The Alliance of Chicago Health Care Network is a non-profit member organization providing services to FQHCs. The Alliance primarily serves and is governed by four of its original member health centers located on the north side of Chicago. These four institutions serve as operating partners in what Alliance leadership refers to as "a joint venture of four independent organizations with the desire and ability to work together on building common infrastructure to improve service delivery and health status."
Annually, the Alliance's core health centers serve 100,000 clients, making over 340,000 service encounters across 32 different service delivery sites. While each of the four member health centers differs in terms of the specific populations served and the scope of services offered, they share a common commitment to delivering high quality health care and social services efficiently to improve the quality of life for vulnerable, uninsured and minority communities in Chicago.
In addition, the Alliance has prioritized expanding its membership to produce economies of scale that would allow them to continue their EHR implementation without external grant support. Rather than restrict themselves to expansion within the city, the Alliance has been building relationships and working towards establishing service level agreements (SLAs) with health centers throughout the nation that have a similar orientation and goals as the core membership. We provide more details on this expansion and second tier of members later in the report.
Exhibit 1 below is a map of main Alliance sites (representing four of the original member health centers and seven total sites) taken from a presentation regularly delivered by Alliance leadership.
Exhibit 1: Map of Core Alliance Health Centers
Network history and purpose. While the Alliance was incorporated as a legal entity in 1997, its origins trace back to the early 1990's when a group of Medical Directors from health centers based on the North Side of Chicago began meeting to discuss their clinical and administrative responsibilities and share challenges and lessons from their experience. While it was a larger group of Medical Directors that met, ultimately four health centers agreed to form the Alliance. These four (Erie Family Health Center, Heartland Health Outreach, Howard Brown Health Center and Near North Health Service Corporation) each enjoyed a long history of serving their communities on the north side of Chicago and enjoyed a large client base and solid reputations on their own. Still, they believed that changes in the health care delivery and payment system warranted an organization like the Alliance that could help them achieve economies of scale, collaborate and share information for the benefit of the communities they serve. A primary source of initial funding for the Alliance was the Integrated Service Delivery Initiative (ISDI) grant program administered by HRSA's Bureau of Primary Health Care (BPHC). The objectives for the Alliance identified as part of that exercise included: managed care readiness and contracting, joint clinical services, health education, marketing, mental health, purchasing and finance and human resources.
After formalizing their association as the Alliance, Medical Directors and leadership from the four core health center members continued to meet and share lessons learned. Originally, there was a belief that Medicaid managed care in the state would transform the manner in which health centers were reimbursed and perhaps require health centers to form their own health plan. While this did not happen, there were ample opportunities for collaboration, particularly in setting quality goals and establishing quality improvement practices. In 2001 the Alliance shifted focus. That year the Alliance became incorporated as a limited liability company (LLC) and became increasingly focused on providing IT applications and services to its members as an important mechanism for achieving the network's goals around quality and administrative efficiency. Exhibit 2 below outlines key events in the history of the Alliance and their movement towards focusing on using EHRs to achieve Quality Improvement (QI) goals.
Exhibit 2: Alliance History, Key Events
||Four original health centers convene to form Alliance
||Alliance incorporated as a limited liability company Restructures, re-focuses on health IT
||Alliance obtains Integrated Communications Technology (ICT) grant from HRSA, BPHC to initiate EHR system
||Alliance obtains Agency for Health Research and Quality (AHRQ) implementation grant to develop clinical data warehouse, develop quality metrics and evaluate
||Initial EHR, data warehouse go-live for core Alliance health centers in Chicago
||Alliance obtains HRSA High Impact Grant to expand network presence, move toward self-funding
||Planned go-lives for initial non-core sites in North Carolina, San Francisco and Michigan
In describing this focus on IT, Alliance and health center leadership cite several factors. First, the Alliance was moving toward efforts to measure improvements in safety, quality and consistency of care and it was determined that EHR supported by a data warehouse was an important tool for achieving these goals. Second, a perceived increase in competition among health centers in Chicago led some to want to differentiate themselves through IT. Third, there were increasing incentives under Medicaid to have tight documentation of care delivery costs and charges to optimize payments under a prospective payment system. And fourth, they noted that there were an increasing number of grants sponsored by HRSA and others that sought to encourage networked computing on the part of health centers.
They decided to pursue a group EMR application rather than practice management, in part because Alliance priorities were driven by Medical Directors more than others and, in part, because it seemed unlikely that Alliance members would be able to agree on the details of how to switch over to a common practice management platform. The effort to pursue an EMR began in earnest following the AHRQ grant that the Alliance received in September 2004. The network engaged in planning and procurement activities through 2006 when they made their first "go-live" at the main site at Near North Health Services Corporation. Since then, the network has continued to support go-lives at member sites throughout Chicago with the last site scheduled to go-live by June of 2009. Network and health center discussants report that for any given site the planning period takes between six and nine months and the process for getting fully up to speed and making substantial use of the EMR functionality takes an additional three to six months post go-live. During this period the EMR implementation requires substantial focus (approximately one quarter to one half time) from several individuals: an Alliance Implementation Specialist, a dedicated trainer, center Medical Directors, QI specialists and site IT leaders.
Characteristics of core members. As noted above, each of the four health centers is a FQHC, but they differ on key dimensions, including the communities they serve, the range of services they provide, the number of care delivery sites and their overall size. We focus here on describing these health centers as they are the health centers represented on the Alliance's Board of Managers, the chief decision making body governing the Alliance.
Erie Family Health Center (29,998 clients served in 2007) has existed for over 50 years. Erie serves a primarily Hispanic population (87 percent) and has a strong emphasis on providing bilingual care. Erie's patients are primarily female and live below the federal poverty level. Erie maintains eight primary care sites, all situated on Chicago's North Side. While the demographics of the neighborhoods where these sites are located have shifted over the 50 year history of the organization, Erie continues to be known as a key provider for Chicago's Hispanic community and many of their clients commute long distances to receive care.
The Heartland Alliance is comprised of two separate but related FQHCs that serve nearly 20,000 clients annually. The Heartland Alliance also includes an agency focused on housing issues as well as an advocacy and human rights organization. The organization's health care focus includes primary care, dental care and mental health care offered across approximately one dozen sites mostly located on the far northwest side of the city.
Howard Brown Health Center (6,284 clients served in 2007) is the leading provider for Chicago's lesbian, gay, bisexual and transgender (LGBT) community. Howard Brown provides comprehensive care to the LGBT community including social and educational services. The center runs two sites primarily dedicated to primary health care and mental health services.
Near North Health Service Corporation (34,926 clients served in 2007) serves the impoverished and uninsured residents of Chicago's Near North region. More than half of Near North's patients are uninsured (51 percent) and the remainder are covered by either Medicaid or Medicare. The center runs five health centers. Each location provides comprehensive primary care services and major sites also provide dental and mental health care.
Organization, staffing and governance. The Alliance is primarily staffed by individuals who have worked at one or more of the four original health centers. Fred Rachman, the Alliance's Chief Executive Officer (CEO) and Chief Medical Officer (CMO) has served as a clinical leader at several Chicago-based health centers including Howard Brown Health Center and Erie Family Health Center. Andrew Hamilton who serves as the Director of Operations and Clinical Informaticist for the Alliance has served as the Director of Patient Care Services for Howard Brown Health Center. Furthermore, many of the Alliance's Implementation Specialists, quality improvement managers and other staff have experience working in one of the four core health centers. In total, the Alliance employs approximately 10 individuals for full or part time for a total of approximately 8 full time equivalents (FTEs). The Alliance noted that the total number of staff and FTEs can differ depending on the number of implementations and planning activities happening at a given time and that their plan for expansion will require them to quickly bring on more staff in key areas.
Although the network shies away from direct outreach, the Alliance's leadership goes out to speak at many meetings and encourages health centers around the country to learn more about their activities and consider joining. In the most recent phase of the Alliance's development expansion is a particular emphasis because of the need to achieve economies of scale that would enable their EHR implementation program to achieve self-sufficiency.
The Alliance members are split into two groups. The first group consists of the four original Chicago based health centers that signed an operational agreement and jointly administer and govern the LLC. Other members are not part of the LLC but have contracted with the Alliance and have service level agreements (SLAs) in place through which they access the Alliance's health IT services. Unlike the core members, members with SLAs do not pay annual dues; instead they pay for the services provided by the Alliance. The Alliance is working to expand their SLA partners, which currently include FQHCs and nurse managed health centers in Michigan, North Carolina and Northern California. Currently, there are four health centers that are SLA-based members of the Alliance and several others that are in the process of becoming members.
The Alliance's governance structure is made up of executive staff, Finance Directors and Chief Medical Officers from the four original health centers. The network staff includes Fred Rachman, Chief Medical Officer (CMO) and Chief Executive Officer (CEO), Andrew Hamilton, Director of Operations and Clinical Informaticist, Jerry Lassa, Director of Performance Excellence and other staff including an Implementation and a Business Operations Manager. Several committees support and coordinate the Alliance's work. These include the Clinicians' Committee, IT Steering Committee, Behavioral Health Committee and the Finance Committee.
The Board of Mangers has ultimate governance responsibility for the Alliance and consists of leadership staff from each of the four original health centers. The second tier of governance includes operations leads from each health center and is led by the Alliance's Director of Operations and Clinical Informatics. The third body with governance responsibility is the EHR Systems Users' Board, which includes representation from all health centers that are part of the Alliance and informs the activities of the Board of Managers and the Operations Group. This group often sets priorities for enhancements to the EHR.
Services and functions. Since 2001, the Alliance has primarily provided IT applications and QI support for member health centers. The Alliance worked with staff from health centers to define requirements and set up a contract with General Electric (GE) to use the Centricity EMR product, customize the product to meet functionality requirements at the network and health center level, deploy the application, set up appropriate interfaces with laboratory providers, maintain a data warehouse housing clinical indicators and to provide reports to health centers allowing them to track quality and efficiency of care.
There are several health centers that are also working with the Alliance to move their practice management platform from a pre-existing system to one that is offered by GE and is seamless with Centricity. While Alliance members did make a decision early on to focus initially on EMR implementation rather than practice management, as the implementation has evolved and the network has gained the trust of member health centers, there is increasing interest among members in switching to a network-supported practice management solution that is seamless with Centricity.
While the Alliance has always facilitated collaboration among member health center Medical Directors on quality, the recent addition of a network-wide QI Director has allowed the Alliance to take a more hands on approach to assist health centers in incorporating a culture of quality and promoting adherence to evidence-based practice guidelines. In particular, the Alliance's QI Director has begun working with Medical Directors and health center leaders on developing ways to link provider compensation and rewards to EMR-generated metrics and evaluating the impact of clinical decision support and disease management functionality on provider behavior. The Alliance also serves as the gatekeeper for matters concerning GE's Centricity, providing an important tier of application and systems support.
Future direction. While the Alliance has undergone tremendous changes and made important accomplishments over the last decade, the network continues to work towards expanding its reach. Given the emphasis on self-financing and sustainability of health center networks beyond the period when they are supported by dedicated grants, the Alliance has been working towards increasing the number of EHR users to allow for greater economies of scale. They are planning an approximately five fold growth in the total number of EHR users over the next two to three years. They also have longer term development plans that include adoption of personal health records, eRx, health information exchange (HIE) and other technologies designed to improve quality.