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Chapter 5: System Integration

Integration has been identified as part of the solution to the current siloing and unsustainability of our fragmented healthcare delivery system in Canada. (1,2) An integrated model of care can be defined as “interprofessional teams of providers collaborating to provide a coordinated continuum of services to an individual supported by information technologies that link providers and settings.” (3)


In its report, the Canadian Institutes of Health Research (CHIR) identified 10 core principles for the successful integration of health systems. (3) They are:

  1. Comprehensive services across the core continuum

  2. Patient focus (value-based decision making)

  3. Geographic coverage and rostering

  4. Standardized care delivery through interprofessional teams

  5. Performance management (accountability)

  6. Shared information systems

  7. Physician integration

  8. Organizational culture and leadership (that support all the above)

  9. Governance structures (that support all the above)

  10. Financial management (that supports all the above).


The federal report on innovation in healthcare (Unleashing Innovation: Excellent Healthcare for Canada) suggests that integration itself should be seen as an innovation in systems (4). While recommendations on how to achieve this at the broader system level are discussed there, our focus emphasizes the potential opportunities of emergency care-related integration. Emergency medicine sits at the interface of many aspects of healthcare: out-of-hospital/in-hospital, primary care/secondary and tertiary care, acute care/chronic care, and hospital care/home care, etc. As a result, it has the power to catalyze change towards a more integrated and better-functioning future.


Networks are defined not by their nodes, but by their connections. How patients transition through their care journey is one example. Links exist between primary care (including home and continuing care), emergency departments (including network-integrated urgent treatment centres and virtual emergency care), and public health. Emergency medical services (EMS) play a coordinating role through its dispatch centre, and a connective and supportive role through its 911 transportation service, together with the integration potential of its mobile health services. (5–7)


Integration with Primary Care and Public Health

For many years there have been multiple calls and attempts to reform primary care in Canada. (8) Our colleagues in Family Medicine currently share our concerns and motivations for change in the crisis we face (9). Perhaps a one-size-fits-all approach to primary care reform is neither feasible nor wise, but there seems to be a growing consensus around the importance of the healthcare home, having a multi-disciplinary, regionally rostered, family health team (10)(11)(12) for everybody. Specific governance, policy, accountability, and physician funding obstacles to implementing such a network are discussed elsewhere, and we endorse those recommendations. (4)(13)(14)


The healthcare home model, combined with improved operational linkages with EDs, means transitions of clinical care become more coordinated and accountable, with more adaptive and dependable mechanisms for dealing with new challenges that arise. Standardized communications methods and tools can be implemented when patients are referred to the ED for an assessment or specific treatment. Universal Electronic Patient Care Records (ePCR) allow for shared knowledge on past medical history, recent tests and investigations, current medications, alerts and allergies, and goals of care. Likewise, improved transitions should be developed for the ED to communicate clinical follow-up with a patient’s own healthcare home team.


Finally, public health is being recognized as essential for a safe and effective healthcare system. (15) Its three core objectives are:

  1. Health promotion and chronic disease mitigation

  2. Infection disease prevention and control, and

  3. Health Security, including emergency preparedness and response as well as biosafety and biosecurity.

Figure 12. The overlap of Emergency Care, Primary Care, and Public Health services, Emergency Medical Services (EMS) can play an important role in coordinating and connecting care across all three areas.


Integration With Emergency Medical Services (EMS)

Emergency medical services are now recognized as a subspecialty in the US, and an Area of Focused Competence by Canada’s Royal College. In 2006 the EMS Chiefs of Canada articulated an important vision for the future which moved the service from a “you call, we haul, that’s all” model, to a collaborative, integrated mobile health service partner. (16) Many jurisdictions have gone forward with those plans, and with Canadian healthcare systems in such crisis, EMS can play a major integrating role between out-of-hospital and in-hospital care. (17)


For example, the EMS central dispatch can become a Care Coordination Centre. In an integrated healthcare system, virtual care is not an end unto itself, but rather a means to an end. A functional model can be established that improves access, quality, coordination, and continuity of care, with virtual triage (risk stratification) and coordination (pathway navigation). (18) 


However, there must be optionality in the care pathways for this care delivery model to work, so that “the right patients, can receive the right care, in the right place and/or through the right medium.” The ED should not be used as the sorting mechanism for non-emergent hospital-based services. (19) Alternative pathways other than the ED must be developed with easy and consistent access for potentially avoidable ED visits such as urgent, but not emergent diagnostic imaging and lab tests; specialist consultation; schedulable procedures (transfusion, pleurocentesis, feeding tube placements, etc.); and non-emergent post-operative concerns.


The concept of emergency physician as the “availabilist” (20) and the potential synergies with EMS-mobile integrated health solutions is gaining traction. To be clear however, any program development in this area should only occur after appropriate staffing is assured for the physical EDs in the system, and when primary care and specialist care services are accountable for their obligations to meet their own patient’s needs. Emergency care systems cannot be seen as the universal contingency plan for unmet needs in the rest of the system. Definitions and standards will also become even more important to assure integration and value, in addition to avoiding the exploitation of low-value retail medicine clinics, (21) or more fragmentation with unconnected, transactional, and low-quality virtual care options.


Multi-option EMS (22) is an idea that has been around for a while, and perhaps its time has come. An evidence-based (or at least rational consensus-based) approach to ambulance trip destination alternatives for some low-acuity patients could be thought of as Choosing Wisely EMS. Over 25 years ago the concept of multi-option EMS described three triage decision points for unique pathways to be developed:

  1. First, the 911 call taker (is an ambulance even needed or would a family physician appointment be better?)

  2. Second, when the paramedics arrive (is transport necessary, if so, by what crew/vehicle type and where to?) and

  3. Third, on arrival at the destination (with more time and information, is the ED still the best destination? (Would an urgent treatment centre or same day/next day appointment at the patient’s primary care home be a better alternative?)

Figure 13. How the central dispatch can play a coordinating role in multi-option EMS.


Reducing the number of low-acuity ambulance arrivals—or low-acuity walk-ins for that matter—will have minimal impact on hospital access block. It will not make a difference to the ED’s fixed costs (staffing, equipment, overhead, etc.) and may only have a minimal impact on the very low marginal costs. (23) It should, however, reduce the transport and off-load unavailability time of ambulances, and free up more units to be ready for the next 911 call; the impact of that alone could justify multi-option EMS. It may also improve patient experience and reduce paramedic burnout.


This report strongly recommends validated prospective field triage and risk stratification tools for a paramedic crew on-scene, with backup from an experienced online emergency physician, to decide in real time where they should transport their patient. For example, if ten 58-year-old men with cardiac risk factors all call an ambulance for their chest pain and mild shortness of breath, and after their ED visit, five of them turn out to be diagnosed with an FPSC (family practice sensitive condition), (24) does that mean that the ambulance service should transport half of their chest pain patients to a walk-in clinic? Of course not! Prospective decision-making and risk stratification in uncertainty cannot be evaluated retrospectively by outcomes; (25) they must be judged by the decisions made with the information available at the time.


Emergency physicians have long known that over-triage is a resource use issue, and under-triage is a patient outcome issue. No field or virtual care triage can ever be perfect; (26) sensitivity varies inversely with specificity. As we develop these trip destination options and pathways, the following questions arise:

  • What level of risk is acceptable for the patients and populations we serve?

  • How do we mitigate the inevitable under-triage?

  • And who bears the medicolegal burden of that risk in such a system?


Such issues cannot be ignored, but they should not block the development and evaluation of these alternative courses of action.


The Patient Care Journey Starts Anywhere, Anytime

A second type of integration can be thought of as being from the home, public space, roadside or clinic to the ED, and then on through to surgery, or admission and ongoing in-hospital care if necessary. This type of vertical integration is essential, even though only 10-25% of presentations, depending on the level of ED categorization, require admission or transfer to another hospital for consultation.

Figure 14. The necessary flow and transition points in an Integrated Network of Emergency Care. Adapted from WHO Emergency care system framework (2018)


After walking in, being sent, or brought by ambulance, patients correctly assume they will receive comprehensive ED care and subsequent in-hospital (+/- transfer) care if necessary. This journey will involve assessment with triage, an examination and interview, and possible investigations in the ED, including laboratory and imaging testing where necessary. Access to these investigational resources depends on their availability, ED configuration, and staff expertise. Patient also trust that further care, consultation, and other definitive care, and/or outpatient follow-up will occur depending on their needs. System coordination is essential for this to happen.


Emergency care success is dependent on the vertical integration of a patient’s healthcare in a timely, outcomes-focused, evidence-informed, resource-savvy, and data-driven system. Weak links involve point-of-care issues, such as whether there are sufficient ED human resources with trained physicians and nurses available, and key immediate downstream issues, such as admission beds, consultant availability, out-patient follow-up options.


Integrated Networks of Emergency Care at a Provincial Level

Rural and remote locations must have well-defined, supported, and responsive avenues of referral and transport to more resource intensive care sites, when necessary, (27) although reliability of these systems currently varies by region and province. More recently, real-time peer-to-peer virtual support systems are evolving and have become essential to preserve rural and remote emergency care and physician/nurse support. (28) Since the onset of the COVID-19 pandemic in 2020, the provision of virtual care, whether in primary care or in emergency care or consultancy services, has evolved considerably. (29)


In a modern-day healthcare system, the assumption is a high level of care integration with a smoothly-functioning comprehensive and well-trained emergency care team to meet patient needs, 24/7/365. Overall, it is assumed that an open, staffed ED can and will take care of the sickest members of that community, region, or province. An essential part of this taking care is the stabilization and transfer on to other disease-appropriate programs, specialists, and sub-specialists if necessary. This vertical integration assumption is often neglected, as EDs become the repository of admitted patients (30)  with no inpatient beds available in the receiving hospital. As a result, the ED’s primary mandate of resuscitation and other acute care obligations becomes compromised.

Figure 15. Schematic representation of a regionalized system of acute care. The inner circle illustrates eight core elements working synergistically. The small gray circles on the perimeter represent the necessary supporting structures/processes. The large black circles on the perimeter represent the potential obstacles to a high- performing system. (31)


Patient Transfers for Rural and Remote Communities

The accepting physician/service, timely transfer and timely ambulance offload at the receiving hospital axis is particularly important for patients presenting to rural EDs with time-dependent illness and injury. (27) Unfortunately, problems at all three components of this patient journey significantly impact outcomes. In addition, negative feedback loops are created when paramedics get stuck in hallways at regional EDs while waiting to hand over their patients, reducing their availability for the next rural transfer.


The Rural Road Map for Action Report (27) which proposed an approach to patient transfers for those living in rural and remote communities is endorsed by CAEP, and all recommendations should become standards in integrated networks of emergency care. That doesn’t mean all patients should flow through one-way funnels to tertiary care centres; in fact, the integrated web model is advised with real-time access to peer-to-peer virtual care, destination options, and safe redundancy built into the system, including an adequately- resourced EMS system that’s responsive to air and ground transfers, as needed.


Integrated systems of care that contribute to ED function and response include care mandates such as:

  • Trauma systems

  • Poison centres

  • Regionalized acute cardiac care

  • Regionalized stroke systems

  • Tertiary acute neonatal care, and

  • Other services (transplant, major burns, mental health, etc.).


To function effectively, these require a demonstrable vertical integration of care. A network of emergency departments, critical care transport systems, and the availability of timely secondary and tertiary care hospital interventions for the specified acute pathology identified must be in place.


Trauma Systems Example: Integrated Health System

We pay a high price for trauma. Beyond the human injury and potential years of life lost, it is also the highest healthcare expenditure—not just in Canada but around the world. Acute injuries remain a top public health issue, especially for people under 44 years of age, where injuries are the leading cause of preventable deaths. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. To reduce this burden, many regions in North America, Europe and Australia have introduced integrated trauma systems. These organized, regional, and multidisciplinary structures create a dedicated network of healthcare professionals who work closely together, with the goal of ensuring excellent care for patients with serious injuries.


Serial observational studies have shown that these comprehensive, regionwide and inclusive trauma systems have reduced mortality and disability. (32,33) This integrated networked model of care has been used in other medical systems with a regional or provincial mandate, including stroke services and cardiac care. Indeed, in terms of their implementation and evaluation, the Canadian healthcare system overall—especially emergency care systems—can base its success on lessons from trauma system models.

Accreditation Canada is a non-profit organization that sets benchmarks for accountability in healthcare. It has a separate Trauma Distinction Process which recognizes trauma systems or networks that demonstrate clinical excellence and an outstanding commitment to leadership in trauma care. Its program promotes a coordinated, systemic approach to trauma, beginning with pre-hospital care and continuing through hospital care and rehabilitation. It consists of specialized standards, protocols, and performance indicators that support excellence and innovation. These are key elements for any component of a modern integrated responsive healthcare system.


Poison Centres Example: Integrated Health System

A Poison Centre (PC) is an interdisciplinary, front-line, 24/7 telephone-based clinical toxicology service that provides patient care directly to the public, prehospital paramedics, emergency department clinicians, and inpatient clinicians. Canada has five that cover large geographic areas, providing services to all provinces and territories (except New Brunswick). Registered nurses and pharmacists with special toxicology training answer the phones and are supported by physicians with fellowship training in medical toxicology. Poison centres embody the concept of horizontal and vertical integration of systems through real-time interaction with patients, paramedics, hospital clinicians, office-based clinicians, and community pharmacists. Expert recommendations are provided at every level of care, and throughout the continuum of care for any given patient. PCs can advise EMS systems on the necessity of transport after a possible toxic exposure, give treatment guidance for anticipated toxicity on the way to a hospital, and real-time advice to the EDs caring for the patient.


Involving PCs and medical toxicologists in the care of poisoned patients has been shown to avoid unnecessary ED visits by keeping exposed patients safely at home approximately 80% of the time, (34) decreasing the number of EMS transports, (35) reducing length of stay in EDs and ICUs, (36,37) improving the use of resources and patient outcomes, (38,39) and creating cost-effective and patient-centred antidote systems. (40)


The patient safety and cost-saving improvements that toxicology expertise delivers could save significant amounts of healthcare resources. Unfortunately, accessing poison centre expertise is often an afterthought for most clinicians, public health officials, and government agencies; the very nature of telephone-based care—as opposed to consultation of visible entities at the bedside—creates a barrier to effective communication and confidence in recommendations. The credibility of the advice PCs provide could be significantly increased with better system integration.


Some progress is being made in establishing and implementing a national surveillance system (Toxicovigilance Canada) as a collaboration between the Canadian Association of Poison Centres and Clinical Toxicology, Health Canada, and the Public Health Agency of Canada. This aims to establish and improve surveillance mechanisms, public awareness, and regulatory action. However, much more remains to be done at a clinical and health system level to optimize the usefulness of poison centres and to harness their potential.


Conclusion

The 10 principles of healthcare system integration should be emphasized as we move towards improving the Canadian medical system in general, and emergency care systems in particular. There are practical opportunities to improve the connections and coordination of care at the nexus of primary care, public health, and emergency care. Reimagining the role of the central dispatch centre, integrating virtual care, mobile healthcare, and multi-option EMS can play important roles here.


Integration must also occur in a vertical direction, from the home or roadside to the ED to definitive care when necessary, and back to the community. This will not happen by itself and requires an all-of-system commitment to the essential elements of a high-performance regionalized approach to care. This is especially important in a vast and rural country like Canada.


Integrated networks of care must be realized provincially and nationally to optimize patient care experience, economic stewardship, system resilience and population outcomes. We must also guard against the risk of transactional, but not integrated, access points to healthcare causing more fragmentation as an unintended consequence. Continuity of care over the longer term, (41) and coordination of care over the shorter term are essential in a Quintuple Aim-based healthcare system.


Recommendations for System Integration

  1. ECCNs should endorse the 10 principles of healthcare system integration [4] and develop and implement projects that follow those principles.

  2. Emergency care systems should experiment with, evaluate, and accordingly adapt, adopt, or eliminate integrated Urgent Care Centre access points and peer-to-peer virtual care support among EDs.

  3. Emergency care systems should work with EMS agencies to implement and evaluate pre-hospital coordination centres and expanded scope EMS concepts.

  4. Emergency Departments must have 24/7/365 access to single call, no-refusal support by specialists, and operational clarity and consistency around transfers and admitting services.


References

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