilings on the level of integration required to
achieve system goals. To paraphrase Ling (2012, p.82) integration “is a space rather than a plan…a
controlled trials are not only not feasible but unlikely to account for the context and dynamism of
such a system; this will be reflected in the methods of this study. Furthermore to determine whether
an integration architecture is delivering value, one must turn to analyzing processes which are
believed to impact integration in order to identify significant correlations. The focus in this study is
on interoperability as measured by health information exchange; a framework to understand and
measure this construct and focused on technical interoperability is now presented.