The Roles of Academic Health Centers in the 21st Century: A Workshop Summary (2002)

The statement of task to the Institute of Medicine Committee on the Roles of Academic Health Centers (AHCs) in the 21^st Century charges it to "examine the current role and status of academic health centers in American society, anticipate intermediate and long-term opportunities and challenges for these institutions, and recommend to the institutions themselves, to policy makers, to the health professions, and to the public, scenarios that might be undertaken to maximize the public good associated with these institutions. The committee will:

1. Assess the development, contribution and performance of AHCs in teaching, research and technology development; patient care, including the provision of specialized care; and community service, including caring for underserved populations.

2. Evaluate whether AHCs are prepared to meet societal needs and expectations over the coming decades in the areas of: a) an educated and trained professional work force; b) assessment of the value and cost effectiveness of new technologies and facilitation of their dispersion; c) provision of health care services to populations dependent upon them (e.g., uninsured, poor); and d) provision of leadership in relation to ethical and social aspects of health.

3. Assess the capacity of AHCs to carry out their multiple functions in an effective and efficient manner.

4. Identify steps that can be taken by AHCs themselves, and by communities, policymakers, and others to maintain and enhance the performance of AHCs."

The Committee sponsored a workshop on January 24-25, 2002, hearing testimony from seventeen experts on the trends and developments in health care, changing health care needs, and the implications and expectations for AHCs in how they carry out their roles in education, research and patient care. These proceedings summarize the presentations and discussions held at the workshop.

The agenda for the workshop was divided into three sections: 1) Changing Needs and Trends in Health Care, 2) Creating a Vision for the Future, and 3) Creating an Environment to Support Needed Changes. The format included brief presentations by one or more presenters, followed by questions and comments from other participants at the workshop. After all questions or comments had been raised during a discussion period, the presenters responded to the group of questions or comments raised. This format permitted maximum participation by all workshop participants. However, in reading these proceedings, it should be noted that questions may have been raised during the discussion that were not directly answered at the workshop. The value to the committee, however, was in hearing the types of concerns raised and the complexities associated with many of the issues.

The workshop covered a diverse set of issues in trying to answer the question of how AHCs can and should respond to the needs and demands of a changing population and health care environment. No findings or conclusions were determined at the workshop, nor should any be drawn from these proceedings. The workshop was intended solely as an information-gathering activity by the committee. However, four cross-cutting issues are highlighted here because they

were raised multiple times throughout the two days. They are cross cutting because they are not role specific, but affect the AHC as a whole. These issues were:

Drivers of Change: Rapid changes in information technology and biomedical advances in health care are likely to affect all the current roles of AHCs. Scientific and technological advances can potentially permit clinical care to intervene early in a disease process by identifying and modifying personal risk. The burgeoning knowledge base will put pressure on all levels of education to use the continuously expanding evidence base and to prepare health professionals for lifelong learning. Emphasis on translational research can support the application of knowledge developed to gain benefits in practice. Another driver of change is the shifting disease burden, which affects the changing health and medical needs of the people using the health care system. More people will be faced with having and managing chronic conditions. In addition, the public's health will likely continue to be affected by communicable diseases and lifestyle-related illnesses, suggesting the need for increased attention to population health, as well as the acute and chronic care needs of people.

Defining Accountabilities: Questions about AHCs’ accountability arose repeatedly. Some participants felt the current levels of performance expectations were generally unclear or undefined, whereas others believed that the expectations were clear for some of the missions, but not all. Many participants suggested that AHCs should be accountable for meeting a broader mission. For example, the mission of AHCs might include using education, research and clinical care to improve the health of a defined population, improving the public’s health, generating and disseminating knowledge, advancing e-health, providing education to current health professionals, providing leadership in global health, providing community service and outreach, or becoming role models for delivering care that has the attributes necessary for clinical practice. However, some participants believed the current missions of education, research and patient care are still the appropriate roles of AHCs, although adaptations may be required within each to meet the changing demands and expectations of the external environment. One participant suggested a narrowing of the AHC mission to limit indigent care, or to AHCs serving as an “insurer” of last resort. Challenges have been encountered in attempts to define accountabilities, including issues related to measurement and availability of information.

Interdisciplinary Approaches Across All The Roles: This issue arose in the context of each AHC role. In terms of patient care, the demands of caring for a population with chronic conditions is expected to rely on the use of interdisciplinary teams in order to deliver the diverse set of services needed by such a population and improve both the quality and efficiency of care. In terms of the education role, interdisciplinary approaches could train people in the types of teams in which they will be expected to work. In terms of the research role, advances in biomedical science— especially genomics— could influence the demand for interdisciplinary approaches to conduct research and apply its results, including input from non-health disciplines, such as engineering or computational sciences. Therefore, discussions surrounding interdisciplinary approaches related to both integration among the disciplines within the AHC (e.g., medicine, nursing, public health and others) as well as other disciplines not typically found in AHCs, but located in other departments of a university, such as engineering, applied mathematics or ethics.

Separating Accountabilities and Integrating Functions: As noted above, integration across the disciplines and functions of the AHC was raised as an issue. However, a number of participants also suggested the need for AHCs to be able to account for each mission separately. They believed this would permit greater accountability, especially for the public dollars provided to AHCs, and could also improve the ability of AHCs to more effectively manage each mission. Separating the accounting does not necessarily imply that each function must be self-supporting,

but rather, that any cross-subsidies are explicitly recognized and counted. As a result, there was a perceived need to integrate the AHC roles, but also to distinguish the accountabilities within each role. It is not clear if such goals are compatible and discussions at the workshop did not differentiate the application of this concept for individual AHCs or across all AHCs, or how broadly or narrowly the concept of accountability might be defined.

This workshop provided an opportunity for the Committee to gather a variety of perspectives on the issues facing academic health centers for the 21^st century. It represents only one input into the overall study process. In addition, the Committee will commission several papers on special topics, review the available literature and examine other recent analytic reports. One of its challenges will be to identify priorities from among the many serious and pressing issues that confront academic health centers. The Committee will conduct its deliberations in a series of meetings during the remainder of this year and issue its final report with findings and recommendations in early 2003. The workshop agenda and participant list are included in Appendix A. This workshop was sponsored with support from The Commonwealth Fund.