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Perspective: Integration can support clinical quality, technology efforts


The integration of small practices into hospital systems could improve clinical quality and technologic efforts, says Robert I. Field, PhD, MPH, JD, in a conversation with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

Robert I. Field, PhD, MPH, JD, on facuty at the Drexel University public health and law schools in Philadelphia, formerly led business planning and development for the primary care network of the University of Pennsylvania Health System. He recently spoke with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

Q: In a previous position, you helped health systems acquire physician practices. What do you think of today’s practice acquisition trends?

A: It’s déjà vu all over again. We’re kind of repeating the 1990s. It seems like a lot of health polices like that just go around in circles, which you can say is either encouraging or discouraging, depending on your point of view.

Because of my background, fundamentally, I think [these acquisitions are] a good idea, but I also was involved with a very specific kind of integration, with a large academic medical center.

Medicine gets more complex almost by the day, both clinically and economically. We cannot have the present level of clinical sophistication without a complicated economic environment.

People pine for the old days of the solo practitioner and the shingle. That was fine when you treated a heart attack with bed rest, but it’s not fine when you have dozens of drugs and procedures and surgeries and diagnostic tests that cost a huge amount of money and that require huge teams to perform. We’re not going to go back to those [solo practitioner] days, certainly not if we want the present quality of care. So that means that a doctor has to be part of a larger organization.

One of the biggest problems with medical care in the United States is its disjointed nature and the extent to which it is compartmentalized and different providers don’t communicate with one another and care is not coordinated. We know that contributes to errors, it contributes to suboptimal care, and it contributes to added costs. All of those problems are crying out for a solution, and integration in some form is the only way you’re really going to get at a solution.

And electronic health record (EHR) systems are pushing integration. It’s very difficult for a small practice to afford an EHR system. It’s not just the cost of the system. It’s also the maintenance of it, tech support, and the downtime while people are learning it and waiting for it to stop crashing and freezing. A larger health system can afford a good EHR system and all the support that goes with it.

Q: The Cleveland Clinic, the Mayo Clinic, and Geisinger all have been pointed to as effective models. Why do you think they are viewed as successful in integration?

A: I think to have an organization controlled by the providers rather than the financial side is preferable. Also, their being large and having tremendous resources at their disposal, and having a commitment to quality care, are factors.

Q: What attracts physicians to employment?

A: Doctors who benefit the most from integration and the ones starting out, partly because they have never experienced a different style of practice and partly because it relieves them of many of the business and financial aspects of practicing and allows them just to focus on taking care of patients.

Do you think a place exists for independent practices in the future? Send your feedback to Also engage at and


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