Zip code key to better care on Chicago's South Side

By Genevieve Beaudoin
01:32 PM
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University of Chicago works with partners to build ‘Community Rx'

The University of Chicago, in collaboration with the Chicago Health Information Technology Regional Center (CHITREC) and the Alliance for Chicago Community Health Services plans to close the loop among doctors, patients and health resources in the South Side community of Chicago with a new system called “CommunityRx.”

The project operates on the theory that understanding a patient’s community context is invaluable to the care team. The work will be funded by a $5.9 million government grant recently announced by the Department of Health and Human Services – one of 26 innovation grants awarded across the country.

Stacey Tessler Lindau, MD, associate professor of obstetrics and gynecology at the University of Chicago Medicine and project director for CommunityRx, says the system offers two main benefits. The first is the generated “Health.eRx” which provides nearby resources and referrals relevant to a patient’s condition and status.

For example, if a patient from zip code 60637 comes to see his doctor with a diagnosis of diabetes, the electronic health record will query the CommunityRx database during the doctor-patient encounter and return with the Health.eRx prescription. The Health.eRx will then show the patient the location of their home in relation to a spectrum of community resources such as podiatry, healthy food, fitness classes and diabetes information classes.

The second benefit comes from aggregated health data in the form of CommunityRx reports, which will be sent to those community-based services involved.

Detailing the referrals made to their organizations each quarter, the report will allow clinics and providers to tailor programs and health services to local needs. If the local YMCA, for example, receives a report that 47 patients were referred to it via the CommunityRx system and 15 of these people were obese and were referred to its weight loss program, and seven patients had child care needs, then the information the YMCA could plan, staff, and launch programs vital to the community needs.

Abel Kho, MD, executive director of CHITREC and an assistant professor of medicine at Northwestern University, maintains that neighborhood context is vital when guiding a patient.

“Patients will often take what I’ve advised and convert it into what they recognize in their own life,” he says. “In many instances, they come back to me and demonstrate that the things in their own community can have as much value and do as much good in improving their health.”

How might the innovation grant change health on Chicago’s South Side? Lindau says she’s discovered through years of working with community health leaders that one key to transforming health in poor communities is to provide youth with job opportunities.

The CommunityRx system aims to train and create jobs for approximately 90 individuals from the South Side. Sixty of the jobs are designated for high school youth, who will be trained in science, technology, engineering and math principles to apply these principles to data collection through the summer in the six different South Side neighborhoods.

“It may not seem like an obvious first strategy,” Lindau says, “but the CommunityRx system is driven by data gathered by high school students who will identify community places, services and programs that can be used by people to improve their health.”

The program will target about 200,000 peoples, most of them Medicare, Medicaid and CHIP beneficiaries.
Working with multiple underserved communities, Lindau and her team at University of Chicago Medicine will look to CHITREC and the Alliance for assistance in implementing the technology necessary for the program.

Lindau points out that studies have already shown “there is a real appetite, even in low-income communities, to use communication technology to improve access to information for health, disease management and resources.”

In fact, Kho has found in his work that if “you look at the rates of adoption of healthcare IT, many sites that we would consider to be working with underserved patients, actually have high rates of health IT.”
The real challenge is time.

Still waiting to hear from CMS about a start date, Lindau and her team have already begun preparations for the work ahead.

Fred Rachman, MD, CEO of the Alliance for Chicago Community Health Services, worries whether the health centers will be able to afford the time and the pressures in the healthcare reimbursement system to spend with the patients in order to fully develop an actionable care plan. A primary care provider himself, Rachman notes that a care team is given a limited time with patients.

Moreover, Rachman believes this project will “undoubtedly shine a light on resource deficits in many communities.” While Rachman believes that patient context will allow a physician’s advice to be “more realistic, more accessible, more cognizant of what consumers are actually available to do,” it will be of limited value if the resources are unavailable.

But if access to information can positively change the patient-doctor experience, then information generated by the project may do the same for the community. As Rachman sees it, perhaps the greatest benefit of this initiative will be the use of information to advocate and work with communities to develop the sources they need.