Enhancing Quality in Patient Care (EQUIP) Project

Bechara Choucair, M.D., remembers the moment that the connection between health information technology (IT) and health care quality became crystal clear to him. A patient of his at Heartland Health Outreach, a community health center inChicago that provides care to homeless people, had uncontrolled edema that several specialists had been unable to explain. Then, one day, the patient's medical file was loaded into the community center's new electronic health record (EHR) system.

"Right away, we got an alert for a drug-drug interaction," Dr. Choucair says. "The drug that the psychiatrist was giving him was interacting with a drug that his cardiologist was giving him." But until the EHRS made the link, no one knew. By dropping one of the medications, Dr. Choucair was able to stop the edema.

Heartland Health is one of four health centers in the Alliance of Chicago Community Health Services, a unique partnership that is blazing a trail for EHR implementation among a group of safety net providers. The Alliance -- which also includes Erie Family Health Center, Howard Brown Health Center, and Near North Health Services Corp. -- encompasses 29 sites in Chicago's Near North Side that provide care to about 100,000 people during 350,000 encounters a year. Services include primary care, dental and mental health care, social services, and health education.

With funding from the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and other sources, the Alliance has deployed a sophisticated, customized EHR system that "provides evidence-based decision-making support to clinicians and aggregates population data for chronic disease management," says Alliance CEO and Chief Medical Officer Fred Rachman, M.D.

The Alliance's health centers are sharing resources, integrating services, and improving quality and efficiency as part of the Enhancing Quality Utilizing Information Technology in Patient Care (EQUIP) project. To date, 10 sites representing all four health centers are using the new system, which is built on a centralized architecture hosted in a secure facility that allows the system to be accessed anywhere, anytime, via the Internet.

"With the data and advanced functionality that we now have, we can look at health trends across populations -- comparing outcomes in different communities, health disparity groups, or among different health centers," Dr. Rachman says. "And that's how we'll start to make a real impact on quality."

The Alliance decided to implement an EHR system in 2001. Alliance leaders had agreed up front that they wanted more than a basic storage-and-retrieval system; they wanted to provide evidence-based decision support to their clinicians, aggregate population data, and manage chronic diseases.

In partnership with the American Medical Association, GE Clinical Data Systems, First Consulting Group, and the Health Research Education Trust, the Alliance customized GE's Centricity EMR system to include the spectrum of health services provided in a community health center, as well as clinical decision support and performance measures tied to evidence-based practice guidelines. GE worked with the Alliance to develop a customized data warehouse that allows population-level analysis of patient data, functions as a patient registry, and supports performance measurement and better understanding of population health and disparities.

The system's flexibility allows Alliance providers to tailor their services to their patients' needs. Heartland Health, for example, is maintaining EHRs for homeless patients, deploying laptops and mobile units to provide and document care. Heartland also operates a school-based health center that provides primary, mental, and dental care services and that's now using the Centricity-based system.

How did the Alliance accomplish its goal? Planning, collaboration, and hard work. In the process, Alliance staff have learned a lot about workflow redesign, customization, building out decision support, and, of course, implementation.

Dr. Rachman says: "Even with thorough planning, implementation is a completely iterative process. You have to rethink things as you learn." Implementation challenges included recruiting proper IT expertise, analyzing and redesigning hundreds of clinical workflow patterns in busy health centers, and developing the right strategies for training staff. Lack of standardization for quality measures and data specifications made some of these tasks even more difficult.

Now the Alliance is poised to go where few -- if any -- safety net providers have been able to go with health IT. Informatics staff are continuing to refine clinical decision support algorithms for an expanding number of conditions, including basic preventive care, asthma, cardiovascular disease, depression, and HIV/AIDS. Improved workflow documentation is helping providers figure out how to do their jobs more efficiently. The centers are just beginning to work with monthly quality reports to help them manage patients better. Trend data already indicate modest improvements in health status and adherence to practice guidelines since the conversion.

What's next? The Alliance is planning implementation of a patient portal that will allow patients to enter new information into their medical records between visits to their providers and view subsets of information from their personal records. In addition, the Alliance is working on strategies for health information exchange with hospital and subspecialty providers and with an immunization registry under development by the state.

If the project leaders achieve their vision, they will support ongoing development of the EHR and decision support system for a growing number of health centers -- offering access to the centrally hosted EHRS and acting as consultants.