Improvements must be designed into the system and measured and, therefore, it is important to identify accountabilities, measure performance, and design incentive structures that are appropriate for the desired outcomes.

In response to the variety of issues raised, Charles Cutler stated that AHCs should be leaders in developing centers of excellence. There is some evidence that although AHC costs are higher, their longer-term outcomes may be better. Knowing this, however, depends on having an approach for accountability and measures of performance. He also suggested that the teaching and research functions need a different balance. The shifting disease burden of the population toward chronic conditions suggests an urgent need to improve the care for such patients in order to affect the health of the population. A shift is needed as to how investments are made and where gains in health are likely.

SECTION II—CREATING A VISION FOR THE FUTURE

The Clinical Service Role

Joseph Bloom, M.D., Dean Emeritus, Oregon Health and Science University (OHSU) 3

Dr. Bloom described the OHSU organization. OHSU has existed since 1887, but in 1995, it was established as a public corporation and as a free-standing university. It remains state-affiliated, but is not considered a state institution. It has established an integrated management and health system under a central officer and trains over half of the health professionals in the State of Oregon, sponsoring more than 95 percent of the graduate medical education programs in the state. OHSU has a history as a safety net provider that is based on its origins as a county hospital.

Dr. Bloom described two major initiatives undertaken by OHSU to strengthen its clinical care role. The first was the need to alter the relationship with the state and become a free-standing university. This came about because of the competitive marketplace and the AHC's deteriorating physical plant. By removing OHSU from the state’s higher education system and becoming a free-standing university with its own board of directors, they established a unique governance structure that made it easier to obtain bond funding, upgrade facilities and enter into several mergers. The second initiative was a set of organizational shifts to streamline management. Centers of emphasis and excellence were formed, each multidisciplinary and integrated within the schools of the university, the hospital and departments in the medical school. They created a single faculty practice group that replaced 35 different entities. The financial meaning for tenure was defined to an endpoint that is affordable. A single academic track was preserved for both clinicians and scientists. OHSU is committed to a funds flow report so departments can be compared internally as well as to external benchmarks.

Current challenges facing OHSU include a nursing strike that is now in its fifth week. Additionally, the recession has given the state a large deficit, which will affect the amount of funding support that OHSU receives from the state, potentially resulting in a significant decrease. Finally, increasing regulatory scrutiny, such as the Health Insurance Portability and Accountability Act (HIPAA), clinical and research audits, personnel law and other factors, all increase the costs of doing business for AHCs.

3  

Dr. Bloom stepped in for Dr. Peter Kohler, who was originally scheduled to speak. Dr. Kohler’s prepared remarks are included in Appendix C.



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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Improvements must be designed into the system and measured and, therefore, it is important to identify accountabilities, measure performance, and design incentive structures that are appropriate for the desired outcomes. In response to the variety of issues raised, Charles Cutler stated that AHCs should be leaders in developing centers of excellence. There is some evidence that although AHC costs are higher, their longer-term outcomes may be better. Knowing this, however, depends on having an approach for accountability and measures of performance. He also suggested that the teaching and research functions need a different balance. The shifting disease burden of the population toward chronic conditions suggests an urgent need to improve the care for such patients in order to affect the health of the population. A shift is needed as to how investments are made and where gains in health are likely. SECTION II—CREATING A VISION FOR THE FUTURE The Clinical Service Role Joseph Bloom, M.D., Dean Emeritus, Oregon Health and Science University (OHSU) 3 Dr. Bloom described the OHSU organization. OHSU has existed since 1887, but in 1995, it was established as a public corporation and as a free-standing university. It remains state-affiliated, but is not considered a state institution. It has established an integrated management and health system under a central officer and trains over half of the health professionals in the State of Oregon, sponsoring more than 95 percent of the graduate medical education programs in the state. OHSU has a history as a safety net provider that is based on its origins as a county hospital. Dr. Bloom described two major initiatives undertaken by OHSU to strengthen its clinical care role. The first was the need to alter the relationship with the state and become a free-standing university. This came about because of the competitive marketplace and the AHC's deteriorating physical plant. By removing OHSU from the state’s higher education system and becoming a free-standing university with its own board of directors, they established a unique governance structure that made it easier to obtain bond funding, upgrade facilities and enter into several mergers. The second initiative was a set of organizational shifts to streamline management. Centers of emphasis and excellence were formed, each multidisciplinary and integrated within the schools of the university, the hospital and departments in the medical school. They created a single faculty practice group that replaced 35 different entities. The financial meaning for tenure was defined to an endpoint that is affordable. A single academic track was preserved for both clinicians and scientists. OHSU is committed to a funds flow report so departments can be compared internally as well as to external benchmarks. Current challenges facing OHSU include a nursing strike that is now in its fifth week. Additionally, the recession has given the state a large deficit, which will affect the amount of funding support that OHSU receives from the state, potentially resulting in a significant decrease. Finally, increasing regulatory scrutiny, such as the Health Insurance Portability and Accountability Act (HIPAA), clinical and research audits, personnel law and other factors, all increase the costs of doing business for AHCs. 3   Dr. Bloom stepped in for Dr. Peter Kohler, who was originally scheduled to speak. Dr. Kohler’s prepared remarks are included in Appendix C.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Ezra Davidson, M.D., Associate Dean, Charles R. Drew University of Medicine and Science Dr. Davidson described Drew as a private university, affiliated with the University of California, Los Angeles. The King-Drew Medical Center is the heart of the clinical enterprise and is a core safety net public hospital in the area. As such, it faces several front-line clinical issues. First, the hospital is indeed recession-sensitive and is facing a serious budget deficit that creates challenges for care. About one-third of the hospital’s budget is generated from Medicaid, about 28 percent comes from disproportionate share funding and about one-third comes from general funds of Los Angeles County, via a contract that provides the faculty and physician supervision for the resident staff. The county funds are especially sensitive to economic changes. Second, the direct delivery of care is challenged by a discordance between what is taught to young health professionals and what is needed in practice. Little progress is being made in resolving social and health problems, yet there is inadequate attention to teaching prevention and behavioral or lifestyle changes needed to effectively address society’s social problems. Direct delivery of care is also affected by the different health care needs, cultures and languages among the populations they serve. The growing diversity of the population, reflected in the multiple languages spoken, affects the efficiency of care provided and the ability of patients to receive needed care. Administrative costs are added on top of the educational costs of treating patients. Better attention should be paid to providing the types of health care benefits that can increase access to care and reduce costs, and reducing the reliance on emergency rooms as the last resort. Dr. Davidson is also concerned that existing disparities in health care outcomes may worsen if the availability of clinical services is reduced for patients in need. Third, the capital needs are high for both the physical plant and for updating systems. The medical center’s physical plant requires greater amounts of capital to maintain. In addition, information technology systems are needed to achieve operating efficiencies. Fourth, better approaches are necessary to engage low-income, high-risk populations in clinical trials. Suspicions about AHCs must be overcome in order to help such patient groups participate in the types of research that will advance understanding of special health needs and how to address them. Discussion During open discussion, several issues were raised, all of which related to organization and governance. Roy Wilson commented that the governance structures in the two institutions represented by the presenters are very different. In Oregon, a President oversees the entire structure, whereas at Drew, because the sources of revenue are so diverse, there can be many parties directing activities, such as the county, UCLA, and the medical school. In other AHCs, the AHC does not own the clinical enterprise. He asked what is known about the advantages and disadvantages of alternative structures. Robert Dickler indicated that the Association of American Medical Colleges (AAMC) has done several studies trying to understand AHC organizational structures. One general observation is that where there is a close and integrated relationship between the medical school and the major teaching hospital (not necessarily joint ownership), there is typically a more research-intensive environment than in settings where there is neither the legal nor philosophical integration of the two entities. As a result, AHCs may take different orientations (and make different decisions) relative to care delivery, with some AHCs viewing the delivery of clinical care as an adjunct to the education and research mission, and others viewing clinical care as the central part of the tripartite mission. Elaine Rubin commented that the Association of Academic Health Centers (AAHC), which includes both allopathic and

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary osteopathic schools, has found many innovative approaches in how AHCs link with their clinical enterprise and develop models for community outreach. Larry Lewin noted that for those AHCs that are heavily involved in the safety net, organizational arrangements most often take the form of affiliation contracts between the medical school and public agencies for the purpose of providing medical faculty for clinical care. These affiliations between AHCs and public agencies are exceedingly difficult to understand, making it almost impossible under current circumstances to achieve any level of accountability. Physician productivity is often poor and physicians may refer patients who have insurance to non-safety net institutions, depriving the public institutions of revenues. In his experience, some of the public hospitals in New York have found it better to build relationships with medical staff in the community than to rely on contracts with the medical schools. John Rowe noted that when considering issues of clinical affiliation, the Veterans Administration system is an important partner for many AHCs. In response to the comments raised, Dr. Bloom commented on the interaction between the clinical care role of AHCs and the educational role. If an AHC wants to grow on the clinical side, the needs of the teaching faculty, training directors, department chairs, residency review committees, and professional societies must be met. It will not be possible to recruit a department chair to run the clinical mission and not attend to the educational mission. Dr. Davidson responded that a variety of governance structures exist today and will in the future as well. Such diversity is not likely to diminish. On an issue specific to nursing, the California state legislature is in the process of regulating nurse-staff ratios, creating a huge financial burden for hospitals. Such a trend could have significant impact on AHCs. The Education Role A Perspective from Medicine Edward Hundert, M.D., Dean, University of Rochester School of Medicine and Dentistry Dr. Hundert stated 10 things that in his view, will be different in the 21st century compared with the 20th century. These include: 1) new applications of science and technology; 2) less time per patient encounter; 3) more cost pressures; 4) older and more multicultural patients; 5) greater use of computers and information technology; 6) more population-based thinking with an emphasis on prevention and wellness; 7) increased accountability; 8) more interdisciplinary practice; 9) more ambulatory care; and 10) an ever-increasing rate of change. He saw the first and tenth items as the most important. These factors create an imperative for AHCs to shift their focus from teaching to learning and to create learning environments. The idea that health professionals are learning how to learn for a lifetime must be taken seriously. Rather than taking time out to learn, the emphasis should be on perpetual learning and creating high learning environments at all stages of education. For example, in the traditional paradigm, the work is done when the material has been covered. In the new paradigm, the work is done when competencies have been achieved. Everything about the stages of medical education work against this, with each level of undergraduate, graduate and continuing medical education having different accreditation standards, rules and regulations.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary The Flexner report4 required the completion of a basic science curriculum before initiating the clinical curriculum. According to Dr. Hundert, this produced an unintended side effect of implying that basic science is put aside when entering into clinical care—the very opposite of what should be conveyed. The University of Rochester has implemented the double helix curriculum, in which the clinical strand and the basic science strand weave through the whole four-year curriculum. Dr. Hundert highlighted a few elements of this curriculum. The first course after a week of orientation is called “Mastering Medical Information.” Taught in the first four weeks and last two weeks of the first year, students learn how to access and navigate through information, gaining skills in data analysis, biostatistics and epidemiology. By the fifth week of medical school, students often know more about how to access and critique the literature than the majority of the faculty. The expectation in the curriculum is that students are self-directed learners, using their new skills to obtain needed information. Another highlight of the Rochester program is student assessment. At the end of the second and third years, there are two 2-week comprehensive assessments of competency. Students meet with their faculty advisor and are expected to create an individualized learning plan to work on their relative weaknesses. The only grade they receive is based on how well they use the data to identify their relative weaknesses, create a learning plan and execute the plan. Another aspect of the curriculum is that advanced basic science blocks are part of the hospital portion of the curriculum, bringing the basic science faculty into the hospital. The effect on the faculty is profound. When the virologist talks to the students about human papilloma virus and the potential for a vaccine to prevent cancer, it happens after the students have seen women with cervical cancer. Students become hungry for information on the basic sciences. Additionally, the virologist interacts with the gynecologist and the oncologist to jointly design new translational research programs and clinical interventions, so faculty members interact in different ways. Another unique element of the curriculum is a one-month clerkship in the fourth year called “community health improvement.” Several years ago, the University of Rochester added a fourth mission to its portfolio, namely to make Rochester, New York “the healthiest city in America.” The content of the clerkship is determined by the health department’s assessment of the local health needs, and varies from providing the pneumococcal vaccine in nursing homes to working with teenagers to quit smoking. The academic content of the clerkship is focused on public health and epidemiology. In summary, Dr. Hundert recommended that the education of health professionals cross boundaries between undergraduate, graduate and continuing education, as well as across hospital, office and community settings. A Perspective from Nursing Colleen Conway-Welch, Ph.D., R.N., Dean and Professor of Nursing, School of Nursing, Vanderbilt University Dr. Welch identified four trends affecting the future of clinical education: work redesign, e-health, workforce issues and bioterrorism. In terms of work redesign, Dr. Welch identified the skill sets that clinicians should have when they graduate: 1) how interdependent teams function, 2) information technology, 3) systems thinking, 4) influence strategies (for those reporting to you and those to whom you report), 5) relationship building, and 6) communications skills. Work 4   The Flexner Report refers to a report in 1910 by Abraham Flexner to the Carnegie Foundation that defined the requirements for medical education. It can be found at www.carnegiefoundation.org.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary design can be influenced by "disruptive technologies,"5 through which new systems of care can be built that are characterized by lower cost, higher quality and greater convenience. New opportunities created by disruptive technologies can also challenge the roles and responsibilities of health professionals. For example, at Vanderbilt, there are about 40 nurse faculty practices. When physicians come to the clinic, they are often surprised at the level of illness and comorbidities among the patients seen. The experience at Vanderbilt has shown that the knowledge base of family practice physicians and of experienced nurse practitioners has many similarities. Work redesign needs to consider the roles of various health professionals in caring for patients. Dr. Welch believes that the fourth mission of AHCs should be to ensure that the promise of e-health is met and sustained. The promise of e-health is to get the right information to the right person at the right time and at the right place, ensuring optimal interactions of people. This will also call for greater interdisciplinary education. Although the work described by Dr. Hundert is exciting, it would be virtually impossible to bring nursing and medical students together because of scheduling problems. If AHCs are to use e-health and create optimal learning environments, more partners in more disciplines will be needed. Furthermore, Dr. Welch noted that the current structures (School of Medicine, School of Nursing and department chairs) may not be the best model for developing interdisciplinary education. In terms of workforce issues, Dr. Welch believes the nursing shortage results from a variety of factors, including more opportunities for women. Another factor is that the current nursing model applied in hospitals uses undertrained nurses in very complex settings and then burns them out. The majority of nurses in the workforce are graduates of two-year programs or diploma programs, not baccalaureate programs. The addition of requirements such as mandatory overtime only exacerbates problems of burn-out. In Dr. Welch’s view, the nursing baccalaureate degree is a generalist degree in a specialty world, and is not well differentiated in the marketplace. Greater attention should be given to the development of educational models that can create seamless opportunities for nurses to move from associate degrees to masters degrees so there is a continuum from clinical practice to management. In addition, more training needs to be provided for nursing leadership in the management of complex activities and organizations. Finally, recent events related to bioterrorism call for greater interaction between AHCs and the public health system. A Perspective from Public Health James Curran, M.D., M.P.H., Dean and Professor of Epidemiology, The Rollins School of Public Health, Emory University Dr. Curran noted that there are 31 accredited schools of public health in the United States and all are located within AHCs. Twenty of them are in the largest AHCs in terms of research funding, which means that the majority of the schools of public health are in the larger AHCs. In addition, there are approximately 60 accredited public health programs, most of which are also located in AHCs. Some unique aspects of Emory’s Rollins School of Public Health is its proximity to the Centers for Disease Control and Prevention and the presence of the medical school, nursing school and public health school on a single campus. This makes it easier to develop complementary, rather than competitive, programs (e.g., the School of Medicine need not have a department of epidemiology, as it is available in the School of Public Health). 5   See Christianson, Clayton M., Richard Bohmer and John Kenagy, “Will Disruptive Innovations Cure Health Care?” Harvard Business Review , September-October 2000, p. 102-112.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Schools of public health are, by nature, interdisciplinary, and have a strong focus on the social sciences, such as anthropology, psychology and economics. Dr. Curran sees this link to the social sciences, as well as the biologic sciences, as an important part of the academic mission of AHCs. Without such linkages, the AHC runs the risk of becoming “just another great big megaplex of hospitals.” Dr. Curran also believes that schools of public health are naturally innovative and entrepreneurial, in part, because of poor funding and small endowments compared with other schools. He believes this helps keep schools of public health focused on their missions. Dr. Curran believes that schools of public health provide a link to communities. Many of the causes of health problems facing communities today—smoking, violence, asthma, AIDS—are not necessarily related to the activities undertaken by AHCs. “Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy.”6 The perspective of public health is based upon the health of populations, in contrast to the necessarily individual perspective of health care practitioners. This population-based perspective results in an emphasis on prevention and priority setting with broad input. Public health priorities are (or should be) determined by: 1) the number people affected or potentially affected by a problem, 2) the severity of the problem; and 3) the ability to affect either of the first two. Discussion Linda Rosenstock, M.D., Dean of the UCLA School of Public Health, briefly described another Institute of Medicine committee that she currently co-chairs on “Educating Public Health Professionals for the 21st Century,” since the work of that committee is likely to complement the work of the Committee on the Roles of Academic Health Centers in the 21st Century. The charge of the Committee on Education Public Health Professionals in the 21st Century is to consider a framework for training future public health professionals, focusing on what schools of public health are doing, but recognizing that much training for public health professionals comes from other parts of the AHC. She noted that AHCs influence public health, whether intentionally or not. The interface between medicine and public health is likely to take on even greater importance in the future and it will be important to consider how collaborative training and research can be undertaken.. Most of the remaining comments raised during open discussion related to the importance of interdisciplinary education approaches. Christine Seidman noted that although each presenter described innovations within their own disciplines, there was a lack of connection between the paths pursued by each of the presenters, because each presenter focused only on his or her discipline. Education innovation does not appear to be crossing boundaries, although she believes the pressure to do so is likely to become even more important in light of the genomics revolution that will identify disease in its preclinical phase. Darrell Kirch noted that despite an understanding of the need for more interdisciplinary approaches in clinical care, education programs do not support that principle. The disciplines are educated separately, and then in practice, tensions arise over scopes of practice. He believes that overcoming this lack of interdisciplinary approach will require the creation of common learning venues around the issues that transcend disciplines, such as professionalism, ethics, communications, or public health. 6   Institute of Medicine, The Future of Public Health , Washington, D.C: National Academy Press, 1988.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Paul Ramsey noted that it is indeed possible to break down barriers across the disciplines. At the University of Washington, six schools have participated in the sponsorship of interdisciplinary programs. One of the challenges of interdisciplinary education is the shift of care to the ambulatory setting and now into the home setting. This may make it even more difficult to implement interdisciplinary education programs in the future. John Porter noted that people outside of health care (i.e., patients) see the boundaries as artificial, so integration across the health professions is likely to take on greater importance. Dr. Hundert noted that although there is much disagreement in the education community, there is general agreement that medical education can take “altruistic, other-oriented people and turn them into bitter cynics in four short years.” Better approaches are clearly needed. Elaine Rubin suggested that education goals, even within disciplines, appear to be changing. For example, at one time the Bachelor of Science in Nursing (B.S.N.) was the goal; now its role is less clear (as suggested by Dr. Welch). It appears that the disciplines may need to resolve internal issues to effectively move toward greater interdisciplinary approaches. Roy Wilson suggested that even larger issues affect the image of nursing and that incremental change will not be sufficient. In response, Dr. Welch commented that better modeling is required in medical school of physician/nurse relationships. Some participants raised issues regarding the role of the university in enabling greater integration across disciplines. Larry Lewin suggested that a better understanding is needed about the relationship between the university, individual schools and the AHC. The Oregon Health and Science University was created as an independent university, which provided it a strength in the marketplace, but he asked how that might have affected their ability to improve coordination with other disciplines, especially those that may not be available at a health sciences university. Linda Aiken cautioned against other factors outweighing the academic imperative of AHCs. She noted that managing the delivery platform from a business point of view has become so difficult that tensions can arise between academic needs and innovation, and necessary business decisions. In response, Dr. Hundert agreed that when the delivery system changes to compete and takes an aggressive business approach, the AHC is functionally doing curriculum reform. In competing in the marketplace, AHCs need to think about how the missions interact and how they can become more synergistic rather than competitive with each other. John Porter raised another aspect about the education role of AHCs in translating science to the public and to policy-makers, who are faced with needing to understand the importance of science and the types of investments needed. What is the role for scientists, journalists, teachers and others in this? How can education broadly reinforce the importance of science and encourage science advocacy? Noting the presentation by James Curran, Ralph Snyderman noted that prevention has been very generic. If the health system is to take a more proactive stance, prevention will likely become more specific to particular conditions and interventions. Dr. Curran responded that physicians do fairly well encouraging prevention within their own specialty, but are less proficient at stopping something from happening in the first place. For example, breast cancer is treated, but mammography is not consistently addressed. In part, financial incentives do not support the desired professional behaviors for promoting prevention. Jeff Goldsmith asked Dr. Hundert how was the University of Rochester was able to implement the major changes they accomplished. Dr. Hundert replied briefly that it required a comprehensive approach focused not only on the curriculum, but also on governance authority

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary and responsibility, resource allocation, promotion criteria and reward systems and that many things were done simultaneously. The Research Role Biomedical Research Gerald Fischbach, M.D., Executive Vice President for Health and Biomedical Sciences; Dean, Faculty of Health Sciences; Dean, Faculty of Medicine, Columbia University College of Physicians and Surgeons Dr. Fischbach commented on the remarkable advances being made today in science and biomedical research. Some of the most promising areas are in genomics and proteomics, non-invasive imaging, robotics and bioengineering and cell-based therapies. It is becoming possible to reverse disease and injury. The effects of these advances represent a type of “big science” not known before. These scientific advances and growth in NIH funding levels make it an extraordinary time to be in biomedical research. Although this is an extraordinary time that represents major advances in medical science, there are also factors that can jeopardize their potential. The structure of the AHC itself is a problem. In Dr. Fischbach’s view, “there is a desperate need to restructure departments in academic health centers.” For example, the AHC enterprise faces a serious tension when trying to recruit a leader in biomedical research who can simultaneously manage a $300 million per year business for the hospital. The relationship between the biomedical research mission and the services of hospitals needs to be re-examined. There is also a great deal of redundancy across departments that prevents scientists from interacting. This hinders development of models for translational research, even though there is general agreement on the need for more research that can translate the discoveries from biomedical research into practice. Translational research needs greater attention, especially in terms of interacting with private industry and training students for career paths in this area. Although AHCs are not organized like scientific organizations (e.g., California Institute of Technology or MIT), forcing people into "outmoded phenotypes" is creating serious problems for accomplishing their various missions. This is a challenge that has been underestimated. Another obstacle is the declining infrastructure of many medical centers and the need to renew physical plants. In many places, the laboratories and environments for research are seriously deteriorated. Finally, a major obstacle is the loss of time available to scientists to think and create, which is the core of their work. An overwhelming amount of time is being spent in seeing patients, writing grants, raising money and focusing on publications. AHCs train many physicians and other clinicians, but also have a large number of doctoral candidates in their organizations. The faculty is pulled apart by two very separate missions: training people in the science of medicine and training people in the art of medicine. Rather than being pulled apart, greater attention should be focused on how to integrate disciplines across science and clinical medicine, as well as across nursing, public health and dentistry. However, this requires examining the structure of the AHC. Academic health centers have the opportunity to spur a new medicine with a much more preventive bent by focusing on early diagnostic tools and using the new sciences to go far beyond traditional clinical medicine to improve the public's health. Achieving this, however, will require better cooperation within academic health centers, but also between them.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Clinical Research Ralph Snyderman, M.D., Chancellor for Health Affairs; Executive Dean, School of Medicine; President and CEO, Duke University Health System Dr. Snyderman began his comments by noting his firm belief that the overarching mission of academic health is the societal good of improving the public’s health. The question is how to fulfill that mission, especially in this period of great opportunity to take research discoveries and translate them into health benefits. A number of research areas are showing great promise, including genomics and proteomics, high throughput screening, and new therapeutics. Translating this new knowledge into practice will require greater emphasis on bioinformatics and biostatistics, development of best practice models and outcomes research. These are new areas for clinical research. Greater collaborations will also be required between academic institutions and industry, as well as with the federal government (specifically, the National Institutes of Health). The strengths of academia include core technology development (cloning, molecular biology, sequencing, proteomics, etc.), new technologies, specialized preclinical development models (e.g., animal models in drug development), trained manpower, source of patients for clinical trials (especially those with complicated and/or chronic diseases), and access to a health care delivery system. The strengths of industry include the identification of leads, drug development, preclinical development, big clinical trials and business expertise, especially for moving an idea down the pipeline to clinical application. There are a number of issues that AHCs have to confront in terms of clinical research. The first is to “get our own house in order.” Greater attention must be paid to making the AHC operationally efficient. AHCs need to be better partners with private industry. Issues related to human subject protection need to be addressed rapidly, including the education of clinical faculty and oversight of their studies. Upgrading and maintaining the infrastructure needed to do clinical research will be costly. At Duke, spending on the research infrastructure has increased many times over, and most of these expenses are not reimbursed. Finally, institutions will need to decide what their clinical research capabilities are and whether that is a focus on one aspect, such as translational research or a comprehensive agenda that includes large phase III clinical trials. Perspectives from Private Industry Samuel Broder, M.D., Executive Vice President, Celera Genomics Dr. Broder sees the primary missions of academic health centers as: 1) defining and providing state of the art care for the patients they serve, 2) generating knowledge, 3) disseminating knowledge, 4) mentoring the next generation of health professionals, 5) providing post-graduate education to the current generation of health care professionals, and 6) providing community service and outreach. The underlying assumption is that AHCs will serve the public good and are “obligated to serve medicine and science, de-coupled from the exigencies of commerce.” Dr. Broder proposed that the metrics of success will be based on improvements in morbidity and mortality statistics, community goodwill, publications, and respect by students and peers. The primary mission of private industry, focusing on pharmaceutical and biotechnology organizations, is to create products and services that are valued by society, using the metrics of the business world (revenues and shareholder value), generating knowledge and disseminating that knowledge. Teaching and post-graduate education may be important goals, but in most cases, the pharmaceutical or biotechnology company has a legally enforceable fiduciary

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary responsibility to the people who provided the capital underlying the existence of the organization. That obligation cannot be unilaterally waived and may not include education. In Dr. Broder's view, the question is how to maximize the interactions between academic health centers and private sector organizations to create the types of relationships that many seek. One of key elements is disclosure. Principles should be established to ensure there is disclosure at every phase of the mission statement of both organizations. There should be disclosure to the academicians and administrators of the institution, to the institutional review board and to patients. Disclosure should include information about who is representing whom, relationships between an individual at an academic health center and a private company (or vice versa), and sources of support at an official level, a laboratory level, a clinical level or a personal level. Equity interest by an investigator need not automatically prohibit participation or leadership on a study, but it should be disclosed. As a final note, Dr. Broder believes that it is important for AHCs and private industry to enter into relationships with mutual acknowledgement of fallibility. Original positions may change as progress on a problem moves forward. In Dr. Broder’s view, some of the most significant problems encountered have originated from a sense of invulnerability. All parties will need to recognize that problems can have many solutions. Health Services Research Ralph Horwitz, M.D., Yale University School of Medicine Dr. Horwitz described health services research as broadly focusing on both the system of health care and the services it provides. This includes issues in organization and financing, access to health care and quality, the efficiency of the system and a focus more on doctors and other providers than on individual patients. This is distinct from clinical epidemiology, which has a focus on patients and outcomes, including the risk for developing disease, susceptibility to treatment, outcomes and technology assessment, and effectiveness of interventions in individual patients. Both omit a focus on public health infrastructure, on populations at risk and patterns of disease, on forces of morbidity and mortality and early warnings of epidemics. The latter point is emphasized to illustrate that much of what AHCs do is very separate and distant from what their fundamental mission ought to be, namely, improving the public’s health. Dr. Horwitz described the fundamental concepts of health services research in order to understand its role within AHCs. The ethos of the health services is defined by the questions asked, the data collected, the methods used, the inferences drawn and the policy recommendations made. The questions of health services research run the spectrum from effectiveness to efficiency to the organization of care and questions of value. The methods used include experimental trials, such as testing interventions for effectiveness; observational studies; statistical modeling and meta-analyses. Data sources are patients, physicians and other clinicians and large databases. The emphasis on data and data management, and especially the transforming of data to knowledge, is essential to universities and, therefore, to academic health centers. One of the critical issues in developing inferences and making recommendations is the inability to effectively differentiate the benefits that are found for groups when applied to individuals. If a study claims a 30 percent reduction in mortality from heart attacks as the result of a new treatment, it is not known whether every patient will experience that reduction in risk or whether the population as a whole will experience the reduction, with some patients achieving complete protection and some patients receiving no benefit at all. This is a fundamental issue in how we think about the value of the data and use the knowledge to improve health.

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The Roles of Academic Health Centers in the 21st Century: A Workshop Summary Health services research has made a number of achievements, but also faces a number of challenges for the future. One is the lag in funding compared with other areas of research. Health services researchers are less effective than biomedical researchers in securing funding. Consensus around priorities and a commitment to resolving specific problems could help to guide funding. More physician investigators are needed and they need to be better prepared to conduct health services research. Too many physicians are conducting work in health services research with insufficient training and experience. Issues related to human subject protection need to be addressed. Interdisciplinary research is critically important, but numerous barriers exist, including separate laboratory buildings that hinder interactions and a focus on disciplines rather than scientific problems. Interestingly, a number of AHCs have a health service research unit, but in general, they have not advanced the field. Data on their value to the internal operations of AHCs, its costs and quality are largely unavailable. Discussion Larry Lewin suggested that AHCs would seem to be natural supporters of health services research, but there seems to be little demand for it from practitioners in academic health centers. He asked if the impetus for health services research needs to come from a broader constituency base, similar to the broad interest that supported expanded funding for NIH. In terms of health services research, Dr. Snyderman noted that it is becoming increasingly clear that we are going to have a growing amount of data and information, and may not be able to use it without stronger health services research to implement new discoveries. Dr. Broder believes that part of the lack of a constituency for greater health services research is its focus on cost-effectiveness, which the public may perceive as limiting their options for care. However, Dr. Horwitz responded that the focus of health services research is on effectiveness—studying what works and what does not—so that people are not exposed to risk without benefit, and that is clearly in the public’s interest. Nancy-Ann DeParle asked why AHCs that have established health services research centers have not been more successful in using them to improve their own operations. Dr. Horwitz responded that, in his view, health services research in AHCs has not been more successful because they have had confusion about purpose. Too often, AHCs view such centers as a tool for managing resources within their institutions, but the faculty view themselves as joining the organization to do research. This conflict of objectives disappoints both sides. Edward Holmes asked about the extent to which AHCs have a role as economic engines for their communities. Many would agree that AHCs have a role in generating knowledge and translating discoveries into new therapies, but also play an important role in the economies of their communities and society. Dr. Fischbach agreed that AHCs are major economic drivers in their local communities. Ralph Snyderman also agreed that AHCs are indeed economic engines for their local communities, but that AHCs should be more articulate in describing the economic benefit that research institutions have for their communities. On the other hand, Dr. Broder urged caution is using an argument of economic vitality as a reason to gather support for AHCs, as it could overtake the other issues that concern people. Brian Biles noted that prior discussions have focused on the various missions of AHCs, and if each should be independently and fully funded. For historical reasons, NIH does not fully fund research projects and requires some cost sharing by institutions. On a related point, Christine Seidman asked whether AHCs will be able to afford to continue their research role. Will AHCs be able to conduct research in the future absent a partnership with commercial