The hospital monitors all of its coordinated activities with an extensive electronic medical records system. The system's contribution to coordinated care is especially evident in the 300,000-patient-per-year emergency room, the nation's fifth busiest. The poor and uninsured tend to use Montefiore's ER for all their medical needs, emergency or not. So teams of nurses and aides input the vital signs and health status of new arrivals as soon as they enter the ER. Those who have routine problems are then "fast-tracked" over to internists, who evaluate all their needs to prevent more serious problems down the line and advise them on where to find primary care in the community. ER doctors on duty can quickly scan the computerized list of patients, seeing who needs immediate care and who's been waiting too long.
It will be far from easy for other hospitals to follow Montefiore's example if doctors aren't on salary, and most aren't. Policymakers worry that ACOs won't work under the fee-for-service system, which rewards doctors for the number of services rendered, not for quality of the care. "There absolutely has to be a change in fee-for-service to do ACOs properly," says Robert Berenson, an expert in healthcare economics at the Urban Institute, a think tank in Washington, D.C. But observant doctors may decide that coordinated, continuous care is the more rewarding way. Mohamed Aniff says he can't imagine better working conditions than treating his elderly patients where they're happiest, while keeping them out of the hospital or the nursing home.