To address our research objectives, we selected a judgmental sample of 15 IDSs that clinically integrate primary, specialty, and acute care and serve uninsured and medically underserved populations. To select our sample, we began by reviewing published research and interviewing researchers with expertise in IDSs. As a result, we identified 44 public and private nonprofit systems from which to select our sample. In December 2009, we sent a Web-based data collection instrument to these systems to determine the extent of their clinical integration and to obtain additional information about organizational features of the system. This included whether the system is made up of subsystems—local or regional delivery systems that are organized below the system level—that integrate clinical care within themselves. We sent e-mail reminders and conducted telephone outreach to systems that had not responded by our requested deadline. In the end, we received completed data collection instruments from 19 systems. We excluded 4 systems from our study because their responses indicated a lack of clinical integration or because of an affiliation with a “closed system”—one that exclusively serves members of the system’s health insurance plan. Our final sample consisted of 15 IDSs, which include five subsystems. (See table 1.) The 15 IDSs vary in many aspects, including the degree to which they are integrated, specific organizational features, and payer mix (e.g., extent to which they serve Medicare and Medicaid beneficiaries and the uninsured) (see app. I). We reviewed the Web sites for the IDSs in our sample, relevant articles and reports about the systems, and other documents the systems provided. Based on our review of the extent of clinical integration of each system, its location (census region and urban/rural), and whether it is publicly or privately owned, we selected for site visits four systems that reflected variation among these dimensions: Ascension Health’s Seton Family of Hospitals, Denver Health, Henry Ford Health System’s Detroit Region, and New York City Health and Hospitals Corporation’s (NYCHHC) Queens Health Network. We administered a structured interview protocol with chief medical officers (or other system officials, as appropriate) to obtain information on organizational features that IDSs use to support strategies to improve patient care; approaches IDSs use to facilitate access to care for underserved populations; and challenges IDSs encounter in providing care, including care provided to underserved populations. To gain additional in-depth information, we conducted interviews with IDS officials at the four sites we visited, including system executives and clinical staff. In some cases, information provided by IDS chief medical officers and officials is specific to underserved populations, and we note it as such in this report. In other cases, the information is more general, relating to the overall system or patient population, which can include underserved patients. Findings in this report are based on a judgmental sample and are not generalizable to all IDSs. The organizational features, patient care strategies, approaches to facilitate access, and challenges that we describe are not necessarily unique to IDSs, but may also be found in other health care settings and experienced by different providers. However, the information we present is from the perspective of the IDSs in our sample. We relied on data obtained through the Web-based data collection instrument, interviews with system representatives, and published studies and did not conduct independent analyses of the effectiveness of strategies. We conducted this performance audit from June 2009 to November 2010, in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. IDSs vary in their organizational configuration and in the continuum of services they provide. They frequently use patient care strategies such as care coordination, disease management, and care protocols. Other providers that are not part of IDSs may also use some of these strategies and may also face challenges similar to those IDSs may face. For example, some IDSs serve a patient population that includes a high proportion of underserved individuals and may face financial challenges in doing so. Other providers who also serve a high proportion of underserved individuals may face some of the same financial challenges. IDSs can be organized in different ways and use various staffing models. Some IDSs are a single entity that includes a delivery system (hospitals, physicians, and other providers) and a health insurance plan. Examples of this type of IDS include NYCHHC and Geisinger Health System. Other IDSs include a delivery system but do not have a health insurance plan, such as Partners Healthcare and Memorial Healthcare System. IDSs may employ their own physicians, rely on community-based physicians who are not employed by the system but are granted use of the hospital facilities and staff, or use a combination of those two approaches. An IDS can be organized at the system level, or it can be more decentralized, having subsystems that organize health care at the local or regional level. These subsystems integrate care within themselves but not necessarily with other subsystems in the overall system. IDSs can consist of multiple subsystems. Because there is so much variation in the ways that IDSs can be organized, it is difficult to determine the exact number of IDSs in the country; however, millions of Americans receive care from IDSs. IDSs offer a continuum of services to a particular patient population or community and can vary in what services are provided within this continuum. For example, some IDSs provide nursing home care within their systems, and others do not. Similarly, not all IDSs provide certain specialized services such as organ transplantation or major burn services within their systems. An IDS may have a contract with other providers to offer certain services, or may refer patients to providers not affiliated with the IDS for a service. IDSs use multiple strategies to improve patient care, such as care coordination, disease management, clinical practice guidelines, and care protocols. Care coordination is the integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of services. It occurs across the continuum of care and across different delivery sites, encompassing both health care and social support interventions, and is often used for patients with special health care needs or chronic health conditions. Care coordination activities can include case management and patient navigation services. Disease management involves providing coordinated health care interventions and communications to patients who have chronic conditions, such as diabetes or asthma, where patients’ self-care efforts can affect their health outcomes. Disease management is a systematic approach to patient care that uses evidence-based practice guidelines. Evidence-based practice guidelines, also referred to as clinical practice guidelines, are systematically developed statements that guide providers and patients in making decisions about appropriate health care for certain conditions. They are typically based on an examination of the best available scientific evidence and broad consensus about the best treatment to follow. Care protocols, which are generally more specific than guidelines, provide more detail about the management and treatment of diseases and conditions. Patient care strategies can be designed to achieve a variety of goals, such as improved health outcomes and quality of care, increased efficiency, and lower costs. They may be performed by physicians, nurses, or other clinical or nonclinical staff members and often are implemented outside of a patient’s face-to-face appointment with a physician. Studies have shown that IDSs are more likely to use patient care strategies than are other providers, such as solo practitioners. For example, a national study of the management of chronic illness for patients with asthma, congestive heart failure, depression, and diabetes found that certain IDSs were significantly more likely to use recommended, evidence- based care management processes than were less organized providers. In addition, a study of physician practices in California in the early 2000s found that physicians affiliated with an IDS were more likely to use disease management programs than were physicians in nonintegrated medical group practices or small practices. Depending on their geographic location and their mission, IDSs serve varying proportions of underserved populations. Individuals who are underserved have higher rates of illness, and they often face barriers to accessing timely and needed care. For example, uninsured patients are more likely than insured patients to have chronic illnesses that are undiagnosed or undertreated. People with limited English proficiency may have problems comprehending health care information and complying with treatment. Rural residents also face barriers to access because of physician shortages in rural areas. In addition, underserved patients may have difficulty obtaining specialty services, including diagnostic services. Integrating care, such as by linking primary and specialty care, can reduce some of the access barriers that underserved populations experience. The 15 IDSs in our sample collectively reported that organizational features such as using electronic health records (EHR), operating health insurance plans, and employing physicians all support various strategies for improving patient care, including care coordination, disease management, and use of care protocols. Officials at some IDSs in our sample told us that using EHRs supports their strategies to improve the quality of patient care by increasing the availability of clinical information and patient population data and by improving communication. All 15 IDSs reported having implemented EHRs to some extent. For example, as of March 2010, Seton was in the process of implementing its EHR, and Henry Ford’s EHR was available at all of its facilities. Clinical strategies supported by using EHRs include care coordination, disease management, electronic prescribing (e-prescribing) and computerized physician order entry (CPOE), and care protocols. According to officials at some IDSs, using EHRs facilitates care coordination because EHRs make patient clinical information more readily available to providers and improve communication among providers, staff, and patients. For example, officials from Denver Health characterized the EHR as a key component of integration.