The role of academic medicine in improving health care quality.

Academic medicine, often entrenched in biomedical and clinical research, has largely ignored the development and application of quality metrics to ensure the delivery of high-quality health care. Nevertheless, academic medicine has substantial opportunities to lead the charge in building a quality infrastructure with the goal of delivering high-quality and cost-efficient health care to all Americans. The American College of Cardiology (ACC) and American Heart Association (AHA) have worked jointly to measure and improve the quality of cardiovascular care. This effort has led to the development of clinical practice guidelines, performance measures, data standards, national registries, and appropriateness criteria for cardiovascular care. Academic medicine should actively embrace and promote the type of quality metrics and criteria developed by ACC and AHA and apply this model across the entire academic medicine community. Academic medicine, with its many resources, could lead the way in the expanding field of quality science by supporting fundamental research in quality improvement, supporting academicians to improve quality at their own institutions, developing educational models for quality assessment and improvement, creating and implementing data registries, and serving as a conduit for developing the emerging science of quality assessment. In this and many other ways, academic medicine must offer the health care community leadership for improving our nation's health care quality with the same fervor presently exhibited for the advancement of basic science, the development of specialized and experimental therapy, and as centers for tertiary and quaternary patient care.     

The emerging relationship between academic health centers and continuing care retirement communities

A survey of the 96 member-institutions of the Association of Academic Health Centers was conducted by the authors during the 1988-89 academic year to determine the number and types of contractual ties with continuing-care retirement communities (CCRCs). Of the 88 academic health centers that responded, 24% had an existing relationship with a CCRC; 26% were in the process of developing such a relationship; 7% had considered but decided against such a relationship; and 43% had not considered developing such a relationship. The authors document a rapid increase in the number of such relationships in the latter half of the 1980s and suggest that this trend is comparable to the increase in formal relationships with nursing homes begun by academic health centers in the early 1980s. Issues raised by those institutions that responded are presented, levels of possible involvement with a CCRC are described, and the contractual agreement between the University of North Carolina School of Medicine's Program on Aging and a local CCRC is presented as an example of the benefits that can be gained from such a relationship.     

Controlling U.S. health spending: opportunities for academic health centers.

This article begins by examining the factors that explain the level and rate of increase in health care spending. Expenditures per capita for health care in the United States are more than double the expenditures per capita in Canada, the United Kingdom, France, and most other industrialized countries. The main reason for the higher expenditures is not that Americans have access to or receive more health care, but that the prices Americans pay for medical services are two to three times higher than the prices in other industrialized countries. The author examines three actions that leaders of academic health centers (AHCs) could take that could reduce the burden of these higher costs on the American public. First, leaders of AHCs could compare the costs in their hospitals to the costs in comparable hospitals in other countries to find out why hospitals in the United States are so much more expensive. Second, they could examine how much they charge the uninsured for hospital services at AHCs-generally two to ten times more than they charge people with insurance. Third, including more people with multiple chronic conditions in clinical trials could make the findings of the clinical trials applicable to a larger patient population and thereby reduce the substantial geographic variation of health care that exists in the United States.     

Beyond adoption to sustained use: telemedicine for rural communities.

The objective of this paper is to identify factors that affect the sustained use of telemedicine in rural communities and to suggest possible ways to improve such utilization. We draw on innovation and network theory to develop hypotheses about conditions that will hinder or facilitate sustained use of telemedicine. Telemedicine systems are expected to achieve sustained use in communities with higher physician-to-population ratios, greater availability of nonphysician providers, and greater consumer knowledge of and support for telemedicine. Additionally, telemedicine is more likely to be used in settings where hospital medical staff structures use contractual arrangements that encourage the use of telemedicine or reimburse through capitated systems. Rural physicians are more likely to use telemedicine if they have previous experience in facilities that serve as telemedicine hubs and if they have strong relationships with physicians in a hub location or with local physicians who are supportive of telemedicine. Physicians whose primary offices are geographically closer to the remote telemedicine installation are more likely to order telemedicine consultations for their patients than are their counterparts further away. Also, telemedicine systems that are well managed and easy to use are more likely to achieve sustained utilization by rural physicians. These hypotheses should be considered by supporters, providers, and managers of telemedicine. A proactive approach to managing telemedicine networks, with an emphasis on the issues raised here, should help telemedicine achieve its potential, namely, improved access and enhanced quality and efficiency of health services in rural communities.     

Aligning the goals of community-engaged research: why and how academic health centers can successfully engage with communities to improve health

Community engagement (CE) and community-engaged research (CEnR) are increasingly viewed as the keystone to translational medicine and improving the health of the nation. In this article, the authors seek to assist academic health centers (AHCs) in learning how to better engage with their communities and build a CEnR agenda by suggesting five steps: defining community and identifying partners, learning the etiquette of CE, building a sustainable network of CEnR researchers, recognizing that CEnR will require the development of new methodologies, and improving translation and dissemination plans. Health disparities that lead to uneven access to and quality of care as well as high costs will persist without a CEnR agenda that finds answers to both medical and public health questions. One of the biggest barriers toward a national CEnR agenda, however, are the historical structures and processes of an AHC-including the complexities of how institutional review boards operate, accounting practices and indirect funding policies, and tenure and promotion paths. Changing institutional culture starts with the leadership and commitment of top decision makers in an institution. By aligning the motivations and goals of their researchers, clinicians, and community members into a vision of a healthier population, AHC leadership will not just improve their own institutions but also improve the health of the nation-starting with improving the health of their local communities, one community at a time.     

Needs and challenges for health services research at academic health centers.

What are the institutional strategies used by academic health centers and other academic institutions to support and maintain the infrastructure that promotes health services research? Using the findings from interviews conducted in late 1998 with health services researchers at ten health services research centers of several types and from several geographic areas, and with the directors of ten health services research training centers, the authors address this key issue by examining four central infrastructure needs and challenges for health services research: (1) organizing core institutional resources (most centers received some level of core financial support from their parent organizations); (2) supporting career development of individual researchers (the more competitive health care system may diminish the ability of academic health centers and other institutions to give such support, but certain opportunities were noted); (3) supporting and enhancing training in health services research (such support comes from many different disciplines and organizations; the typical career path is in academic settings); and (4) establishing and supporting research partnerships (there are growing opportunities for such alliances). The authors reach a number of conclusions from their study, including the fact that there are a wide variety of models of successful health services research centers, with very different missions, organizational and interdisciplinary configurations, research and policy objectives, and collaborative relationships. Additional studies are needed to further specify those infrastructure elements that foster effective and productive health services research in academic health centers and other university settings.     

Generation X: implications for faculty recruitment and development in academic health centers.

Differences and tensions between the Baby Boom generation (born 1945-1962) and Generation X (born 1963-1981) have profound implications for the future of academic medicine. By and large, department heads and senior faculty are Boomers; today's residents and junior faculty are Generation X'ers. Looking at these issues in terms of the generations involved offers insights into a number of faculty development challenges, including inadequate and inexpert mentoring, work-life conflicts, and low faculty morale. These insights suggest strategies for strengthening academic medicine's recruitment and retention of Generation X into faculty and leadership roles. These strategies include (1) improving career and academic advising by specific attention to mentoring "across differences"--for instance, broaching the subject of formative differences in background during the initial interaction; adopting a style that incorporates information-sharing with engagement in problem solving; offering frequent, frank feedback; and refraining from comparing today to the glories of yesterday; to support such improvements, medical schools should recognize and evaluate mentoring as a core academic responsibility; (2) retaining both valued women and men in academic careers by having departments add temporal flexibility and create and legitimize less-than-full-time appointments; and (3) providing trainees and junior faculty with ready access to educational sessions designed to turn their "intellectual capital" into "academic career capital."Given the trends discussed in this article, such supports and adaptations are indicated to assure that academic health centers maintain traditions of excellence.     

Building a transcontinental affiliation: a new model for academic health centers.

The recent affiliation of The Methodist Hospital (TMH) with Weill Medical College (WMC) of Cornell University and NewYork-Presbyterian Hospital is the first transcontinental primary affiliation between major, not-for-profit academic health centers (AHCs) in the United States. The authors describe the process followed, the issues involved, the initial accomplishments, and the opportunities envisioned. The key enablers of this affiliation were a rapid process, mutual trust based on existing professional relationships, and commitment to the project by Board leadership. Because of their geographic separation, the parties were not competitors in providing clinical care to their regional populations. The affiliation is nonexclusive, but is reciprocally primary in New York and Texas. Members of the TMH medical staff are eligible for faculty appointments at WMC. The principal areas of collaboration will be education, research, quality improvement, information technology, and international program development. The principal challenge has been the physical distance between the parties. Although extensive use of videoconferencing has been successful, personal contact is essential in establishing relationships. External processes impose a slower sequence and tempo of events than some might wish. This new model for AHCs creates exciting possibilities for the tripartite mission of research, education, and patient care. Realizing the potential of these opportunities will require unconstrained ideas and substantial investment of time and other critical resources. Since many consider that AHCs are in economic and cultural crisis, successful development of such possibilities could have importance beyond the collective interests of these three institutions.     

Strategies for defining financial benchmarks for the research mission in academic health centers.

Valid financial benchmarks are needed for the research mission in academic health centers (AHCs). Databases listing institutional success in obtaining sponsored research funding are publicly available. However, these databases are generally not adjusted for AHC size, confounding useful comparisons between institutions. The authors suggest simple strategies, which depend on a form of ratio analysis, to circumvent this limitation. Annual rates of growth (rates of return, R(f)) are determined for total National Institutes of Health research grant dollars, number of research grants, and average dollars per research grant for 15 U.S. AHCs. Selected institutions are compared to one another and to the total pool of medical school funding. Performance is evaluated over a ten-year period (1992-2001) to illustrate the advantages, limitations, and applications of the ratio analysis approach. Alternative strategies are suggested for individual AHCs to evaluate their departmental and organizational performance, again without regard to institution size, and also dependent on ratios. Application of these strategies, especially when individualized to the particular AHC, permits more accurate assessment of past performance and more accurate and effective planning for future growth.     

Electronic medical record systems at academic health centers: advantages and implementation issues.

The growth of managed care has fueled expectations for a more coordinated delivery of clinical services and a reduction of unnecessary utilization. Among the most important issues that constrain these expectations is the transfer of medical information. Electronic medical record (EMR) systems appear to offer substantive advantages over paper records for both containing costs and improving the quality of care. However, incorporation of EMR systems into practice settings has languished. Among the barriers to implementation are software problems of codification and entry of data, security issues, a dearth of integrated delivery systems, reluctant providers, and prohibitive costs. The training programs of academic health centers (AHCs) are optimal environments for testing and implementing EMR systems. AHCs have the expertise to resolve remaining software issues, the components necessary for integrated delivery, a culture for innovation in clinical practice, and a generation of future providers that can be acclimated to the requisites for computerized records. The authors critically review these and other issues of implementing EMR systems at AHCs and propose four necessary steps for financing their implementation.     

Physician workforce shortages: implications and issues for academic health centers and policymakers.

A physician shortage is likely given current levels of medical education and training. Because an increase in physician supply through expansion of U.S. medical school capacity will require ten or more years, there is little time left to affect the supply of new physicians in 2020 when a substantial number of baby boomers will be over 70 years of age. Even with a substantial increase in medical education and training capacity, it is unlikely that all of the increased demand for health services can be met with physicians. In addition to the challenges of expanding medical school enrollment, the nation will need to grapple with other ramifications of demand exceeding supply. This includes assessing how to deliver services more effectively and efficiently and the future roles of the physician and other health professionals. These challenges are particularly difficult for medical schools and teaching hospitals, the cornerstones of medical education and training in the United States. Osteopathic and off-shore schools targeted to Americans have been willing and able to grow more quickly and less expensively than U.S. medical schools, in part because of their more narrow approaches to medical education. In addition, physicians from less developed countries continue to migrate to the United States in significant numbers. Medical schools, teaching hospitals, and policymakers will need to address several major questions as they respond to the shortages. They will either confront and address these issues in the next few years or they will be forced to change by others in the future.