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October
12 1993
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(919) 684-2255
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Arnold Epstein, M.D.
Executive Office of the President
Domestic Policy Advisor for Health Care
The White House
1600 Pennsylvania Avenue
Washington, DC 20500
Dear Arnold:
I was delighted to have the opportunity to meet you during the October 7th
meeting of the Association of Academic Health Centers. I thought your presentation
was excellent and it certainly increased my comfort level with the Clinton Health Plan.
I have a great personal interest in seeing that academic medical centers, in particular,
Duke University Medical Center becomes part of the solution to our national health
problems. To do so, we must redirect our efforts towards understanding societal needs
and determining the mechanisms for increasing the efficiency and impact of what we
do. Ultimately we will have to compete in the market place but such competition is
clearly complex because much of what we do cannot be paid for solely by the cost of
the health care we deliver. You clearly understand this issue as well as anyone in the
country today. I would like to offer whatever help I could give you in your new
function in the Executive Office of the White House.
Last year, Duke University Medical Center added a new core mission to those of
education, research and health care delivery. The mission is an overarching one to
apply our core missions in education, research and health care delivery to solving
societal health needs. We are serious about this and I hope to have the opponunity to
work with you or appropriate individuals in the Administration to see that health care
reform comes out right. While the present system has many flaws and inefficiencies
that need to be changed, it is important not to destroy a delicate network which has
grown together and has allowed the United States to be the engine which drives health
care improvement throughout the world.
I look forward to seeing you again in the near future and hope you return to
your Alma Mater soon.
With warm wishes,
Sincerely yours,
Ralph Snyderman, M.D.
Dean, School of Medicine
James B. Duke Professor of Medicine
RS:bn
�Academic Health Centers: Their Role in Solving the Nation's Health Needs
by: Ralph Snyderman, M.D.
Addressing problems associated with health care is one of the top domestic
issues in the United States today.
Uncontrolled costs, insufficient access and
portability, undue bureaucracy, inadequate service and the perception of some health
care providers being remote from patient's needs are but a few of the important
problems. This has led to the creation of the Clinton Health Security Act as well as
other proposals to solve health delivery problems. Amongst the greatest challenges for
any health care policy will be to control costs while increasing the number of insured
and yet maintain and improve the quality of health care. With all its faults the
American health care system has been the force internationally for the development of
the most dramatic improvements in the diagnosis, treatment and care of disease.
Despite the revolution in medical progress, we are merely on the threshold of what
science and technology can bring to bear. The daunting task will be to harness this
power cost effectively to meet societal needs while providing for the depth and breath
of care that our country requires. Academic Health Centers (AHC) are institutions
comprised of medical schools, other health professional schools and affiliated hospitals.
Frequently affiliated with major universities, AHCs typically train the preponderance of
the nation's medical manpower, perform the great majority of biomedical and clinical
research which leads to new health care technology and provide a high percentage of
hospital care. Teaching hospitals associated with academic health centers provide a
majority of the nation's inpatient care, with a greatly disproportionate share of treating
the indigent and the very sick. Given the dominant role that AHCs play as providers of
the nation's health care needs, they can either be part of the nation's health care
problems or provide a means for their solutions. In reality, only the academic health
center can address and solve many of the nation's health needs.
Missions of the AHC
Most academic health centers identify their core missions as education, research
�and patient care with the goals being to train the finest practitioners, to produce
important research discoveries, and to provide first rate health care. Given the
academic nature of these institutions, they have not generally considered it their
mission to specifically address such national health care needs as developing the models
and implementation systems to provide more cost effective quality health care with
enhanced access. It is clear that the federal and state governments will play the major
role in developing health care policy. Nonetheless, governmental solutions alone are
unlikely to be wholly appropriate or sufficient. Indeed, market forces are already
leading to dramatic restructuring of health care delivery systems. To meet our nation's
needs, independent or collaborative approaches by health care providers, particularly
academic health centers, must play a substantial, if not dominant, role in improving the
nation's health care and delivery systems.
Given their resources and social responsibilities, it is necessary that AHCs focus
the opportunities provided by their core missions to provide solutions for our national
health needs by developing continuously improving models and implementation systems
for increasing the cost-effectiveness and access of health care of the highest measurable
improving quality.
The impact that AHCs can have on our nation's health can be illustrated by
examining what they can do through each of their core missions.
Education
In education, they must focus on producing highly skilled medical manpower
specifically trained to practice medicine in ways which enhance cost effective health
care with, for example, greater understanding of the marginal benefit of medical
procedures, the need for preventive approaches and the value of efficient health care
teams. AHCs must also take the lead in increasing the number of generalists, physician
extenders, and in the development of other types of professionals trained to promote
preventive medicine, primary care and wellness. AHCs could better educate these
professionals in the principles of networking, teamwork and consultation. Given their
�high technology capabilities, AHCs could take the lead in providing networks of
continuing medical education including, for example, telecommunication (Table I).
TABLE I
MEDICAL EDUCATION
Increase emphasis on:
3.
•.-^•4...."
:
3w 8:^
Cost-Effectiveness of Health Care
Measurable Quality (outcome)
Patient Service
Ethical Issues
Primary Care (Generalists)
Preventive Medicine
Healthteam Approaches (teamwork)
Continuing Medical Education ;
1
�Research
In research, AHCs must sustain and improve their basic research capabilities.
They must also develop better mechanisms to identify practical applications of
unfocused research discoveries and to facilitate their transfer into practical application.
Not only will this enhance the rapid application of discoveries to human benefit, but it
will also improve the nation's economic competitiveness and provide additional funding
for AHCs own research programs. Clinical research combined with outcomes research
can also test the value of contemporary and new technologies for their costeffectiveness (Table II).
BIOMEDICAL RESEARCH
Develop:
1.
2.
4.
5.
Appropriate Organization for Interdisciplinary
Science and Discovery
Enhanced Identification of Relevance of :
Discoveries (ie, practical application)
New Sources of Revenue from Technology Transfer
Enhanced Clinical Research and Development
�Patient Care
In patient care, the AHC will continue to develop innovative approaches to
diagnosis and treatment of both common and rare diseases. Through prospective
outcomes research, the AHCs could help to establish and improve the standard of care
as well as to determine and continuously improve the cost-effectiveness of such care.
They will be the centers of excellence where new technologies can be assessed in a
controlled way, both for their effectiveness and its cost-benefit ratio. Moreover,
through the appropriate networking of primary, secondary, tertiary and home care,
AHCs could substantially improve the quality, accessibility and cost-effectiveness of
health care. Table III
;:PATIENT_CARE:f^
Increase; emphasis on: f
:
1 .'
2.
3.
p
U : Innovative Approaches to; Diagnosis and Treatment (Research to
:
: Standards of Care Development (Outcomes Based)
Centers for Controlled New Technology Assessment
Health Care Delivery
In the new mission of providing cost-effective accessible health care delivery,
academic health centers, by using their highly developed information systems, research
skills, highly trained clinician personnel, clinical capacity, capital resources and
community networking strategies can develop constantly improving standards of
medical care and health care delivery networks. Indeed, many AHCs are currently
developing health delivery systems through affiliation with community based primary
care physicians and hospitals. The focus of AHCs in health care delivery could be on
producing the highest quality of health care to communities at the lowest possible cost.
�By appropriate networking throughout their region, academic health centers could also
play a major role in providing increased access to and appropriate distribution of
generalists and physician extenders throughout their referral areas along with ongoing
continuing medical education. Moreover, given the dominant role they play in providing
health care, AHCs can be a valuable source for the development of new ideas in health
care policies (Table IV).
:
:::
i:-;H^Lra CARE DELI^
; IMPROVE THE NATION'S HEALTH CARE WHILE DECREASING COSTS AND
•
"•.Deyelbp:;;;':;;;-;
1.
2.
:
Interdisciplinary: Centers of Excellence ':•
Cost effective incorporation of Technological Advances
^
(Primary through quaternary care)
f \.• 6.
Prevention Strategies
Duke University Medical Center is currently developing new strategies to solve
regional health care problems through mechanisms described above. We are fully
committed to joining in partnership with regional and national leaders in identifying
those solutions that will result in better health care for all Americans, and we challenge
our sister institutions to work vigorously with us to this end.
October 12, 1993
�LONG RANGE PLAN
Progress Report
DUKE UNIVERSITY MEDICAL CENTER
FEBRUARY 1993
�CONTENTS
Letter of Transmittal
1
Executive Summary
5
Missions and Perspectives
Mission Statement
Environment
Vision Statement
Planning Process Timeline and Activity
Priorities for 1993-94
5
5
6
9
10
11
Education
School of Medicine
Physician/Scientist Programs
Post Graduate Medical Education
Graduate Education in the Basic Sciences
School of Nursing
Allied Health Professional Education
Continuing Professional Education
13
14
14
14
15
15
16
16
Research
Interdisciplinary Programs
Core Technologies
16
18
19
Clinical Service
Performance Trends
Strategic Initiatives and Programs
Clinical Support Services
Cost-Effectiveness and Quality Measurement
Interdisciplinary Clinical Programs
Duke Health System
Clinical Facilities
19
21
25
26
27
28
30
30
Leadership
33
�Coordination within the University
Undergraduate Teaching, Graduate School, School of Engineering,
Fuqua School of Business, Combined Degree Programs, School of
the Environment, Divinity, Shared Resources, Health Services,
Management Services
34
Programmatic Initiatives
International Initiatives
Human Resources
Total Quality Management
Library Services
Office of Grants and Contracts
Office of Science and Technology
Information Services
Communications
Development
37
37
38
38
39
41
41
43
49
S
O
Resource Profile
Update on 1991-92
Facilities
53
53
56
Supporting Documents
Departmental Summaries
Education
Research
Index to Exhibits
61
61
84
92
96
�r
1
»
O
z
i
��LETTER OF
TRANSMITTAL
Dear Colleague:
The 1991 Long Range Plan emerged from a planning process designed to develop institutional as well as departmental goals and priorities. Furthermore, the plan began to articulate the
resource requirements necessary to pursue the stated goals. The 1993 Progress Report expresses
achievements in pursuit of targets contained in the 1991 Plan, identifies critical issues which have
surfaced during the past eighteen months, and identifies various managerial and programmatic
initiatives designed to position Duke Medical Center for continued success.
The modifications to the 1991 plan contained in this progress report form a base-case plan
and are derived from the best information and judgement currently available. Existing commitments and programmatic requests supporting our education, research and clinical missions exceeded the projections for available resources; therefore, priorities were determined by matching
current institutional strengths and weaknesses with strategic opportunities and threats. Difficult
choices were made regarding commitments to the number, timing and financial support of faculty
recruits, funding levels for core technologies and new initiatives, and the scope and configuration of
facilities.
What appears in the plan is less than requested in all areas but is, in the view of the Medical
Center leadership, compatible with our vision and ability to achieve it. Our investments are dependent on concurrence of University leadership and the Board of Trustees, on achieving stated revenue goals, and on the continuous monitoring of changing environmental needs. If financial goals
are not met or the environment changes adversely, faculty recruitment, investment in technologies
and the rate of facilities investment would be modified accordingly.
The February 1993 plan has a considerable portion devoted to the clinical mission. This
does not reflect a change in the balance of our core missions. It is, as reported to the Trustees and
University leadership, the consequence of the timing related to facilities planning, modification of
clinical services, and the development of a care delivery system responsive to rapidly changing
societal expectations.
�Since the presentation of the September 1991 Long Range Plan to the Board of Trustees, by
any objective standard, Duke University Medical Center has done exceedingly well.
In education, our School of Medicine is generally acknowledged by our peers and the press
to be amongst the nation's finest. Our position is reflected by a 20% increase in the number of
applicants to our medical school in the last two years, by our ability to select the best students, and
by our ability to place our graduates in the best residency programs. Likewise, our School of
Nursing has been revitalized by a new dean and faculty which has in turn led to inaeased applications for admission and research funding. Similarly, our Allied Health Professional Programs,
including the physical therapy and physicians assistant programs, continue to grow and develop as
providers of skilled professionals in short supply. Our PhD programs have been reorganized to
promote interdisciplinary studies and to recruit more high quality students to Duke.
In research, we have had remarkable success in recruiting outstanding junior faculty as
evidenced by our ability to secure our first choice from national searches in virtually all instances.
Our investment in superb research talent should pay important dividends in discovery and innovation during the next few years. We have continued to recruit the very best basic science
chairpersons who will enhance our national research position. We are among the top institutions
receiving NIH research funds and in the past year increased our funding by 2.5% or $2.4 million.
We are proud to be among the nation's leading recipients of clinical research funding from industry; collaboration with the public and private research sectors is a bulwark of scientific tradition at
Duke.
Our programs have been equally successful in the clinical arena. We have recruited outstanding clinical chairpersons and faculty who lead our patient-centered focus on clinical excellence. Our clinical practice plan and hospital performed well financially and created strategically
important capital that will allow us to modernize our clinical services and facilities and invest
further in critical infrastructures, such as information systems, which will better position ourselves
to meet the demands of a more competitive environment. Our clinical facilities plan, developed
after 18 months of intense data-gathering and market analysis, continues to be refined and will be
presented to the Board on a continuing basis.
With enhanced capacity on campus, we will continue our development of a Duke Health
System designed to fulfill our core mission and position Duke as a preeminent national and international medical center. We are indeed fortunate to have recently recruited Dr. Mark Rogers as the
Executive Director of Duke University Hospital and Vice Chancellor for Health Services, Mr. Steve
Sloate as Associate Vice Chancellor for Medical Center Planning and Ms. Vicki Saito as Assistant
Vice Chancellor for Health Affairs and Director of Duke University Medical Center
Communications.
�These successes are counterbalanced by the weight of a mammoth national health care
crisis. The high cost of care and lack of universal access are some of our greatest national concerns.
We are faced with impending major changes in the organization, delivery and financing of education, research and clinical service. As one ofthe nation's leading academic health centers, Duke
University Medical Center is capable of providing solutions to this national health crisis.
Since September of 1991, this medical center has inaeasingly focused on enhancing its
academic excellence as well as its responsibility in solving regional and national health care problems. Within our core missions of education, research and delivery of health care, we must refocus
our efforts to respond appropriately to the nation's need for accessible, cost-effective, quality health
care.
The February 1993 plan will further position our medical center as a strong contributor to
overall University goals and as a leader in solving regional and national problems while sustaining
our commitment to our core academic missions in education, research and patient care.
While the challenges are great, we believe the opportunities are even greater, and we have
never been in a better position to pursue them. In the plan that follows, we outline our progress
during the past eighteen months, the issues that currently face us, our goals, and the means to
achieve them. Our overarching goal is to be nothing less than an internationally preeminent
academic health center.
/ ^ t ^ ^ ^ ^ ^ m ^
Ralph Snyderman, M.D.
Chancellor for Health Affairs
Dean, School of Medicine
James B. Duke Professor of Medicine
�EXECUTIVE
SUMMARY
Missions and Perspectives
MISSION STATEMENT
The goal of Duke University Medical Center is to provide leadership in fulfilling its core
missions which are:
To provide the most advanced and comprehensive education possible; to
prepare our students and trainees for lifetimes of learning and careers as
leaders, practitioners, or researchers.
To perform biomedical research producing discoveries that add to understanding
life processes and lead to preventing and curing disease and maintaining health.
To translate, to practice and make available to the public, with compassion,
the benefits of the unique clinical and technological resources of the
Medical Center and to support our educational and research missions.
However, in our endeavors to improve human health and well-being through education,
research and patient care, we have the opportunity, and indeed the responsibility, to make a
positive and lasting impact on society. Duke University Medical Center has therefore taken the
bold step of broadening its mission statement in response to the increasing need to address regional, national and international health care problems. The following statement represents an
overarching mission of Duke University Medical Center:
To the maximum extent possible, we will apply our core missions in education,
research and health care delivery to develop the means to solve regional and
national health care problems, including providing accessible, cost-effective health
care of measurable quality.
�THE ENVIRONMENT
Anxious about skyrocketing costs, insufficient access to care and undue bureaucracy, the
American public has unequivocally placed health care at the top of the nation's agenda.
As a result, the subject of national health care reform has at last become inevitable. Each
day's headlines bring new evidence that change is imminent for American health care, as various
interest groups — physicians, insurers, hospitals, policymakers — soften, or even abandon, longheld positions and announce their own proposals for reform. But the certainty of change ensures
neither the effeaiveness of the reforms that are to come nor the ease with which they will be
enacted. As the new administration and Congress set about the difficult task of health care reform,
they should not overlook a vital resource in achieving fundamental, lasting change: the nation's
academic health centers.
Comprised of medical schools, other health professional schools and affiliated teaching
hospitals, academic health centers are in a pivotal position to contribute to solving the nation's
health care problems. Generally associated with major universities, they train virtually all of the
nation's physicians, nurses and other health care personnel; they perform the majority of biomedical research and clinical research; train the next generation of scientists; and they provide an
extraordinarily high percentage of hospital care, including a disproportionate amount of the care
for the indigent and the very sick. For example, while teaching hospitals represent only 19 percent
of all U.S. hospitals, they provide 47 percent of the nation's inpatient services, 49 percent of all
outpatient care, 41 percent of all emergency room care and more than 50 percent of charity care.
Similarly, reflecting in part the greater acuity of their patients, academic health centers generate 56
percent of all hospital revenues.
Traditionally, academic health centers have identified their core missions as education,
research and patient care. Until recently, we have not generally considered it a part of our responsibility to address the broader societal needs associated with our nation's health care system.
However, with the problems facing American health care today, academic health centers
must realize that, in addition to our traditional tripartite missions of teaching, research and patient
care, we must also assume responsibility for a broader overarching mission: to provide solutions to
our nation's health care problems. Inherent in the traditional missions of academic health centers,
and a consequence thereof, is a much broader need to develop the models for cost-effective, accessible, quality health care. If academic health centers do not focus on directly solving societal
problems, we will inevitably become part of the problem.
By recognizing and striving to fulfill this newly emerging responsibility, we expect Duke
University Medical Center to be a major contributor to improving our nation's health care system.
It is clear that in doing this our core missions will not change; however, the means by which we
carry out our commitment to education, research and patient care must change in response to the
environment and the opportunities. Meaningful and lasting change in health care delivery will
�require changes in the education of practitioners, enhanced opportunities for technology transfer
and information-driven changes in clinical practice designed to improve cost-effectiveness.
We are already working to define and implement effective strategies in each of our core
missions to deal with our emerging role as a leading academic health center. The inherent potential
for effecting meaningful change is readily illustrated in the Executive Summary and our plans for
modification in how we discharge our core missions noted in the appropriate sections.
The education, research and clinical service missions have traditionally relied on various,
reasonably predictable sources of revenue for stability. Prior to the 1970's, clinical service was
largely a means by which dedicated and compassionate academicians trained new physicians and
pursued knowledge; clinical service was not an economic necessity. The significant growth of the
clinical service component of academic medicine began in the late 1970's and has accelerated ever
since. Clinical service now comprises greater than 40 percent of revenue for medical schools on a
national basis. Increasing competition for the best students, research resources, and the faculty and
staff to pursue our vision has created a financial dependency on clinical income to sustain and
enhance our excellence in fulfilling our missions (See exhibits 1 and 2).
EXHIBIT 1
SOURCES OF SUPPORT-U.S. MEDICAL SCHOOL
100%
4%
13%
90%
•
Tuition & Fees
ffl State & Local Gov't
i l Development and
Endowment/Investment
Income
9%
80%
31%
70%
60%
50%
O Grants & Contracts
•
39.ff/o
40%
42%
30%
Faculty Practice & Hospital
Reimbursement
20%
10%
0%
FY60/61
NOTE: Actual 90-91 (Latest AAMC Data)
FY70/71
FY80/81
FY89/90
FY90/91
�COMPOSITION OF REVENUE
EXHIBIT 2
PERCENT
100 -j
90
• Tuition and Fees
80
ffl State & Local Gov't
70
• Development and
Endowment/Investment
Income
60
• Grants and Contracts
40
• Faculty Practice &
Hospital Reimbursement
-
30
50
-
20
10
0
NOTE: Actual 90-91 (Latest AAMC Data)
U.S.
Medical
Schools
Private
Schools
Duke
Medical
School
The 1990's will present us with significant challenges to clinical service revenue in the form
of much needed national health care reform and managed competition. The alignment of the
public's desire for change with corporate activism ensures that academic centers that survive the
turn of the next century will be those that provide accessible, cost-effective care of measurable
quality. Purchasers of care (e.g. state and federal government, large employers and group purchasing
cooperatives) are increasingly unwilling to pay a marginally higher price to academic centers in
support of education and research. While these purchasers are frequently the direct beneficiaries of
our discovery and innovation, we must modify our approach as providers to the maximum degree
possible, use our academic strengths to enhance our clinical efficiency yet also build alternative
sources of revenue to sustain our education and research missions.
While the federal and state governments will play the major role in developing health care
policy, governmental solutions alone are unlikely to be wholly appropriate or sufficient. Independent or collaborative approaches by health care providers, particularly academic health centers,
must play a substantial role in improving the nation's health care services and outcomes.
Outstanding leadership and substantial support services will be required to design and
develop the Duke Medical Center envisioned by the turn of the century. Talented, dedicated and
skilled professionals and staff serve as the core of our institution, and continued success in the
recruitment, motivation and retention of these increasingly scarce and frequently expensive people
�remains a management priority shared with all of the University. Duke Medical Center must strive
to provide employees with an environment that fosters innovation, provides management systems
that enhance resource productivity and rewards people based on their performance toward a clear
set of expectations. In addition, the Medical Center must achieve diversity at all job levels in its
workforce. When people and their support systems are aligned with institutional objectives, we
can make great strides toward our goals.
Academic health centers have long been in the business of creating solutions to complex
problems in patient care, education and research. Using these same skills, Duke must now reach
beyond its traditional missions and work to provide the solutions to the nation's health care
problems.
VISION STATEMENT
Great universities, through innovation and action, capture the imagination of their peers
and broadly influence entire fields at different times in their history. Duke University is entering
such a time and through the Medical Center, can and will have a profound impact on improving
health through education, research and patient care.
We envision Duke University Medical Center becoming an internationally preeminent
academic health institution recognized for the creative and energetic use of its academic resources
to educate and further our understanding of human biology and disease and to develop solutions to
societal health problems.
�Planning Process Timeline and Activity
Development of departmental plans
Jan-Mar 1991
Integration of departmental plans
into Medical Center goals and priorities
Apr-June 1991
Consensus Building and Document Production
July-Sept 1991
Medical Center Policy Advisory Committee
(MedPAC) Ratification
Aug-Sept 1991
Presentation to Board of Trustees
Sept 27, 1991
Implementation, Monitoring and Evaluation
Nov 1991-Nov 1992
Updated Presentation to DUMC Faculty
May 1992
Approval by Buildings and Grounds Committee of
project planning for Specialty Clinic, Parking Deck
replacement and Duke North Addition
Sept 1992
Updated Report to Davison Club Members
Oct 1992
Updated Report to Medical Alumni and Council
Nov 1992
Updated Report to DUMC Faculty
Nov 1992
Report Progress and Update Departmental Plans
Nov-Dec 1992
Preliminary 1993 Plan Report to Board of Visitors
Dec 1992
Report Progress and Develop 1993 Medical Center Plan
Dec 1992-Jan 1993
Consensus Building
Dec 1992-Feb 1993
Coordinate with Duke University Master Plan
Oct 1992-Jan 1993
MedPAC Ratification of 1993 Progress Report
Feb 1993
Present 1993 Progress Report to Board of Trustees
Feb 1993
Request for approval by Buildings and Grounds Committee
of project planning for primary care facilities
Feb 1993
Continue to Monitor Long Range Plan
Ongoing
Design and Implement a Strategic Management
and Planning Process for Medical Center Departments
and Operating Units
Mar-Sept 1993
10
�An important new element of our planning process is the participation and review by the
Medical Center Board of Visitors. Formed last year, the Board of Visitors is composed of members of
the University Board of Trustees and DUMC alumni, national leaders in science, biotechnology,
academic medicine, and business. The Board of Visitors will become a key advisory and critical
resource for the leadership of the Medical Center. This advisory group is available as a source of
informed opinion for the Board of Trustees and the President as well.
One of the key success factors in moving toward a strategic management process will be the
close coordination of the Medical Center process with that of Duke University as a whole. The
interdependencies that exist in such areas as interdisciplinary program development, facilities
planning, information services and a wide range of management services necessitates open communication and the solid coordination of planning efforts and outcomes.
From the perspective of the Board of Trustees, the Medical Center's Plan is intended to
provide information, enumerate strategic issues, discuss future directions, and mark progress over
time. Any specific initiatives brought forward in the Plan that require Board approval or action will
be processed through standing Board committees according to established procedures.
PRIORITIES FOR 1993-1994
Education
• Revise the Medical School curriculum to satisfy thc needs of practitioners and clinicianscientists into the 21st century
• Improve, expand, and financially stabilize graduate basic science training
• Continue to strengthen and enhance the graduate nursing school
• Identify new leadership for continuing medical education and adopt programs to meet
regional and national needs
Research
Recruit outstanding new basic science chairs and faculty identified in the plan
Increase external grant support and financial reserves for the basic sciences
Enhance clinical research trials and their support systems
Develop an internationally prominent human genetics initiative in both basic and
clinical sciences
Enhance technology transfer
Improve core technologies and other research support systems
Expand interdisciplinary programs bridging basic and clinical sciences
11
�Clinical Services
• Recruit outstanding new clinical chairs and faculty identified in the plan
• Enhance clinical services for patients and referring physicians
- Reauit a Director of Human Resources
- Continue to implement model workplace initiative (e.g. Total Quality Management
[TQM], the Gallup Survey and the Training Program)
- Enhance the management infrastructure with an emphasis on information systems
- Support multidisciplinary clinical initiatives
• Respond to needs for accessible and cost-effective health care of measurable quality
- Implement cost saving strategies
- Enhance patient care management efforts
- Foster clinical evaluative sciences (e.g. outcomes research efforts and the development
of standards of care)
• Development of integrated Duke Health System
- Enhance primary care capacity and quality
- Develop home care capabilities and capacity
- Establish comprehensive managed competition strategies
- Implement a marketing plan
• Clinical facilities planning completion for:
- Replacement of outdated subspecialty clinics
- Expansion of primary.care clinics required to serve Duke Health Service and respond to
managed care initiatives
- Inpatient renovation including the Children's Hospital
Financial Resources
• Establish focused development efforts for major capital initiatives
• Enhance cost-effectiveness of clinical programs and continue to build resources for
clinical operations
• Strengthen corporate collaborations and technology transfer
• Establish a more proactive approach to competing for external grant support
12
�Education
SCHOOL OF MEDICINE
Education is a core mission of Duke University Medical Center, and the need for Duke
University to educate physicians was clearly expressed in the Duke Indenture. Duke Medical School
is considered to be amongst the nation's finest. For three years in a row, U.S. News & World Report
has ranked Duke among the top three medical schools in the country, placing us in excellent
company with Harvard and Johns Hopkins. Historically, our medical school has trained leading
academic physicians, physician-scientists and specialists.
The explosion of scientific knowledge and changing societal needs have begun to reshape
our programs. Our curriculum must inaeasingly balance the need to train the outstanding physician-scientists, academicians and specialists for which we are nationally renowned with societal
needs to expand the supply of generalists. Our medical school graduates must be prepared to
practice cost-effective medicine with more emphasis on disease prevention. And our students and
faculty must better reflect the diversity of this nation. In all categories, the nation demands people
dedicated to the provision of accessible, cost-effective care of measurable quality who are prepared
for a life-long learning process.
•\
Duke has a unique medical school curriculum that provides total integration of medical
practice with medical science and produces life-long learners. The first year covers the basic sciences and an introduction to clinical arts, and the second year contains required clinical clerkships
in various areas of medicine. In most other medical schools, the first two years are devoted to basic
sciences. The third year at Duke is reserved for scholarly research and additional science
coursework, and the fourth provides a series of clinical electives. A distinguishing feature of the
Duke curriculum is the constant interweaving of the basic and clinical sciences which permits the
student to integrate earlier and more fully thc art and science of medicine. The other is thc emphasis on and time available for scholarship.
Under the leadership of Duke's new Dean for Medical Education, Dr. Dan Blazer, an effort to
increase the students' understanding of the disease process by the use of standardized patients in
the first year clinical arts program was further developed last year. Small groups of medical students
and a team of clinical and basic science faculty investigate a series of standardized patients in terms
of clinical diagnosis, treatment, and basic science. Standardized patients are trained to simulate the
symptoms of specific diseases as well as the human anxieties associated with diseases. This provides
first year students with an immediate introduction to both the human and diagnostic aspects of the
practice of medicine. With the assistance of a grant from the Macy Foundation, and in conjunction
with three other North Carolina medical schools, a standardized clinical evaluation experience has
been introduced at the end of the second year. A pathophysiology course, designed to consider
medical problems in terms of basic science, has been introduced in the third year.
13
�A core curriculum is being developed for the first year that will integrate the basic sciences
and clinical praaice. This should be ready by Spring or Fall 1994 and will be coupled with a systematic procedure for evaluating first year instruction. The second year curriculum will be reviewed
to improve training in ambulatory and primary care. Third year study will be better integrated with
basic science research and will expand to include human population health and epidemiology. This
expansion reflects Duke's desire to train more primary care physicians who are skilled in carrying
out clinical research responsive to national needs. We have recently begun an initiative to foster
the teaching of cost-effectiveness, preventive medicine and other socially relevant content in our
medical and postgraduate medical training.
PHYSICIAN-SCIENTIST PROGRAMS
The Medical Scientist Training Program (MD/PhD) at Duke has been rated by NIH as one of
the best in the country. Physician-scientists with MD/PhD training play a key role in bridging basic
science discoveries and clinical practice. The 32 students in the program are among our very best
medical and graduate students and represent future leaders in medical research. Because of the high
quality of the pool of students available (300 applicants for 5 places), we are seeking to expand this
program and have submitted a proposal to the Markey Charitable Trust for this purpose.
POST GRADUATE MEDICAL EDUCATION
DUMC's reputation as a leading academic health center is in part based upon its excellent
postgraduate medical education programs which train medical school graduates in their chosen
specialty. The outstanding residency and fellowship programs that have characterized Duke for
many years continue. There are currently 880 residents and clinical fellows in 11 clinical departments, and all residency and fellowship programs successfully passed accreditation review. Recognizing that graduate medical education programs are decentralized, the Office of Medical Education
will work with residency training directors to ensure minority representation and recruitment as
well as to assure that programs comply with the standards of the Medical Center and hospital. In
addition, the office will explore ways to help graduate trainees become better educators of medical
students. In addition, the Dean's Office is exploring ways to develop core curricula regarding
general contemporary medical issues such as medical ethics and cost-effectiveness.
The Biometry Training Program was developed to meet the need for formalized academic
training in the quantitative and methodological principles of clinical investigation. Designed
primarily for clinical fellows and other physicians who are training for academic careers, the program consists of an integrated sequence of courses in research data management, study design and
biostatistical methods. Participants take one course at a time in a 10-month academic year consisting of three terms, allowing the learner to integrate the program's academic training with his or her
clinical training. The program consists of two tracks: a degree option leads to a Master of Health
Sciences in Biometry, a professional degree awarded by the School of Medicine; a non-degree option
is available to qualified individuals who want to acquire specific skills but who do not want to
pursue the master's degree. The program is offered by the faculty of the Division of Biometry and
14
�Medical Informatics in the Department of Community and Family Medicine. Implemented in
1986, the program graduated Its first cadre of clinician-scientists in 1989. Presently, there are 75
active participants in the program, 20 of whom are degree candidates.
GRADUATE EDUCATION IN THE BASIC SCIENCES
An outstanding graduate program in the basic sciences is necessary to train the next generation of biomedical researchers, to produce research that sustains leading edge medical care, and to
recruit and retain outstanding faculty. Last year, the graduate program was reorganized to improve
access to the highest quality students and to inaease their numbers to balance the inaease in the
number of research faculty. Reauiting outstanding graduate students is vitally important. A coordinating committee has been formed consisting of representatives from Medical Center basic science
departments, University training programs, and the University outside of the Medical School. This
committee will share and coordinate recruitment information that will result in a more unified
piaure of Duke to prospective students. In addition, students will now be able to move freely
between departments, and clinical faculty will have better access to secondary appointments in the
basic sciences. To further integrate the basic sciences, plans include continuing improvement of the
admission process, presenting research programs through a graduate student day, and having
faculty from many departments present courses to the entire student body. Because graduate
students are essential for our outstanding research programs which will expand with the addition of
new faculty, the number of graduate students should also increase from about 260 to 375 by 1998
to maintain a student faculty ratio of about two. This will require inaeased financial support for
graduate students. Consequently, DUMC seeks to establish a 20 million dollar endowment fund by
the year 2000 for this purpose. Thus far, about one million dollars has been identified to start the
endowment. At present, the largest source of funds for graduate student support in the first two
years is tuition payments from NIH training grants, but these grants at present provide less than one
million dollars per year and are not keeping pace with inflation. Therefore, we will need to increase the number of NIH training grants. Approximately two million dollars will be required to
maintain the desired steady state. Expansion from the current level will be dependent on the
acquisition of additional training grants and/or endowments. After their first two years, graduate
students are normally supported by faculty research grants.
SCHOOL OF NURSING
Dedicated to advancing nursing science and practice, the Duke School of Nursing enhances
both our medical care and research capabilities. In response to societal needs, new clinical areas of
specialization are being added that are essential for primary medical care. In 1992, the school
began Geriatric Nurse Practitioner and Pediatric Nurse Specialist programs and developed clinical
rotations for rural and other underserved sites. The strong academic programs at the Master's level
will provide the infrastruaure for a doctoral program in nursing. As evidence of the school's
growing reputation, enrollment has increased from 60 (32 full time equivalents) in 1991 to 122 (50
full time equivalents) in 1992 and minority enrollment inaeased from 3% to 9%. Enrollment is
projected to inaease to 75 full time equivalents over the next three years, with a goal of 10%
15
�minority students. This will require more endowment for student financial aid. This need has been
incorporated into our development plan.
ALLIED HEALTH PROFESSIONAL EDUCATION
Training allied health professionals continues as a high priority. These allied health professionals serve as physician extenders for primary care in rural settings as well as vital members of the
tertiary health care team. Perhaps the best known of our allied health programs is the highly
competitive Physician Assistant Program which was the first of its type in the nation. This program
has over 900 alumni, half of whom are employed in primary care specialties. The Graduate Program
in Physical Therapy, which offers the MHS, is equally renowned, and admission is very competitive.
The possibility of offering a PhD is being explored. A new masters level Program in Transfusion
Medicine enrolled its first students this past summer.
CONTINUING PROFESSIONAL EDUCATION
Medical education should be a life-long process of continually acquiring new knowledge.
Practical application of medical advances requires health care practitioners to keep abreast of recent
developments, and state licensing boards are increasingly requiring physicians to certify continuing
medical education (CME). In response to this need, Duke will enhance its CME program. The
retirement of the Associate Dean for Continuing Medical Education in 1992 provided the opportunity for reevaluating current programs. An external review was conducted in December 1992 of the
overall CME program to advise Medical Center leadership regarding the qualifications and role of a
new Associate Dean for Continuing Professional Education. A national search for a new Associate
Dean for Continuing Professional Education who has a record of commitment and success in
continuing medical education is underway. Current CME resources will be reviewed in order to
develop a program that is better integrated into the Medical Center and its outreach networks.
Research
Academic health centers remain the fountainhead of discovery and innovation in health
care. The acquisition, validation and transfer of knowledge and technology provide us with tremendous challenges. We are faced with the need to balance the pursuit of basic science with the
increasing need for mechanisms to identify practical applications and transfer research discoveries
to beneficial use via public and industrial collaboration. We must design mechanisms to allow our
basic and clinical scientists to have their discoveries translated to maximum human benefit without
sacrificing their primary academic efforts.
While Duke remains one of the top research centers in the country (See exhibit 3) competition for public and private grants and contracts has inaeased in the face of a plateauing of the total
money available. The growth of interdisciplinary research programs, enhancement of research
16
�support activities, and the focusing of research efforts in areas of national priority will continue to be
the attributes of a successful research enterprise. The collaborative establishment during the past
year of a university-wide Office of Science and Technology to facilitate the transfer of medical and
non-medical discoveries into commercial applications will be a key success factor as it becomes a
predictable source of revenue. Expansion of our funding from industry and foundations for basic and
clinical research from 60 to 100 million dollars over the next five years is planned (See exhibit 4).
NIH EXTRAMURAL AWARDS
Direct Costs Only
1987
1988
1989
1990
1991
1992
• Contracts, Research, Training Grants H] Research Grants
I
EXHIBIT 4
GRANTS AND CONTRACTS
Millions
160 ,
Projected
Actual
140
120
100
80
60
40
20
0
H
8788
8889
8990
9091
9192
9293
Industry & Foundations Direct &
Indirect Costs
17
9394
9495
9596
9697
Federal Direct & Indirect Costs
9798
�INTERDISCIPLINARY PROGRAMS
Research artivities at the Medical Center run the gamut from very basic to applied medical
practice. The aim is to facilitate the transfer of knowledge among individuals who span the basic
and clinical sciences. This requires highly interdisciplinary research. The flow of information
necessary for improving medical treatment begins with basic research and progresses through
clinical research to patient care in the clinics. This progression is an important societal need.
Interdisciplinary research requires a matrix organization across a variety of organizational units.
Important examples of interdisciplinary research includes genetics, signal transduction, neurosciences, immunology and structural biology.
Genetics — Genetics spans the basic and clinical sciences. The Section of Genetics has hired
several new faculty and is involved in the recruitment for a senior position in the Howard Hughes
Medical Institute that will have an outstanding research program in animal/human genetics. In
addition, the Department of Surgery has recruited Dr. Eli Gilboa, who is internationally recognized
for his work in the field of genetic therapy. This important area of genetics will continue to develop
with new appointments in animal/human genetics and by establishing a Human Genetics Program.
There will be cross appointments between the clinical and basic sciences. A specific area to be
developed is the use of transgenic animals as models for human disease to permit determination of
specific gene function (gene knockout experiments). To this end, an extensive transgenic animal
facility is being planned.
Signal Transduction — Signal transduction is the study of how cells become activated in
response to environmental signals. It is a broad important area that covers a large portion of
modern research in the medical sciences. Thus, every basic science department has some members
that carry out research in this area. As evidence of our increasing strength in this research, NIH has
just approved a graduate student training grant in Cancer Biology that will span the University but
will be of special importance to the Section of Cell Growth, Regulation, and Oncogenesis and the
Department of Pharmacology.
Neurosciences — The neurosciences remain on the frontier of both the basic and medical
sciences and will continue to be a focus for the Medical Center. Neuroscience spans many departments but is particularly appropriate for thc Departments of Neurobiology, Pharmacology, Psychiatry and Radiology, and the Division of Neurology in Medicine. Plans call for faculty to be hired in
these areas. Progress can be measured by research grants and publications. For example, in the
Department of Neurobiology, grant support increased from about 1.5 million dollars in 1990 to over
2.5 million dollars in 1992, and publications increased from about 37 to 47 per year over the same
period.
Immunology— Immune system research is important in both basic and clinical research and
is highlighted by its relevance for AIDS, transplantation and vaccine development. With the
recruitment of a Chair for the newly formed Department of Immunology, additional new faculty
and expertise can be anticipated. During this year, significant progress has been made in develop-
�ing vaccines for AIDS, and the Medical Center is considering the possibility of launching a brand
new initiative in the human vaccine area. Organ transplantation capabilities also have been enhanced both in clinical activities and basic research. With the Inaeasing impact of AIDS, the many
autoimmune diseases, and continuously improving capabilities for organ transplantation, immunology remains a focal point for research at the Medical Center.
Structural Biology — The importance of structural biology in understanding the molecular
basis of biologic processes cannot be overstated: the relationship of structure to function is key to
designing new treatments of disease. During this past year, an X-ray crystallography center for the
determination of macromolecular structures has been successfully established. A Center for Macromolecular Structure, including X-ray crystallography, nuclear magnetic resonance, and molecular
graphics will be placed in the Levine Science Research Center (SRC). This facility will be headed by
Dr. Leonard Spicer and will serve the entire University. In addition, there are important developments in the use of electron and light microscopy in several departments, and research in the
Department of Radiology continues to improve our imaging capabilities. Structural biology will be
a key long term element for both research and medical care.
CORE TECHNOLOGIES
Core (shared) technologies are essential as no single investigator, or even department, can
afford to invest in the technology necessary for high level research. The Medical Center has heavily
invested in core technologies and launched new initiatives. The Cancer Center has been instrumental in this process. Together with the Department of Chemistry, we are planning to improve
our capabilities in mass spectrometry with a unified facility. This technique is proving to be essential for the molecular analysis of proteins and their biological modifications. Plans are underway for
an expanded transgenic animal facility for genetic research that would serve the entire campus.
This facility will probably be located in the Levine SRC. The use of transgenic animals in research is
rapidly increasing and will be important in all areas of biology, as well as in the School of the
Environment for toxicology studies.
Clinical Service
Delivery of health care is a core mission of Duke University Medical Center and is also
necessary for the pursuit of the institution's education and research missions as well as for intrinsic
societal good. Without a robust clinical service we could not train medical students, nursing students or postgraduate learners nor could we perform much of our biomedical research. Health care
delivery also provides a substantial portion of the total revenue needed for further investments in
education and research. Given the medical center's financial dependency on clinical activities as
well as the societal need for the health services we provide, we must remain keenly aware of changing demand for different delivery models.
19
�To reduce the cost of health care, purchasers (e.g., insurance companies and employers of all
sizes) are organizing into public and private purchasing cooperatives in search of comprehensive
regional systems designed to manage care using innovative insurance mechanisms which transfer
financial risk to the provider. This form of managed competition is a cornerstone of national and
state health reform initiatives targeted at reorganizing the delivery of health care. The public's will
for change along with corporate activism to reduce costs will likely reshape the health care landscape in profound ways. Anticipated needs are as follows:
1. The provision of accessible, cost-effective care of measurable quality.
2. The development of standards of care based on prospective outcomes researchessentially, research into what treatments work best.
3. The packaging and pricing of services that span the entire continuum of care,
including services from physician group practice, ambulatory, in-patient and
homecare— the "one-stop-shop."
4. The provision of primary care services in convenient locations.
5. The cost-effective use of specialized diagnostic and therapeutic treatment modalities.
6. The economic justification of new technology based on actual cost-benefit
comparisons that consider dimensions such as thc quality of life.
7. The presence of a Total Quality Management philosophy with demonstrable results.
8. The ability of a health system to provide total care to sizable populations on a capitated
basis, i.e., in exchange for a fixed amount of money per person, per month. All services
provided to the patient would be funded by that fixed pool of premium dollars.
Medical Center leadership must ensure the integrity of our academic missions while competing successfully in a vastly different marketplace over the next several years. This will require the
restructuring of our health care delivery system to meet societal needs for the cost-effective accessible delivery of health care. The cultural fabric of the institution will be tested in ways that challenge our substantial capital and intellectual resources. Creativity and agility will be the hallmarks
of academic institutions that anticipate and adapt to the rapidly changing clinical marketplace.
20
�PERFORMANCE TRENDS
Several statistical indicators support a recent but accelerated movement toward managed
competition in what has been a fragmented buyer's market. Our volume of ambulatory visits
continues to grow at an average annual rate of greater than four percent. The continued migration
of inpatient admissions to the ambulatory environment has been driven primarily by innovative
technology such as our pioneering Bone Marrow Transplant program at Duke which has taken an
expensive inpatient procedure with a long length of stay and moved it into the ambulatory care
setting at a fraction of the cost. Furthermore, significant reimbursement pressure will accelerate the
need to move more patients out of expensive inpatient beds into ambulatory and homecare settings.
We expect the ratio of clinic visits required to sustain the projected level of hospital discharges to
increase considerably from the historic rate of approximately 16 visits per discharge. We also expect
to see a continued decline in the average number of days that a patient stays in the hospital. The
average length of stay has dropped 6.6 % from 9.1 days in 1988 to 8.5 days in 1992 (See exhibit 5)
and is projected to fall to 7.0 - 7.5 days over the next five years. At some point, length of stay will
begin to rise because only very complex patients, e.g. transplants, trauma and other cases utilizing
intensive care units, will require inpatient care .
More than just the loci of care delivery are changing. Duke is beginning to experience
changes in the composition of the referral markets and the payor mix within those markets. There
are early indications of a geographic contrartion in the referral base: fewer patients are coming to us
from the secondary and other service markets. (See exhibits 6, 7A and 7B). Furthermore, the payor
mix of those markets is changing as purchasers move away from the traditional indemnity insurance
products to managed care or negotiated volume discount arrangements. Our loyal referring physicians may be increasingly restricted from referring patients by aggressive managed care organizations
unless we are participants in a preferred provider organization. This is evidenced by the fact that
while Duke Hospital has a very effective billing and collection process, for a time we experienced
higher deductions from gross revenue due in part to mandated and negotiated reimbursement
arrangements that pay less than our charges. Fortunately, this trend has stabilized (See exhibit 8).
21
�EXHIBITS
Discharges
HOSPITAL VOLUME TRENDS
Patient Days
(Thousands)
(Thousands)
36
r 304
35
302
300
34
298
33
296
32
r
- 294
31
Patient Days
292
Note: Excludes aJI neonates.
30
Avg. Length 1988
of Stay (Days) 9.1
290
1989
9.2
1990
9.1
22
1991
1992
8.6
8.5
�Duke University Medical Center Service Area Definition
Primary Service Area
Secondary Service Area
Source:
DUMC Outreach Department
�LXH1BIT 7A
D S H R E BY SERVICE A E
ICAGS
RA
FISCAL YEARS 1988 • 1992
18,920 18,861
Primary Svc Area • Counties within a 1 hour drive
Secondary Svc Area • Counties within a 1-3 hour drive
Other Svc. Area - Other NC counties and out of state
NOTE: Percentage in bar represents each market
area's share of the total for that fiscal year
"SB
B
.
9 8 2
9.1B0 » . «
5
8 1 1 8
"
,
n
8,820
7
7.528 - " 9
PRIMARY
SECONDARY
1988 •
1989 •
7,760
OTHER
1990 ED 1991
1992
KXHIBIT 7B
TOTAL DISCHARGES BY PAYOR
Discharges
FISCAL YEARS 1988-1992
in nnn -r"*"
17842
ID.UUU J
, —
„
1 6 8 M
6M6
7121
8125 6068
3651
17S 17% 1B%
m
WM
BC/COMM
MEDICARE
H
1988 •
1989 •
MCAID/ST
1990 •
1991
M 1992
NOTE: Percentage in bar represents each payor's share of the total for fiscal years 1988-1992
24
2592
1963 1829
7% 6%
SELF
1761
�EXHIBITS
DEDUCTIONS FROM REVENUE
30% T
24.80%
25.20%
26%
25%
20.80%
20%
15.60%
15% "
DEDUCTIONS FROM REVENUE: CONTRACTUAL ADJUSTMENTS (MEDICARE, MEDICAID, ETC.),
CHARITY CARE AND PROVISIONS FOR UNCOLLECTIBLE ACCOUNTS
10%
1988
1989
1990
1991
1992
STRATEGIC INITIATIVES AND PROGRAMS
Taken together, these performance trends indicate that strategic initiatives and programs
articulated in the 1991 Plan and furthered in this Progress Report are critical to the continued
success of the clinical enterprise in support of the academic missions.
Duke is nationally recognized as an outstanding medical care provider. The faculty and staff
of Duke University Medical Center have performed exceptionally well in clinical operations. In the
most recent of U. S. News and World Report's "Best of the Best" issues, published June 15, 1992, the
surveyed physicians cited Duke University Hospital for excellence in four specialties: geriatrics,
gynecology, orthopaedics and urology. In addition, 69 Duke physicians were listed in The Best MDs
in America. And for two consecutive years, Coping magazine, a publication written for and about
cancer patients, has named Duke as the best place in the United States to get treatment for cancer.
Nonetheless our quality of service to patients and referring physicians needs substantial improvement. Our ambulatory appointment scheduling and billing systems need integration. Our parking
is insufficient and our clinics are poorly accessible, overcrowded and spread throughout Duke South
Hospital and various parts of Durham. Our capacity to deliver primary care is inadequate to meet
current needs and far less than what will be needed in the near future.
25
�CLINICAL SUPPORT SERVICES
Amongst our highest priorities in the clinical area is to enhance the quality of our patient
and referring physician services, e.g. to provide the finest health care in an easily accessible, userfriendly environment. We have identified the need to improve our systems in appointments,
consultation and billing and to enhance service to consumers as well as our ability to transmit
clinical information to patients and referring physicians on a timely basis. To meet these objectives, we need a better trained, highly motivated workforce and the information system infrastructure to allow more efficient appointment, consultation and billing systems.
The ability of our workforce to deliver efficient patient oriented service requires far more
effort towards training, communications, and a more motivational working environment. Enhancing overall clinical service and efficiency is a necessity and therefore a high priority. Because the
Medical Center's workforce will be a critical factor in achieving that vision, an increased emphasis is
being placed on human resource issues. In short, we are committed to making the Medical Center a
model workplace, and to achieve this goal several initiatives were begun.
In November 1992, the Gallup Organization was commissioned to conduct a comprehensive survey to identify specific areas of employee concern and needs. This information will allow
more focused efforts to improve the working environment. In addition, because of the special
human resource requirements for a medical institution, a Human Resources function will be established within the medical center and will be fully integrated with the central Human Resources
office.
Total Quality Management (TQM) is being implemented throughout the Medical Center
with initial emphasis in the clinical services. TQM is a process which we are currently using to
ensure the development of the highest quality care at the lowest appropriate cost to our patients.
At its core, it uses the creative energies of all of our Duke employees by developing an interactive
process that enables the knowledge and experience of the employees to be put to its best use. TQM
represents a fundamental change in management philosophy in that it strives to develop a customer driven organization which recognizes that continuous quality made through team behavior
will increase resource productivity and lower costs. We have experienced progress in the form of
several Quick Start pilot projects in Cardiovascular Services and the Referring Physician Database.
The TQM approach is bolstered by the continued national leadership of Duke in the area of the
clinical evaluative sciences: Caremapping for different types of patients and superb progress in
methodologies for measurement of clinical outcomes as evidenced by having won two of the
thirteen national PORT project grants from the federal Agency for Health Care Policy and Research.
We have initiated several enhanced training initiatives including a 20 hour course for all
managers and supervisors designed to facilitate their ability to educate and support our workforce.
We have also engaged outside consultants to provide guest services training for our front desk
employees. We see these measures as a way not only to provide better and more cost-effective
health care, but also as a way to give employees opportunities to grow and develop and to make
their work experience more rewarding.
26
�The Medical Center's information systems will evolve in close coordination with those of
the University, particularly with respect to the backbone network and the institutional database (see
Information Services section of this document). However, the Medical Center will continue to
Invest in the development of the management and information infrastructure required to support a
large, complex organization with multiple missions. The information services required to serve the
growing need to support our appointment, consultation, billing and clinical information needs as
well as to monitor academic productivity, measure the cost and quality relationship within the
clinical services and general management programs only begin to highlight the complexity of our
organization. To serve these needs, we've reauited Landen Bain, a proven information and computing specialist, to direct our information services. We've assembled a clinical services task force,
now led by Dr. Mark Rogers, key clinical chairmen, and other high level administrators, to identify
and prioritize areas for rapid change to improve our clinical operations. We are achieving "buy-in"
for needed change by large groups of clinical faculty, nursing and other key stakeholders.
Because these goals are at the heart of so many improvements we expect to make at Duke
University Medical Center in the years ahead, we have committed significant resources and energy
and fully expect to see real progress in these areas.
COST-EFFECTIVENESS AND QUALITY MEASUREMENT
Over the past four years, concerted efforts were made to reduce needless expenses at Duke
Hospital. During this time, the rate of growth of expenses has been reduced from 14% per year to a
current rate of less than 6%. Coordinated budget planning processes between hospital officials and
users (i.e. clinical practitioners, laboratory personnel) are being developed to better align resource
needs with expenses. The ongoing installation of cost accounting systems for the Hospital and
Medical School will greatly enhance our ability to understand and manage current patterns of
resource consumption. We must lower the total costs of the services provided to all customers.
These and other resource productivity measures are key success factors in optimizing research
overhead recovery, pricing clinical services and negotiating managed care contracts.
Care mapping strategies designed to enhance the efficiency of patient management in the
hospital has been implemented in selected units and is being expanded. We will markedly inaease
our use of information to develop continuous evaluation of diagnostic and therapeutic interventions with outcome. Our participation in the Academic Medical Center Consortium provides the
opportunity for information exchange on clinical outcomes data amongst 12 leading academic
medical centers. This will allow the development of ever-improving standards of care as well as
reduction of cost. The length of hospitalization is a key factor in hospital costs and the development of a home care entity will allow more rapid discharge to the more desirable and cost-effective
home environment for those who need it.
27
�INTERDISCIPLINARY CLINICAL PROGRAMS
Multidisciplinary approaches to medical care vastly improve quality, service and efficiency,
and we have made significant progress in developing multidisciplinary programs and centers in the
past eighteen months.
The Aging Center won grant support to create the Claude Pepper Center for research on
aging, implemented a gerontologic nursing program, engaged a research program on the natural
history of depression, and competed successfully for funding for the Duke Older Americans Independence Center.
The Heart Center continues to pioneer new invasive cardiology procedures, has expanded
the number of mobile catheterization labs to two and expanded mobile echocardiography service to
outlying areas. A fourth interventional lab has been opened to support growing service volumes.
Duke continues to serve society with the largest international mortality study in cardiovascular
disease. Two new interdisciplinary programs have just been initiated within The Heart Center, one
is the vascular program and the other is adult congenital heart diseases. Cardiac services for children
have been enhanced by the recruitment of Dr. Arthur "Tim" Garson, the new chief of Pediatric
Cardiology.
The Comprehensive Cancer Center was named number one among all United States Cancer
Centers by Coping Magazine, recognizing the outstanding care provided to cancer patients and the
innovative support programs provided by volunteers, recreation therapy, oncology social work and
the cancer care consortium. A 26 bed residence, the Caring House, has been opened on Pickett Road
to facilitate outpatient cancer care. The Bone Marrow Transplant program provides national prominence as it continues to pioneer lower cost applications in devastating diseases such as breast
cancer. With advances in technology, it has been possible to provide care immediately post transplant to patients at an outpatient facility on Hillandale Road, reducing the cost of transplantation.
More than 750 bone marrow transplants have been performed at Duke over the last eight years.
Organ Transplantation services will benefit from the ongoing development and appropriate
resourcing of a Transplantation Center. The recruitment of Dr. Jeffrey Piatt, a national leader in the
immunology associated with xenographic (cross-species) organ transplantation, should catalyze
further the stellar science for which Duke is renowned. For example, in November 1992, a 22 year
old man was kept alive with the use of five pig livers until a donor organ could be identified. A
suitable liver was located five days later and implanted. This patient left the hospital in good condition a few weeks later.
I or the past several years, the medical leadership has considered the question of how to
improve children's services. Patient care is currently provided at locations that are widely scattered
throughout the Medical Center. This configuration is neither efficient nor user-friendly. Service
28
�would be far better provided in a facility that consolidates all outpatient and inpatient children's
services. Moreover, it is appreciated that there is no children's hospital in the entire state of North
Carolina. The Medical Center is committed to putting in place such an entity at Duke. The challenge that we face, however, is how to provide for a children's hospital while planning what is likely
to be a deaeasing need for beds in Duke Hospital in general.
The organization of the Human Genetics Program remains one of our highest priorities.
National competition for the relatively scarce and appropriate leadership is intense but we are
developing the resources needed for a major program in this area which will significantly impact
the practice of medicine early in the next century
Wellness programs have expanded rapidly during the last two years and are generating
greater interest and support than ever before. Combining clinical service with intensive investigation, the Center for Living is now the focus of research into stress management, mechanisms of
congestive heart failure, cardiac disease among young women, peripheral vascular disease, and
behavioral medicine. In addition, the Center collaborates with the Sarah Stedman Center for Nutrition Research in treatment of patients and research in lipids, bone density, and estrogen replacement. Nearly 30 clinical trials are now underway, funded by food and drug companies as well as
the NIH and philanthropy, and more are being initiated.
The Medical Center continues to extend prevention and wellness services to the greater
Durham community Through its clinical departments, Duke participates actively in the programs of
the City of Medicine, the Lincoln Community Health Center, and other community organizations
sponsoring ongoing or special activities and performing various health-screening services, from the
elderly (prostate cancer) to the very young (PKU testing of babies). (PKU is a metabolic disorder that
can cause server mental retardation when left untreated.)
The Division of Occupational and Environmental Medicine in the Department of Community and Family Medicine coordinates the Live for Life program that serves all Duke employees. The
department's Diet and Fitness Center now serves an average census of 80 to 100 patients year
round, providing services focused on lifestyle change as well as weight loss. Many of the Center's
patients come with chronic illnesses (e.g., hypertension) related to their lifestyles, and about onethird are able to change their lifestyles enough to give up medications. The Center will pay off its
mortgage at the end of this year, and it will then be able to launch studies of metabolic rate and
body composition now being developed. In addition, the Center is now conducting a quality of life
study funded by George Grune and the DeWitt Wallace Fund.
The Duke University Clinical AIDS Program has its primary research affiliation with the Duke
Center for AIDS Research. These collaborations have generated three Duke-based clinical protocols
which were developed as extensions of scientific observations made in Duke laboratories. Clinically, we will continue to provide outstanding care to almost 700 HIV-infected persons, many of
whom participate in various clinical trials as they become available. DUMC recently founded the
North Carolina HIV/AIDS Consortium and has applied for funding in the Women's Interagency
HIV Study.
29
�DUKE HEALTH SYSTEM
The rapidly changing environment combined with our own innovative growth in the
number and types of services available clearly point to the need to design and develop a more
integrated approach to health care delivery. We must become a regional provider of cost-effective
care to sustain our missions in an environment of managed competition. Investigating our relationship with various health insurance products, re-organizing our approach to contracting with
managed care entities, developing the necessary local and regional clinical service capacity and
managing the complex relationships required to sustain a Duke Health System (DHS) will dominate
our clinical strategic thought in the immediate future and are essential if we are to flourish financially.
The Duke Health System is envisioned to become the geographic extension of our education, research and clinical services throughout a network of primary care affiliates which will be a
source of referrals of patients to the central operation. To enhance the quality and cost-effectiveness of our clinical services, a mechanism to deliver home health care via a Medical Center-owned
entity is being contemplated. We are in the most rudimentary planning phase of the Duke Health
System, but it may look like a "hub and spoke" system anchored by a strong campus core of education, research and clinical service capacity which is linked electronically to a home health care unit
and a network of collaborating primary care physicians, many of whom may be our own alumni.
In anticipation of fundamental changes in how medical care will be provided, Duke University Medical Center has organized a comprehensive Office of Managed Care. While North Carolina
currently ranks 37th in the country in the extent of managed care provided, we fully expect very
rapid growth in this field and have organized to respond. An integrated planning group incorporating Duke Hospital, the Private Diagnostic Clinics, and individual departments is now meeting on a
regular basis to extend our strategic planning into a comprehensive program in managed care. We
expect to be fully prepared for all anticipated national and regional changes in managed competition and also expect that the Duke Health System will be the predominant provider in managed
care not only for North Carolina but also for our entire region.
In essence, we must convert from an almost entirely hospital-based health provider to a
more realistically balanced provider of ambulatory, hospital, home, and managed health care. As
the country moves toward managed competition and toward decreasing expensive hospital-based
costs, it is appropriate that we develop such a flexible health system. Furthermore, this is necessary
not only for our financial needs but also to train our students in sites and practice patterns relevant
to how they must function in the 21st century.
CLINICAL FACILITIES
It is important to point out that our efforts to build facilities for outpatients (primary care
and specialty care) as well as the organization of a home care network are key components of our
ability to respond to managed care. As a result, we are poised to enter this new era as fully prepared
as possible.
30
�We are currently contemplating selected growth of clinical facilities to support our programmatic needs. The proposed growth of our core ambulatory capacity through the Specialty Clinic,
Parking Addition and expanded primary care facilities would ensure adequate patient friendliness,
efficiency of operation and capacity to anchor the local/regional component of the DHS.
The proposed addition to Duke North Hospital that would consolidate all inpatient beds in
Duke North would reconfigure a lower than current bed capacity (i.e. fewer beds than currently
exist in Duke North and Duke South). The nature of this inpatient addition may be subject to
modification due to changes in the clinical environment. Our planning for this facility will remain
flexible with respect to its scope and timing based on environmental changes. These projects
combined with the renovation of existing space would give DUMC additional flexible capacity to
meet unanticipated needs. Indeed, it is anticipated that 35,000 square feet of space would be
available in Duke South for Medical Center-University collaboration. For example, location of
student health services, the Center for Health Policy, Research and Education or other universitywide programs could potentially be accommodated in Duke South after relocation of other services.
Objectives for the Specialty Clinic
The continuing and rapid migration of services historically provided in the hospital to the
ambulatory environment mandates the development of appropriate specialty clinic capacity to
support education, research and the clinical service needs of the market. Duke Medical Center
leadership continues to pursue the following objectives:
- Support the changing emphasis on medical teaching in the ambulatory setting
- Design services that enable the delivery of patient care services in a more efficient and
consumer-oriented manner.
- Support the configuration of multidisciplinary services along programmatic lines such as
cancer, women's health, geriatric services, and cardiac services
- facilitate the provision of increasingly complex care in the ambulatory environment
- Design capacity that is flexible enough to manage expected changes in medical practice.
Objectives for inpatient facilities
We will continue to monitor the influence of environmental changes on the nature of the
inpatient capacity that will be required to support the programmatic initiatives contained in the
Plan. The following objectives continue to frame the general dirertion:
- Consolidate all acute inpatient services in a convenient, single location
- Create an identifiable Children's Hospital with consolidation of pediatric specialty care
- Improve the quality of psychiatric inpatient facilities
- Develop the appropriate multispecialty services and intensive care units
- Organize inpatient resources to accommodate the increasing complexity of the inpatient
services.
31
�Primary care
Our primary care services (e.g. Family Medicine, General Medidne, General Pediatrics, and
Obstetrics & Gynecology) are scattered throughout five buildings, two on campus and three in the
community. Physical decentralization in close proximity to campus hinders the provision of costeffeaive, patient convenient services. The current configuration provides inadequate capacity to
compete effectively for vital managed care contracts. Decentralization also impedes the development of an integrated primary care service which would foster collaborative efforts among primary
care specialists and thereby, enhance education and research endeavors.
We have grown from 122,000 visits in FY 1991 to 150,000 in FY 1992. This growth has
produced unacceptable wait times of up to three months for appointments. Our current planning
process estimates the need for about 250,000 primary care visits in a campus location by the year
2000. When combined with other pressures for change such as the societal need for the development of more primary care practitioners, the needs of the Duke Health Service and our local community, and the increasing emphasis on research into access, prevention, wellness and primary
care, Duke is faced with the strategic need to reconfigure and expand existing primary care capacity.
Accordingly, we have established the following objectives:
- Develop an integrated primary care program that provides accessible, cost-effective care of
measurable quality in an attractive setting to members of the Duke University community
and residents of the local community.
- F.xpand educational opportunities for physicians, nurses and allied health professionals in
the appropriate setting.
- Provide an environment conducive to multidisciplinary clinical research into issues
highlighted by the reform of the nation's health care system; the development and use of
practice guidelines; the expanded utilization of physician extenders, etc.
- Provide an entry point to DUMC's clinical services for patients insured through a variety of
managed care/contractual arrangements.
- Seek authorization for detailed evaluation of a primary care facility on the "North of
North" site at the February 1993 meeting of the Buildings and Grounds Committee.
The anticipated construction of a new Specialty Building and parking deck would affect
student traffic from North Campus to West Campus, but every effort will be made to minimize any
inconvenience to the students. Student foot traffic in the proposed area of construction will be
accommodated by temporary walkways around the construction sites for the parking garage and the
Specialty Clinic. When the Specialty Clinic construction is complete, students will be able to walk
on either side of Trent Drive to the main entrance of the Duke Hospital South complex from there
entering the building and exiting Davison Building at the west quad.
32
�Leadership
Duke University Medical Center recognizes the fact that strong and visionary leaders are
essential if we are to achieve the ambitious goals and objectives outlined in this long range plan. It
is the responsibility of these leaders to set the goals for their functional units and to recruit the
individuals essential to achieve their goals. The success that the Medical Center has experienced in
the past four years in its recruitment efforts is highlighted below These individuals, along with the
administrative officers, form the core leadership of the Medical Center.
LEADERS RECRUITED DURING 1989-1991
Mary Champagne, Ph.D.
School of Nursing
Michael Frank, M.D.
Pediatrics
Gordon G. Hammes, Ph.D.
Administration
Anthony Means, Ph.D.
Joseph Nevins, Ph.D.
Patricia O'Connor, Ph.D.
Salvatore Pizzo, M.D., Ph.D.
Leonard Prosnitz, M.D.
Dale Purves, M.D.
Joseph Revcs, M.D.
Michael Sheetz, Ph.D.
Pharmacology
Genetics
Nursing
Pathology
Radiation Oncology
Neurobiology
Anesthesiology
Cell Biology
LEADERS RECRUITED, 1991-Present
David Epstein, M.D.
Allen Frances, M.D.
Thomas Tedder, Ph.D.
Dan Blazer, M.D., Ph.D
Mark Rogers, M.D.
Ophthalmology
Psychiatry
Immunology
School of Medicine
Duke Hospital
Landen Bain
Barbara Echols, J.D., M.B.A.
MC Information Services
Administration
Susan Feinglos
Library Services
Michael Gower
Vicki Saito
Financial Services
Communications
Administration
Steven Sloate
Administration
Robert Taber, Ph.D.
Technology Transfer
SEARCHES UNDERWAY
Biochemistry
Community and Family Medicine
Microbiology
Human Resources
Chair
Chair
Chair
Director
TO BE RECRUITED, 1993-1996
Human Genetics
Medicine
Surgery
Director
Chair
Chair
33
Dean of Nursing
Chair
Vice Chancellor
for Academic Affairs
Chair
Section Head
Executive Director
Chair
Chair
Chair
Chair
Chair
Chair
Chair
Chair
Dean, Medical Education
Executive Director and
Vice Chancellor for
Health Systems
Director
Assistant Vice Chancellor
for Academic Affairs
Director
Director
Director
Assistant Vice Chancellor
for Health Affairs
Associate Vice Chancellor
for Planning
Director
�Medical School alumni and other professionals who trained at Duke are vital contributors to our
history and our future. Their expertise helps us understand how educational programs could be
improved to meet the needs of current practitioners and scientists. Furthermore, they form a
superb regional, national and international network that contributes ideas and contacts with public
and private organizations critical to our success. We will continue to work actively with alumni
leadership to enhance relationships by expanding our educational and research outreach services to
meet the growing needs for continuing education and participation in clinical research.
Coordination Within the University
One of the Medical Center's strengths is its association with and physical location in a great
university. Indeed, the great academic health centers of this country arc all associated with strong
universities. The sharing of facilities, resources and human talent benefit both general academic
and medical communities with an intellectual continuum of opportunities across broad areas of
interest. Conversely, the University as a whole benefits from its association with a great academic
health center. Duke University Medical Center provides the University with the nation's finest
educational and research opportunities in the biomedical sciences. It provides the University access
to outstanding core research technologies and with one of the country's best health care institutions. Moreover, the reputation of thc Medical Center is a great attraction not only for university
students but also for development opportunities. As an example, in thc last survey of Duke University alumni, the excellent reputation of the Medical Center was the most frequently cited recollection of those surveyed.
At Duke, the Medical Center faculty benefit from collaborations with colleagues from
virtually every school and/or college, including Arts and Sciences, Law, Health Policy, Business,
History and Divinity. In addition, Duke University provides its School of Medicine with some of
the brightest medical school students, with nearly one-fourth of our medical students being Duke
graduates. Duke undergraduate and graduate students benefit likewise as Medical Center faculty
participate in the teaching of pharmacology, neurobiology, cell biology and immunology to undergraduates. In addition, an undergraduate concentration in biochemistry has been initiated involving the Departments of Biology, Biochemistry and Chemistry.
A strong History of Medicine program is being developed that bridges the Department of
History and the Medical Center: a new faculty appointment, joint between the Departments of
History and Medicine, has just been made and a curator for our outstanding library collection in the
history of medicine (Trent Collection) hired. The Center for Health Policy Research and F.ducation
is a key joint initiative between Arts and Sciences and the School of Medicine with important
education and research activities relevant to the national health care concerns. A key recruitment
for this Center to fill the McMahon Professorship was successfully completed this past year by the
Schools of Medicine, Art and Sciences, and Business.
34
�Medical Center faculty play a key role in our world renowned Biomedical Engineering
Program, as well as the National Science Foundation supported Engineering Research Center (Center for Emerging Cardiovascular Technologies).
In the training of PhDs, many programs centered in the Medical Center span the University.
The Toxicology Program trains students from the School of the Environment and Arts and Sciences,
as well as the Medical Center. Scientists from Arts and Sciences participate in the Neurosciences.
Both Genetics and Cell and Molecular Biology are major University programs involving many
Medical Center faculty, and the Department of Biological Anthropology and Anatomy is joint
between the Medical Center and the School of Arts and Sciences.
In addition to the Toxicology Program, the School of the Environment and the Division of
Occupational and Environmental Medicine are developing a masters degree program in biohazard
science which has been funded by an extramural grant and will begin within the next year.
The Medical Center is a key component of the Masters in Business Administration program
for students specializing in health business careers. In addition, there are overlapping and mutual
interests in health economics which are likely to be increased in the years ahead as Fuqua attracts
faculty in this area. This will greatly enhance the existing relationships in the Center for Health
Policy Research and Education (CHPRE).
The School of Divinity and Duke Hospital operate a clinical pastoral education program
which provides integrated service/education within thc hospital. The School also provides consultation with regard to medical ethics.
In addition to education benefits of this close integration, many core research facilities,
primarily supported by the Medical Center, benefit the entire campus. Animal care, the NMR center,
a transgenic mouse facility, molecular biology techniques, and cell sorting are but a few examples.
This sharing provides the non-medical portion of the campus with access to complex and expensive
research technologies at very favorable rates without capital investment. The Medical Center
contributed to the development of the Levine Science Research Center in that it provided the initial
funds for its planning, will occupy roughly a third of its space as an equity partner and will equip a
significant portion of the interdisciplinary shared facilities.
Student health services are provided through the cooperative efforts of the Office of the Vice
President for Student Affairs and the Department of Community and Family Medicine. The student
infirmary is located in Duke Hospital South and the outpatient site is in the Pickens Building. No
matter how clinical facilities of DUMC are rearranged in the future, priority will be placed on
locating student health services conveniently for the students served.
35
�Employee health services are a joint activity of the Department of Human Resources and the
Department of Community and Family Medicine. Like the student infirmary, the Employee Health
Clinic is located in Duke Hospital South. Environmental safety is closely linked to employee health.
The environmental safety program is University-wide and operates under the joint direction of the
Chancellor for Health Affairs and the Executive Vice President for Administration.
Through the Duke Health Service, the Medical Center is providing quality healthcare to the
University's employees at a heavily discounted rate. In the last fiscal year, these discounts
amounted to more than $10 million, divided about even between employees and the University's
fringe benefit pool. The Duke Health Service has provided employees and their families with access
to high quality medical care while holding the per employee cost to the University to one of the
lowest rates in the nation. In 1991, the University's cost of health care per participant was $2,529;
42.5% less than the cost for all major national employees, 36.3% less than other educational institutions, and 24.5% less than health service institutions.
As described above, Duke Medical Center recognizes the benefits derived from being a
vibrant part of an outstanding university and through the discharge of each of its core missionseducation, research and patient care- is providing the entire campus community invaluable intellectual opportunities and services. The Medical Center expects not only to sustain but also to
strengthen such collaborative efforts for the greater good of Duke University.
36
�PROGRAMMATIC
INITIATIVES
International
There are several reasons for expansion of major international initiatives for Duke University Medical Center. First, in this era of international communications, a great university must have
international vision and international missions, and this is also true of a great medical center. Next,
the pursuit of knowledge of the causes and treatment of human diseases must have access to all
relevant human populations and must contribute to improving human health on a global basis.
Seminal contributions to curing major health problems have global implications.
Some of these contributions will be in basic science discoveries and some will be in the area
of education and of clinical service. Whether the scientific discoveries are in cancer, in infectious
disease, in immunotherapy or in other areas in which Duke is preeminent, Duke's role will be
international. With regard to education, the development of access to future international leaders
in health care for training at Duke is a natural expansion of our existing outstanding training
projects. When combined with our expanding continuing education programs and enhanced by
telecommunications, the horizons for an international education role at a new level of commitment
are virtually unlimited. Further, our existing programs in countries as distant as Tanzania and
Taiwan are wonderful platforms on which to build these efforts.
Finally, Duke has long been a national and international center for clinical care. This has
grown from the recognized excellence of individual physicians, and we need to leverage this into an
organized institutional approach by collaborative arrangements with partner hospitals and medical
centers throughout the world. As we develop these relationships, we can naturally expect to enhance our international recognition and the flow of patients to Duke to those program areas in
which we are internationally unique. We expect to grow our international efforts so that 1-2% of
our clinical activities are based on international patients in the next five years.
37
�Human Resources
To achieve the vision that we have proposed for Duke University Medical Center will
require the commitment and dedication not only of those in leadership positions but of employees
at all levels of the Medical Center workforce. We must have energetic, enthusiastic employees who
understand and share in a common vision for the Medical Center's future and who work together as
a team to make that vision a reality. To achieve its ambitious goals, the Medical Center must have a
talented and motivated workforce focused on service and continuous quality improvement.
Clearly, if we are to have such a model workforce, we must make the Medical Center a
model workplace. To achieve this objective, several initiatives were begun to improve the work
environment. Probably the most important of those initiatives, and the one that will determine the
future direction of our workplace improvement efforts, was the Gallup survey of employees.
In an effort to identify specific areas of employee concerns and needs, in November 1992,
the Gallup Organization was commissioned to conduct a survey of non-faculty Medical Center
employees. Almost 70 percent of our employees participated in the survey, which sought to assess
both employee attitudes toward the work environment at DUMC and the Medical Center's
strengths and weaknesses compared to various quality hospital organizations both regionally and
nationally. A Steering Committee has been appointed to review the survey results, establish overall
strategies, identify issues affecting the entire Medical Center, and recommend policies, changes or
other initiatives needed to achieve a quality, caring work environment.
It is clear that Human Resource issues in the Medical Center need attention if we are to
reinvigorate our employees and staff with a commitment to efficient, friendly patient care and
ourselves, to improving job satisfaction. One of the key initiatives now underway is the hiring of a
Human Resources Director for the Medical Center who, in concert with thc University, will be
involved in promotion, career path, hiring, and grievance issues that arc relatively unique for the
clinical service areas of the Medical Center, as compared to the University as a whole. When this is
combined with leadership in the hospital committed to these same principles, we expect to see the
badly needed progress in Human Resources for the Medical Center start to unfold in the near future.
Total Quality Management
As part of our ongoing efforts to improve patient care effectiveness and to maintain and
increase Duke University Medical Center's clinical market share, we established a strategic initiative
to enhance the quality of our services by improving the productivity and quality of the Medical
Center workforce. A aitical part of this was to implement a Total Quality Management program
38
�throughout the Medical Center over the next three to five years. TQM is a fundamental change in
the way we manage the institution. It employs rigorous statistical analyses to document current
behavior, establish targets for change and then continuously monitor and enhance quality. For the
first time, all types of medical, administrative and service personnel involved in the delivery of a
service participate as partners in analysis and decision-making to enhance performance.
We began implementation of a Total Quality Management program with the assistance of
Organizational Dynamics Incorporated, a consulting firm working with many academic medical
centers. We have progressed well in implementing a total quality management program and
establishing quality advantage artion teams to analyze issues imparting delivery of care to patients.
The areas being studied are as follows:
• Medication Delivery Systems
• Patient Discharge Summary-Referring Physician Database
• Medical Record Availability
• Discharge Cleaning of Patient Rooms
• Cardiovascular Surgery and Angioplasty
All reports and data received from the team efforts at this time are very encouraging in
terms of improving the timeliness and quality of our services to patients and in improving the
working relationships between departments involved in the process of delivering these services. We
anticipate continued interest and positive outcome as we further implement the total quality
management program within Duke University Medical Center.
A second important effort is the organization of a 20 hour training program for over 1100
DUMC managers and supervisors during calendar year 1993. The purpose of this training program
is to assist our managers and supervisors in developing appropriate skills to work most effectively
with a changing workforce that must be more involved in the decisions and processes that affect
their work. The first four hours of this training is complete.
Library Services
The mission of Duke University Medical Center Library is to support actively the patient
care, teaching, and research activities of Duke University Medical Center. Our academic medical
library must work in partnership with the Medical Center in its core missions: "educating the next
generations of health care professionals, making the discoveries that allow new insights and interventions in life's processes, translating these into practical application, and developing and implementing new ways of treating the sick."
Significant progress has been made during the past two years under the new Director, Susan
Feinglos. Accomplishments include the networking of locally mounted data bases (MEDLINE,
39
�GRANTS AND AMAFREIDA, CANCERLIT, HEALTH, NURSING AND ALLIED HEALTH LITERATURE,
and CURRENT CONTENTS [in 1993]), improved access to resources through a library-staffed photocopy service, inaeased open hours, new workstations, installation of multimedia work stations, and
appointment of a library advisory committee. Physical improvements and key personnel appointments have been made, including a new curator for the historical collections.
In the future, academic health sciences libraries must deal with the rapid growth of information, its technology, and skyrocketing costs. The concept of "libraries without walls" inaeasingly
becomes a reality as methods of access proliferate. The passage of the High-Performance Computing
Art by Congress in November 1991 established the high-speed fiber optic National Research and
Education Network (NREN) which will further electronic access to information.
The cost of scientific information is rising rapidly; comprehensive research colleaions will
be replaced by information from external sources acquired to meet the needs of the user instead of
the library's needs. Duke University Medical Center has a burgeoning electronic environment with
the Common Services Network as its backbone. Its staff, students, facilities and resources are
physically scattered throughout a growing area. Information resources must be supplied to users
when and where they need them, and we must continue to keep abreast of new information.
Two areas are of primary importance in the future: elertronic information and enhanced
outreach. With regard to electronic information, library functions must be fully automated using
DRA (Data Research Associates) hardware and software contracted by the TRLN (Triangle Research
Libraries Network.)
A centralized Learning Resources center must be established, including an clearonic classroom for hands-on instruction in computerized resources, a multimedia lab to support the evaluation and use of interaaive learning materials, a microcomputer cluster for general applications use,
and to study educational software and access medical information systems and campus computing
systems. Access to TRLN library holdings must be increased through public access terminals; improved policy planning for the management of academic information sources within the Medical
center must be implemented through 1AIMS; and mechanisms will be investigated for obtaining
electronic access to materials in Medical Archives.
In terms of outreach, a number of initiatives are required. The library's resources and expertise must be extensively marketed. This requires increased user-education programs and innovative
methods to train users. Collaborative, proactive relationships will be developed with Central
Teaching, the School of Medicine, and other Medical Center teaching programs. To improve
communication, the library newsletter will be revamped and offered through the developing electronic Bulletin Board System (BBS) supported by IAIMS.
Library courses on information seeking strategies and information management will be
developed as a formal component of the degree-granting programs in the Medical Center. We will
work in conjunction with Medical Center Administration in marketing library resources and ser-
40
�vices to potential referring physicians and will investigate the possibility of creating a separate
library-administered patient information collection in the library and/or the Medical Center.
These efforts must be coupled with improved administration, including regular review
procedures and staff training. Standardized procedures for resource development and review will be
developed, including space utilization. At the same time, the efficiency of the library must be
enhanced to hold down costs, for example, cross-training of staff and use of student workers. The
funding base will be broadened by fee-for-service activities and external fund raising.
Office of Grants and Contracts
The goal of the Office of Grants and Contracts is to expedite the submission of grant proposals, to assist in the preparation of research contracts, to provide information about funding
opportunities, and to maintain a faculty database containing information about the research
funding of faculty. In addition, this office will provide support for the Institutional Animal Care
and Use Committee and the Institutional Review Board.
Several important changes have occurred during this past year. Records have been converted
to CD-RAM, thus eliminating the need for the storage of large amounts of paper (one roomful) and
permitting easy computer access to grant records. A new quarterly newsletter provides information
about funding opportunities. In addition, a subscription database has been installed in the library
that contains data about virtually all funding sources. The faculty/grant database has been improved with the goal of having an accurate information source for the entire Medical Center.
The Grants and Contracts Office is essential for continued development of our research
capabilities and will become even more proactive in providing essential services to the faculty.
Future plans include establishment of better communication, development of a training program
for departmental personnel and additional services such as computer searches for potential research
grants.
Office of Science and Technology
Technology transfer is of vital importance to the University, both in terms of establishing
research collaborations with industry and in exploiting intellectual property development at the
University. A single office has been established at the University to deal with technology transfer.
The Office of Science and Technology (OST) is headed by Dr. Robert Taber who has just been
recruited to Duke. While Dr. Taber reports directly to Dr. Snyderman, he is establishing a proactive
organization that will serve all Duke faculty and the University in interactions with the corporate
world.
41
�To facilitate the movement of technology from research to practice, OST must do the
following: (1) protect and license intellectual property, (2) promote sponsored research, and (3)
promote entrepreneurial activity.
The protection of intellectual property, primarily through patents and copyright, is fundamental to commercializing research. Such protection is key to establishing the exclusive positions
necessary for any enterprise to proceed with the major development expense required in the biomedical arena.
The role of OST in protecting intellectual property is multifold. One role is to educate the
faculty as to the value of intellectual property and how to protect it. Another role is to provide
surveillance to identify research discoveries at Duke that may have commercial applications. Success
in this area is measured ultimately by the number of issued patents that have commercial potential.
Another OST role provides the administrative infrastructure which supports the complex legal
process of obtaining a patent. Success here is measured by a combination of the satisfaction of the
research community and the successful prosecution of patents in the most cost-effective manner.
OST functions to commercialize Duke's intellectual property in several ways. One is to license the
technology to the companies that can best fulfill the promise of the technology while also realizing
a sound financial return to the faculty member(s) and to Duke. OST also facilitates other forms of
commercialization such as the development of research collaboration and new business ventures.
Commercial entities are increasingly supporting medical center research. The role OST plays
in the patent and license process can be leveraged to increase the amount of sponsored research at
the Medical Center. The contacts and relationships developed in the above process provide exceptional access to decision makers in industry. OST intends to take a proactive position in developing
this opportunity by aggressive interaction with our present and potential licensees. In addition, OST
will be exploring major programs with industry in broad areas of interest.
in the past fifteen years many billions of dollars have been invested in new biomedical
companies. These companies have grown to both compete and cooperate with the long established
major pharmaceutical and medical device companies. This new generation of companies is now
beginning to realize its promise and play a major role in the marketplace.
The formation of such companies is considered a valid way to convert exciting technologies
(tissue plasminogen activator, human growth hormone) into useful medical products. Important
agents now in clinical practice such as erythropoietin, hepatitis B vaccine, granulocyte stimulating
factor, etc. have been developed by biotech companies with many more agents in the regulatory
pipeline. A high percentage of both groups were developed on a base of university technology.
DUMC, through DUMAC, has generated two companies, Sphinx and Macronex, which
represent this new genre. Both are based on DUMC technology and have raised many millions of
42
�dollars in financial markets. DUMC holds equity worth several million dollars, much of which is
now liquid, in both companies. We believe this model which has evolved over the past few years is
a sound one. We also believe that several technologies now exist at DUMC which can best be
developed through the mechanism of new ventures.
OST will collaborate with DUMAC to develop these technologies where appropriate. This
involves (a) developing a preliminary plan for commercializing the technology, (b) exploiting ties
with the venture capital community to secure initial financing, and (c) negotiating a position for
DUMC or other university components in return for a license to the technology.
The goal of the OST is to perform its major functions while becoming a financially self
supporting office. In order to reach this goal, three things must be accomplished. The first is to
accelerate activity on all the above fronts. The second is to allocate inaeased resources to the OST
to promote this acceleration. The third is to develop a formula which recognizes the contribution
of the OST in obtaining licensing revenues, increased sponsored research revenues, and equity
positions.
Considerable progress has been made in the area of technology transfer: our corporate
support in 1991-92 was about 38 million dollars, and 9 patents were issued to Duke. At the present
time, technology transfer activities require significant financial resources. However, it is anticipated
that this office will become self supporting within a few years and will markedly increase the
corporate support of research.
Information Services
In recent years, the Medical Center has integrated its various information needs which calls
for broad cooperation among its components: the Office of the Chancellor, the School of Medicine,
the Hospital, and the Private Diagnostic Clinics (PDCs). Different information systems, each with
its own acronym, serve these components. The hospital has DHIS, the PDCs have IDX, and several
departments use TMR. Given this situation, the strategy for Medical Center Information Systems is
to design for diversity. The Common Services Network (CSN) and the Common Data Repository
(CDR) are systems that serve all components of the Medical Center, while allowing each some
freedom in solving its own problems. But the Medical Center's system exists within a larger Duke
University system.
Because the Medical Center is part of the University, information systems must be discussed
in that context, treating relationship issues as primary and technological issues as secondary. The
Medical Center's information needs in education, research, and administration resemble those of
the University at large. The School of Medicine needs academic computing to support both education and research, while administrative computing supports the management process. All the
components of the Medical Center share the University-wide need for a common computer infrastrurture. Patient care, however, creates unique information processing needs.
43
�The relationship between the information technology in the Medical Center and the University, can be desaibed with terms borrowed from the computer world:
- in the area of academic and administrative computing, the Medical Center is in a client/
server relationship with campus
- with respert to the Common Computing Infrastructure, the Medical Center is tightly
coupled with campus
- in patient care, the Medical Center and campus are in parallel processing mode.
ADMINISTRATIVE AND ACADEMIC COMPUTING
In academic and administrative computing, the Medical Center is in a client/server relationship with campus. The term "client/server" describes both a specific technology and a relationship.
Applied to technology, the term means that a smaller computer (the client) is linked to a larger
computer (the server), and relies on the larger server for access to data. Thc client and server require
a common language and cooperation among disparate parts.
The Medical Center is the client of information systems on campus and relies on the server
to meet its needs. To that end, Thc Medical Center has formed a new programming group within
MCIS, the Administrative Development Group, to address the needs for administrative and academic support systems.
Projects for this new group include:
- faculty management system
- financial management system
- research management system
- space management system
- educational management system.
Each of these projects will benefit from an institutional data bank, which will allow the
Administrative Development Group to focus on developing workstation-based software to access
the centrally-stored information. This technology will allow business managers in the Medical
Center to use workstations to access data in the institutional data bank and process those data
locally. The Medical Center is the client of the University computing group that wants to develop
the data bank.
LIBRARY
The Medical Center Library provides access to Medline literature searches through a product
called CD Plus. This resource, while purchased for the Medical Center, has value for the rest of
campus as well. The Medical Center Library has a capacity for 40 CD Plus simultaneous users and
44
�has already been networked to university locations outside the Medical Center. When CD Plus is
expanded, the library will develop a new policy for general on-line access. Ultimately, both the
Medical Center and the University will be clients of the Library system
COMMON COMPUTER INFRASTRUCTURE
With respect to the common computer infrastruaure, the Medical Center is tightly coupled
to the rest of campus. When two computer systems are tightly coupled, any change in one affects
the other, and the two must be kept in sync. The Medical Center will, accordingly, stay in constant
contact with those who are building and maintaining the infrastructure for the campus.
NETWORK
The Medical Center began work on its Common Services Network (CSN) as part of the
IAIMS initiative in 1987, slightly before the University began developing the DukeNet backbone.
The two networks, evolving along parallel paths, have blended. The staff responsible for developing
the respeaive networks cooperate in evaluating technology and connecting the nets.
When it was begun, CSN was a sparsely-populated colleaion of networks with no
mission-aitical systems and a low change rate effected by few people. Since then, CSN has evolved
into a densely-populated internet, with many mission-aitical systems and a high change rate
effeaed by many people. This growth in use and importance has forced the Medical Center to
strengthen its level of network support, tighten its network change policies, and move toward
network ubiquity and higher bandwidth.
Network Support- Although the technology of CSN and Dukenet is essentially the same, CSN
has service requirements that distinguish it from Dukenet. The Medical Center operates
twenty-four hours a day throughout the year. Network dependent systems such as the Operating
Room Information System and the Laboratory Information System require absolute reliability. The
Medical Center has a separate network support group for installation and day-to-day support, which
has recently been strengthened to reflea the growing complexity and importance of CSN. This
support group should continue to be tightly coupled with the network support staff on campus,
especially in the realms of network planning and technical assessment.
Network Change Policy - CSN, like Dukenet, is a network of networks - an "internet."
Smaller networks, called "LANs," connect to the backbone through intelligent hubs and provide
service to departments and other work groups. Typically, these LANs are managed by LAN administrators who have some autonomy within their own areas. A network administrators' group meets
six times per year to discuss network issues. One important issue is that changes to LANs can have
unprediaable results for the backbone. The Medical Center is drafting policies for network change
management and welcomes campus collaboration.
45
�NETWORK EXPANSION
The CSN support group has proposed an ambitious and expensive expansion of the physical
network to wiring closets within three hundred feet of each office in the Medical Center. This
expansion would enable ubiquitous data connections within the Medical Center. Important issues
of wiring media and voice/data integration are being considered as the Medical Center plans this
expansion.
In addition to physical expansion, the Medical Center is considering expanding its network
capacity by adopting the higher bandwidth protocol, FDDI. While campus networking also is
moving toward this technology, the Medical Center is moving more quickly because of interest in
transmitting medical images. The Medical Center could serve as the vanguard in testing newer highspeed technologies. Certainly, the Medical Center will closely cooperate with colleagues on campus to do this testing.
ELECTRONIC MAIL
The Medical Center will cooperate with the Hermes project in bringing electronic mail to
the entire campus. Dempo, a Medical Center mail router, is adaptable to campus-wide use, as the
Hermes committee sees fit.
The Medical Center strongly endorses the development of campus-wide electronic bulletin
boards and access to general information such as class schedules, job postings, and health benefits
information. The Medical Center has the lAIMS-supported bulletin board, on a PC Novell-based
system.
DISASTER RECOVERY
The Medical Center has invested heavily in disaster recovery for its mainframe-based information systems, DHIS. As applications move to distributed platforms, disaster recovery schemes
need re-evaluation. There is an opportunity for the Medical Center and the campus computing
centers to develop mutual backup capabilities that would provide disaster-preparedness at less cost
than the commercial scheme now in use in the Medical Center.
PATIENT CARE COMPUTING
With respect to patient care, the Medical Center is in parallel processing mode with the rest
of campus. Parallel processing describes a computing environment in which processes can occur at
the same time, and in similar ways, but with relative independence. This term also describes how
the Medical Center will work in parallel with the University, as both information systems groups
work to solve related problems, with similar approaches, but independent from each other at the
level of specific applications.
46
�Patient care computing in the Medical Center is similar to information systems on campus.
Both the Medical Center and the University have mainframe-based legacy systems that continue to
give value but which need to be replaced because of aging architecture and lack of friendly user
interfaces. The goal for both groups is to migrate to a more open platform while preserving functionality and minimizing the risks which accompany re-formulation. The migration paths of both
use common data repositories and client/server technology.
HISTORICAL PERSPECTIVE
A large mainframe application, known as DHIS, serves most of the patient care information
needs of the hospital. DHIS, like many mainframe applications of its generation, is a victim of
success. It is widely used but taken for granted.
The defects of DHIS, i.e. its highly structured user interface and long application development cycles, have obscured the value of the day-to-day operations of the system. The challenge is
to maintain the value of this important system while moving toward a new paradigm, the same
paradigm which Project Gateway articulates.
DHIS is not alone in its dilemma. No single hospital information system has been able to
solve all problems within a major hospital. The trend in the hospital computing industry is for
departmental systems to solve problems in specific niches, leading to a network of systems, rather
than using a monolithic mainframe as the platform.
CURRENT CHALLENGES
Last fall, hospital administration asked MCIS to consider a vendor-based replacement for
DHIS. MCIS staff evaluated a number of systems, ranging from those that run on a mainframe
platform to those running on mini and workstation platforms, and generated a list of ten which
showed promise. These ten systems were then investigated in greater detail by talking directly to
the vendors and comparing the functionality of each system with DHIS. Despite widespread
dissatisfartion with DHIS, MCIS agreed that no system currently available would be any better. In
fact, most hospital information systems on the market have the same architecture as DHIS and
share many of its limitations. Based on this analysis, the Medical Center adopted the following
working strategy:
1. Continue to support and enhance DHIS
2. Look toward implementing MCIS-1 concept as an eventual replacement for DHIS
3. Continue to watch the marketplace to see how the vendors' systems evolve
4. Purchase vendor systems for hospital departmental needs.
The MCIS-1 document described an architecture that would permit diverse departmental
computing within the hospital while allowing for common access to institutional data. This document, which will be reviewed, expanded, and clarified over the next year, resembles the data
47
�topology in Section One of this plan. Notably, the hospital wants to establish a Common Data
Repository (CDR), like the institutional data bank, to hold data from departmental systems, and to
use client/server technology to allow access to these data at the workstation level.
By acquiring the Cerner Pathnet system in laboratories, the hospital has entered the world
of distributed processing and begun to acquire other departmental systems. A Radiology Information System has been purchased, and similar systems are being considered for Respiratory Therapy,
Intensive Care Units, Emergency Department, Pharmacy and Dietary. This shift to decentralized
computing creates a need for data exchange standards. The Medical Center recently joined the HL7 standards group which wants to set industry-wide standards for interfacing departmental systems.
The separation of physicians and hospital services creates a major challenge to patient care computing in the Medical Center. The Private Diagnostic Clinics (PDC) and the hospital want to establish
common registration and scheduling systems and ultimately, common data bases of patient demographic and insurance information. Creating a common patient database within the CDR, which
accepts data from diverse departmental systems, is one of the main technical challenges now facing
MCIS.
A second purpose of the CDR is to provide access to clinical data from ancillary systems,
management, billing, and clinical care. Data will be fed to the CDR from departmental systems
such as the Cerner Pathnet system in Laboratories and the Smith Dennis and Gaylord Radiology
Information system. As more and more clinical data are captured, the CDR approaches that elusive
goal: the electronic medical record.
Access to the CDR initially will be through legacy systems such as DHIS, TMR, and IDX. But
the future will see more direct access to these data through workstations, using client/server technology. One important development, partially funded through IAIMS, is a workstation-based Care
Management System, which will provide structure to what takes place daily on thc nursing units by
defining Care Maps. Eventually, these same workstations will provide direct access to medical record
data in the CDR.
MIGRATION STRATEGY
Migrating from the DHIS legacy to the new paradigm of distributed, open computing takes
place on three fronts:
1. Replacing existing DHIS functionality with new departmental stand-alone systems
2. Replicating existing DHIS (and other) databases with the more accessible CDR
3. Changing existing DHIS ordering and reporting functions with workstationbased front ends, to general purpose workflow engines. This "deconstruction" of
DHIS will take place gradually, as opportunities arise. Existing DHIS functions
must be fully maintained, and in some cases enhanced, while the replacement
systems are being acquired and implemented.
The Medical Center Information Systems is based on a concept called teleological design,
where visualizing success precedes acting to accomplish the vision. By focusing on the "telos," or
48
�vision-goal, of an open and integrated architecture of diverse departmental systems, information
systems can effectively meet individual actions and decisions flow without having to plan every
step in advance.
Communications
To meet the objectives outlined in the long-range plan, Duke University Medical Center
must attract, develop and retain the best students, faculty, staff who will contribute further to
advancing our programs and reputation. We must distinguish ourselves as the institution of choice
for finandal support from both the public and private sedors. We must also attrad managed care
contrads, employers, patients and referring physicians to enable us to deliver the best, most costeffedive health care of measurable quality. To achieve these goals, it will be essential that we
effedively communicate our unique human and physical resources.
In 1991, the Chancellor for Health Affairs retained the services of four consultants with
extensive expertise in medical communications. The committee conduded an in-depth review of
the existing public relations program and made recommendations for change. It was the determination of this committee that neither the current programmatic efforts nor the leadership of the
department were sufficient to meet the needs of the institution. After a 10-month national search,
Ms. Vicki Saito was identified, and she assumed her duties in June of 1992. A new team of communicators is being assembled, and Ms. Dorothea Bonds, the new Associate Diredor for Publications, is
organizing the institution's first publications office.
The following mission statement guides the efforts of the communications professionals
being assembled to lead the institutional communications program:
The Medical Center Office of Communications (MCOC) is comprised of communications
specialists whose primary goals are to develop and implement the strategies that will inform our
various constituent audiences of the unique resources of DUMC, to advance the overall reputation
of Duke University Medical Center, and to use communications strategies to fulfill our core missions and to strengthen the financial position of the institution.
The following priorities guide the department's efforts:
- Improve internal communications to achieve a more cohesive spirit of understanding and
cooperation among all elements of the medical center and university communities
- Enhance DUMC's reputation and image locally, nationally and globally, with a special
focus on its professional and academic standing
- Inaease awareness of the fad that DUMC is one of the nation's premier health care
providers
49
�- Strengthen relationships with DUMC's various constituent groups, e.g. faculty, students,
employees, alumni, trustees, DU officials, referring physicians, elected officials, policymakers, patients, donors, and the public at large.
A strategic plan for the department has been developed and a departmental structure established that will best meet the identified communications needs of the institution. The following
strategies will be employed: improved internal communications; increased utilization of media
(regional, national, print, broadcast) in support of institutional goals; promotional campaigns and
materials that our enhance patient care efforts; publications; external relations; and community
relations.
Development
DUMC development continues to substantially increase philanthropic funding, focusing
on DUMC-wide initiatives (See exhibit 9).
Development is pursuing four critical objectives at this time.
1. FOCUS AND ENHANCE EXISTING FUND-RAISING INITIATIVES
Development has organized to promote pro-active, major gift focused efforts:
• Development designed and is implementing strategic and operating plans
• Formed a new Board of Visitors, which has begun its work.
• Empowered front line fund-raisers to raise additional funds. During 1992-93,
special emphasis is on:
- Identifying and determining strategies for DUMC's top 200 prospective
donors.
- Identifying and qualifying new prospective donors (primarily DUMC alumni and
patient constituencies) through geographic networks, electronic screening, and
review of historical information including past donors, past prospects, planned
giving mailing responses, and those helped by the Patient Relations department.
- Developing and investigating geographic networks and committees to assist
in major gift efforts.
- Preparing for an enhanced capital fund-raising effort (possibly a capital
campaign).
One potential strategy to address these multi-faceted issues is to structure a capital campaign. By working closely with colleagues in university development, we will undertake a university-wide feasibility study (2/1/93 - 7/1/93) to determine how a capital campaign might be formed
to meet both university-wide and DUMC funding priorities.
50
�EXHIBIT 9
TOTAL PRIVATE SUPPORT TO DUMC
1989-90 through 1994-95
Millions
Projected FY92-FY95
100 T
$92.9
$86.6
90
Actual FY90-FY92
80 +
$80.7
$79.1
70
$58
60
$48
50
40
T
30
20
10
0
1989-90
1990-91
1991-92
ffi Actual Philanthropic Suppon • Projected Philanthropic
Suppon
1992-93
El Actual Research Support
1993-94
1994-95
11 Projected Research Suppon
2. DETERMINE DUMC PRIORITY PROJECTS AND FUND RAISING POTENTIAL
The DUMC Long Range Plan has identified several priority projects including four construction projects, graduate education, and human genetics. Through 1997-98, the Plan calls for
$82 million of cash to be available through fund-raising for capital investment in these major
initiatives (See exhibit 11 in the Resources section). However, the potential scope of the Medical
Center's fund-raising agenda through the end of the decade could approach five hundred million
dollars.
Initial assessment of fund-raising opportunities for the decade ahead have produced a
preliminary list of DUMC-wide priorities that totals $225 million of fund-raising and department
and program desires that could amount to an additional $250 million of restricted philanthropic
support. Evaluation and refinement of this considerable fund-raising agenda will continue during
the next several months. A realistic assessment of the Medical Center's fund-raising potential and
fit with institutional development strategies will be done in this same period of time.
51
�PRELIMINARY DEVELOPMENT GOAL
1991 - 2000
Total Development Goal: (preliminary estimate)
$ 475,000,000
By Category:
DUMC-Wide Priorities:
Unrestricted $ 10,000,000
Restricted
$ 17,000,000
Endowment $ 86,000,000
Buildings
$ 97,000,000 +
New Priorities $ 15,000,000 +
$ 225,000,000 +
Other Restricted Support:
$ 250,000,000
3. DETERMINE CRITICAL FUND-RAISING STRATEGIES
Seven separate, yet interwoven, strategies are being developed within the context of enhanced capital fund-raising efforts. These strategies are: top 200 prospects and ongoing prospect
identification, DUMC alumni with specific focus on house staff alumni, DUMC patients and families, cities/areas strategy, faculty/staff, centers/departments, and corporations/foundations. Initial
implementation of the strategies is already underway. Further refinement is also underway, and
plans are expected to be enhanced by the feasibility study.
4. IMPLEMENT EFFECTIVE CAPITAL FUND-RAISING PLAN
Once the feasibility study is complete, the DUMC priority project list is refined, and the
goals validated and/or modified as appropriate, our best effort will be initiated with a focus on
implementing the fund-raising strategies. Of critical importance will be the identification, involvement and solicitation of DUMC's top 200 prospective donors. Specific, detailed plans have been or
will be assembled for the following DUMC-wide priority projects: SRC, MSRB, Children's Hospital,
Specialty Clinic Building, graduate training, human genetics, and medical school scholarships.
Philanthropic support for the major initiatives in this Plan Update as presented in the
Resources section are focused and achievable. Inaeasing the capability of Development to form
capital for future investment in our evolving priorities is a key issue for the University and its
Medical Center.
52
�RESOURCE
PROFILE
Update on 1991-92
Financial performance during the first year of the 1991 Long Range Plan (fiscal year 199192) was very favorable in comparison with the Plan objectives and projections. The formation of
capital for investment in the major initiatives that are planned is more than $27 million ahead of
schedule at the end of fiscal year 1991-92. Hospital operations provided $16.5 million to this
outcome; cash gifts raised through Medical Center Development were $4 million ahead of the Plan;
and Medical School operations, primarily grants from industry and medical practice activities,
provided $7 million of this favorable performance.
Capital investments in major initiatives amounted to $26 million in fiscal year 1991-92,
about $7.5 million less than called for in the 1991 Plan. This is primarily due to a slower pace of
investments in buildings and facilities. Investments in faculty recruitment and new chairs were $1
million higher than the 1991 Plan target at $9.2 million.
The financial results from the operations of the Medical Center were better than planned for
fiscal year 1991-92 because of the strong performance of the three major categories of operating
revenue. Revenue from grants and contracts was 5% higher than planned; medical practice net
revenue was up 10%; and hospital net revenue was up 11% in comparison with the plan.
MAJOR INITIATIVES
The major initiatives requiring the investment of capital through fiscal year 1997-98 are the
same as in the 1991 Plan and are presented in exhibit 10. Planning in collaboration with Chi
Systems, a nationally prominent consulting firm, for new and replacement clinical facilities is
ongoing, and after 18 months of detailed analysis we have a much better defined view of the scope
and timing of capital investments in these physical resources than was the case when the 1991 plan
was reported. Details of the facility initiatives are provided under the heading "Facilities" in this
section.
53
�Capital Uses for Major Initiatives
EXHIBIT 10
(in Millions)
1992-93
Faculty Recruitment
and New Chairs
Computing and Communications
Core Research Technologies
Buildings and Facilities
Levine Science Research Center
Medical Sciences Research Bldg.
Parking Deck m
Renovations
Parking Deck Replacement
Specialty Clinic
Primary Care Clinic
Hospital Addition
Medical Equipment
for New Clinical Facilities
New Clinical Technology
TOTAL
1993-94
1994-95
1995-96
1996-97
1997-98
$7.7
5.0
0.8
$8.1
5.0
0.8
$14.4
5.0
2.0
$9.2
5.0
2.0
$6.3
5.0
2.0
$3.8
5.0
2.0
7.3
13.8
6.9
2.0
12.3
1.8
7.0
20.6
4.7
2.0
2.5
3.2
1.5
0.7
3.0
0.6
7.0
7.0
7.0
5.0
20.0
19.4
2.4
41.8
1.6
15.7
17.4
0.8
29.8
2.4
17.3
35.0
11.6
30.0
14.8
85.0
22.5
51.0
5.0
$61.1
3.0
6.0
$82.8
3.0
6.0
$91.3
4.0
7.0
$78.5
20.0
7.0
$46.0
30.0
36.0
$422.3
5.0
$62.6
TOTAL
•
$49.5
30.0
9.6
Assuming that the financial objectives will be attained, the Plan update provides for the
addition of about eleven tenure track faculty per year devoted to research and teaching and a like
number of faculty additions committed to clinical service and teaching. The Plan also anticipates
the addition of about seven non-tenure track faculty per year whose efforts will be spent in clinical
service and teaching. The forecast of operating revenue and expense provided in this Plan update
includes these anticipated faculty additions.
The additional basic science faculty were essentially presented in the September 1991 Long
Range Plan and can be attributed to the development of three new Basic Science Departments and
two new Sections as a consequence of the Paculty Coordinating Committee report of 1986-87.
Several of the additional faculty positions are the result of the recruitment of new chairs and the
split of the Microbiology and Immunology Department into two separate departments. These basic
science and clinical research faculty are needed to position our Medical Center amongst the nation's
finest biomedical research institutions and to allow us to translate the fruits of the biotechnology
revolution into clinical advances. The increase in the clinical faculty are needed to introduce new
technologies, enhance primary care and modestly expand ambulatory patient volume. These
faculty will teach medical students and postgraduate courses. They will also participate in outcomes
research and patient care. Clinical faculty derive much of their salary from clinical revenues, and
their recruitment and retention will be governed by the clinical environment.
The addition of these faculty follows through on our previous plans to restructure and
reinvigorate basic science and is consistent with our need for the further development of the clinical service delivery system of the Medical Center in a rapidly changing and inaeasingly competitive
environment. We have also planned for the capital required to reauit the very best individuals into
54
�six departmental chairs over the next several years and to fulfill commitments made to twelve
chairs recruited in the past several years.
CAPITAL SOURCES
Capital sources for these major initiatives are categorically the same as in the 1991 Plan.
The favorable performance of the hospital in 1991-92 and 1992-93 has allowed us to step down its
contributions to capital formation over the Plan period (see exhibit 11). This is consistent with our
expectations that operating margins for the hospital will decline as expected changes in the nation's
healthcare system are implemented. The timing of capital investments vis a vis the formation of
capital is better matched in this Plan update than in the 1991 Plan which should eliminate the need
to use debt to fill cash flow gaps in the capital budget.
Capital Sources for Major Initiatives
EXHIBIT 11
(tn Milhons)
1992-93
Whitehead Scholars Fund
Research Depreciation Fund
Basic Science Reorganization Fund
Clinical Development Fund
The Duke Endowment
Medical Center Building Fund
Medical School Capital Funds
Genetics Fund
Hospital Tax-exempt
Hospital Operations
Bonds
$0.3
5.0
0.9
5.6
3.0
0.8
1993-94
1994-95
1995-96
1996-97
$0.6
$1.1
$1.4
$1.6
5.0
1.9
5.0
5.0
5.0
1.8
6.9
1.8
4.0
0.8
4.2
1.7
4.0
0.8
2.0
1.8
2.0
7.8
0.4
6.8
0.5
7.8
0.5
27.6
24.0
2.0
1.7
4.0
3.7
1.0
1997-98
TOTAL
$1.8
5.0
0.8
1.0
$6.8
$30.0
7.0
21.7
7.0
2.0
0.8
19.0
27.7
0.5
19
18.0
18.4
6.0
146.0
66.0
9.4
6.0
40.0
12.0
30.0
5.0
1.0
7.0
5.0
1.5
9.0
9.0
1.5
9.0
1.7
11.0
1.7
12.0
15.0
18.0
27.0
2.0
21.0
$74.6
7.5
7.5
$92.4
$78.9
$74.1
$70.6
$67.9
Hospital Depreciation and
Working Capital
Technology Transfer/Collaborations
Development (incremental)
University Tax-exempt Bonds
Commercial Debt
TOTAL
OPERATING REVENUE AND EXPENSE
A summary of general assumptions that underlie the Medical Center's forecast of operating
revenue and expense is provided (see exhibit 12). These assumptions are deflated in comparison
with the 1991 Plan in recognition of our current view of the general economy, anticipated growth
of the federal research budget, and substantive changes in the healthcare system.
The forecast of Medical Center operating revenue and expense is provided (see exhibit 13).
This table incorporates all of the anticipated revenue and expense effect of the major initiatives
enumerated (see exhibit 10). This forecast anticipates a considerable slowdown in the rate of
growth of net operating revenue in comparison with that actually experienced from 1988 through
1992 (see exhibit 14).
55
82.0
7.5
7.5
$458.5
�EXHIBIT 12
Summary of General Assumptions
1993-94
General Inflation
Tuition and Fees
Federal Research Budget Inflation
Gifts
Physician Fee Inflation
Endowment Income
Investment Income
Cash Management Pool
Intermediate and Long-term Pools
Sixteen % of Unassigned Income Pool
Salary and Wage Inflation
Medical Student Financial Aid
Graduate Student Support
Plant Maintenance and Operations
General and Administrative Expense
1994-95
1995-96
1996-97
1997-98
4.0%
forecast
4.0
7.0
4.2
1.9
4.0%
6.0
4.0
7.0
3.9
2.7
4.0%
6.0
4.0
7.0
3.6
3.5
4.0%
6.0
4.0
7.0
3.3
4.2
4.0%
6.0
4.0
7.0
3.0
4.9
4.0
6.5
forecast
4.9
8.5
11.0
6.0
forecast
4.0
6.5
4.5
4.9
8.5
11.0
6.0
5.0
4.0
6.5
4.5
4.9
8.5
11.0
6.0
5.0
4.0
6.5
4.5
4.9
8.5
11.0
6.0
5.0
4.0
6.5
4.5
4.9
8.5
11.0
6.0
5.0
Operating Revenue and Expense Forecast
EXHIBIT 13
(In millions)
Projection
1992-93
OPERA TING
1993-94
1994-95
1995-96
1996-97
1997-98
$10.55
178.14
13.82
10.09
128.34
$11.55
$12.24
$12.98
$13.75
$14.58
190.25
14.15
10.80
135.75
539.64
14.67
5.81
$922.62
202.41
15.04
216.04
15 58
12.37
231.88
15 50
13.23
160.89
622.58
17.49
248.66
16.58
14.16
169 78
649 92
18.32
6.97
REVENUE
Tuition and Fees
Grants and Contracts
Gifts
Other Sources
Medical Practice Net Revenue
Hospital Net Revenue
Endowment and Investment Income
Sixteen Percent of Unassigned Income Pool
TOTAL NET OPERA TING REVENUE
OPERATING
EXPENSES
Instruction and Departmental Research
Sponsored Research and Training
Other Multipurpose Programs
Medical Practice Expense
516.10
13.99
5.57
$876.60
$100.21
115.89
19.07
61 26
$107.36
123.70
20.40
65.22
$126.16
140.32
$134.41
21.83
69.45
529.14
23.36
73.81
24.99
78.21
594.17
30.00
4.82
13.64
27.60
3.05
1263
13.55
2.08
13 65
14.30
2.28
15.02
18.06
2.40
15.77
6.62
8.77
0.39
9.23
$864.67
$11.93
TO/(FROM)
EXPENSES
RESERVES
6.66
$1,081.98
$117.06
131.56
Hospital Retention for Working Capital
TOTAL OPERA TING
6.36
$1,026.73
467.89
40.00
General and Administrative Expense
Appropriations and Transfers
Contingency Provision (1 % of Sources)
152.26
594 60
16.54
$973.72
Hospital Operating Expense
Hospital Transfer to Capital Initiatives
Scholarships and Stipends
Plant Maintenance and Operations
Library
499.42
11.56
143.86
566.93
15.61
607
4.52
14.64
560.51
24.00
4.14
$142.93
161.10
26.74
82.39
634.41
18.40
600
3.78
3.01
17.42
2.52
16.55
16.66
21.92
2.64
17.38
0.43
9.74
0.45
10.27
0.48
1082
$905.78
$962.20
$1,016.88
$1,074.28
11 39
$.1,133.34
$16.84
$11.52
$9.85
$7.70
$5.63
56
15.65
19.14
150.42
$1,138.97
26.38
2.78
18.25
0.54
�Operating Revenue and Expenses
EXHIBIT 14
Average Annual Percent Increase/(Decrease)
Actual
1988 thru 1992
Operating Revenue
Tuition and Fees
Grants and Contracts
Gifts
Other Sources
Medical Practice Net Revenue
Hospital Net Revenue
Endowment and Investment Income
Sixteen % of Unassigned Income Pool
Total Net Operating Revenue
Operating Expense
Instruction and Dept. Research
Sponsored Research and Trainng
Other Multipurpose Programs
Medical Practice Expense
Hospital Operating Expense
Scholarships and Stipends
Plant Maintenance and Operations
Library
General and Administrative Expense
Total Operating Expense
Forecast
1993 thru 1998
7.8
12.1
24.0
7.9
12.1
13.0
9.2
4.6
12.5 :
5.3
7.0
5.5
9.2
6.1
4.3
3.4
4.2
5.2
10.9
13.2
12.0
10.7
10.2
8.7
12.7
5.4
11.7
10.8
7.6
7.1
7.0
6.4
6.1
7.1
15.5
7.0
6.7
6.7
FACILITIES
As already presented to the Board and its subcommittees, we face the need for major capital
investment in clinical facilities during the plan period in order to facilitate the care of our patients
and to compete effectively with modern, efficient facilities that have been built in this region. The
need for new ambulatory care facilities has been a discussion item for at least five years within the
Medical Center. The advantages of locating all inpatient care at the north division of the hospital
have been under review for the last two years. This plan proposes the investment of $195 million
in new specialty and primary care clinic facilities, a new parking structure and additional inpatient
facilities. The Board of Trustees gave initial planning approval for the specialty clinic, hospital
addition and replacement parking structure in September, 1992. The primary care clinic will be
presented to the Board for initial planning approval in February, 1993.
Program planning for the clinical facilities has been undertaken over the last year to determine patient volumes, market conditions and space needs. Our planning consultant and physician
staff have established the specialty clinic will require 400,000 square feet to accommodate an
estimated 600,000 annual patient visits. The space requirements have been developed with anticipated improved exam room utilization and recognition of our medical education responsibility in
the ambulatory setting. Utilization of exam rooms will increase from approximately 1,300 visits per
room per year to approximately 1,800 visits per room per year. The specialty clinic will provide
clinic space for the medical, surgical and ob-gyn specialties in addition to clinics for the heart center
and oncology programs. The facility will include an ambulatory surgery suite, imaging center and
clinical laboratories designed and located to be convenient and patient friendly. The building itself
is estimated to cost $85 million.
57
�The program planning continues on the hospital addition and primary care clinic. Plans for
the hospital addition include creating a Children's Hospital which co-locates the pediatric specialty
clinic and inpatient services. The addition provides for improvement in the quality of psychiatric
inpatient facilities and will enable consolidation of all acute inpatient services. Analysis of the
volume projections and trends in hospital length of stay and hospital census are continuing. Projections for space needs will follow those analyses. Our present projections of space anticipate
approximately 200,000 gross square feet at a cost of $51 million.
The primary care clinics should provide space for our family practice, general medicine,
general ob-gyn, general pediatrics and potentially other primary care services. Patient volumes for
primary care are projected to reach 250,000 visits per year by the year 2000. Important strategic
Issues about the primary care program are under review. However, our preliminary calculations for
space needed for primary care clinics and physician offices is 150,000 square feet and at an estimated cost of $22.5 million. These facilities are being planned to accommodate managed competition and to provide accessible cost-effective care of measurable quality.
The final space analyses for the hospital addition and primary care services will be completed in mid-1993. A tentative design and construction schedule and site plan illustrating locations for facility expansion through 1998 are located on pages 59 and 60, respectively. The schedule
does not include primary care facilities, which will be receiving initial review by the Building and
Grounds Committee in February 1993.
58
�EXHIBIT 15
DUKE UNIVERSITY MEDICAL CENTER
FUTURE FACILITIES SCHEDULE
1992
1993
1994
1995
1996
1997
1998
JFMAMJ JASOND JFM AMJ JAS OND JFMAMJ JASOCTO JFMAMJ JASOND JFMAMJ JASOND JFM AMJ JAS OND JFMAMJ JASOND
Parking Garage III
CONST
LSRC
MSRB
CONST
DES. | B |
CONST
Research Buildings
Renovations
Parking Garage I
Relocation
Speciality Clinic
Building
Duke North
Inpatient Addition
|
DESIGN
|B|
CONST
SET
PROP | DEStON
|B|
CONST
fa
DESIGN
PROO
CONST
•...^.•...w, V-^ , .
>
PROG
|
DESIGN - CONST
|B
Duke North & South
Renovations
vv
CONST
D«ilgn
| E CONST
D.tlgn | B 1 CONST |
HLM
i.:6.93
91095.00
SUMMARY
The Medical Center's financial performance has been much better than targeted in the 1991
Plan. We have more precise data regarding the capital investments required for the major initiatives
to which we are committed. We are ahead of schedule on the formation of capital for investment
in those initiatives. Our updated Plan anticipates that the Medical Center will operate in a more
competitive and financially restrained environment than has been the case in the past. We have
accordingly incorporated a cautiousness in our forecast of the future; however, our past performance, the quality of the faculty and staff of the Medical Center, and the strength of our programs
give us confidence that our forecast is attainable.
59
�X
Hi TIRLUf.l.'T
HOUE
E
DUKE UNIVERSITY MEDICAL CENTER
Facility Expansion by Year 2000
Hansen Lmd Meyer
�SUPPORTING
DOCUMENTS
Department Summaries
AGING CENTER
(includes departmental and interdepartmental efforts)
Accomplishments
• Created new Claude Pepper Center from special grant for research on aging
• New research program in national history of depression
• Enhanced clinical geriatrics research with funding of Duke Older Americans
Independence Center
• Implemented gerontologic nursing program
Plans
• Enhance basic biological aging research
• Develop integrated clinical services for the aging to provide care and function as the
base for research and education
• Increase medical school teaching in geriatrics and gerontology
• Stabilize activities with long term care and life care community programs
61
�ANESTHESIOLOGY
Accomplishments
• Reauited Dr. Jonathan Mark, as Chief of VA Anesthesia Division
• Expanded acute pain services into nontraditional areas such as painful radiation
oncology and radiological procedures
• Expanded critical care programs with other units such as surgery and pediatric
intensive care units
• Consolidated ambulatory surgical services in Duke North Hospital
• Expanded faculty involvement in teaching medical students
• Established molecular pharmacology research program
Plans
Seek new faculty leaders in thc following areas: neuroscience research, and
transplantation; and clinical faculty in traditional areas
Develop new initiatives in clinical pharmacology
Enhance pain clinic and acute pain service - extend to cancer pain
Develop and manage an ambulatory surgery center that is patient- centered and
cost-efficient
Expand outpatient screening clinic to include all ambulatory surgical patients
Increase leaures in pharmacology and physiology for first year medical students and
expose second year students to primary principles; expand Continuing Medical
Education courses.
Established geriatric anesthesia research program
Develop a collaborative clinical pharmacology program with relevant departments
62
�BIOCHEMISTRY
Accomplishments
• Developed Center for Macromolecular Structure, including X-ray crystallography,
nuclear magnetic resonance, and molecular graphics
• Undergraduate Arts and Sciences concentration in biochemistry
Plans
• Continue developing structural biology, including siting of a university-wide shared
resource facility in the Levine Science Research Center.
• Expand research in: biochemical regulatory systems, with particular emphasis on
human biology; and biochemistry involving nucleic acid structure/function broadly
defined, including gene expression, replication, recombination, etc.
• Recruit an outstanding Chair for the 1993-94 academic year
63
�BIOLOGICAL ANTHROPOLOGY AND ANATOMY
Accomplishments
• Sponsored an International conference: Anthropoid Origins; the fossil evidence
• Matt Cartmill received a Golden Apple Teaching award
Plans
• Develop interdisciplinary research in evolution and population biology,
bringing together faculty from the Department of Zoology, the School of the
Environment and possibly the Center for Tropical Studies and the Center for Tropical
Conservation
• Request an additional tenure-track faculty in developmental biology; biomechanics, or
molecular genetics
• Develop research collaborations with other basic science faculty
• Expand the department's participation in tracking third year medical students
• Bring thc department's faculty together in a single building close to the Medical
Center
64
�CANCER CENTER
Accomplishments
• Rated number 1 Cancer Center by patients in Coping Magazine
• Helped recruit six new faculty in basic science departments and eight in clinical
departments
• Established Multidisciplinary Clinical Trials Program and a Cancer Prevention,
Detection and Control Program
• Upgraded core resources facilities, including X-ray, molecular graphics, nuclear
magnetic resonance, flow cytometry, and transgenic animals
• Established Outpatient Bone Marrow Transplant Clinic and a Women's Screening
Clinic to study ovarian cancer
Plans
• Renew core grant
• Help recruit bridging scientists in the Medical Center to strengthen research in
pharmacology, hematopoiesis, gene transfer, epithelial cell biology and metastasis
• Develop capacity for drug monitoring/phase 1 evaluation and molecular
pharmacology
• Double outpatient facilities and make more user and operator friendly
• Develop outreach programs both locally and in the Southeastern United States
• Improve communication/education of: patients, community physicians, scientists,
fellows, medical students, undergraduates, high school students, and government
representatives
65
�CELL BIOLOGY
Accomplishments
• Recruited four outstanding new faculty
• Created new courses, emphasizing relationships between medicine and developmental
biology and physiology
Plans
• Collaborate with clinical scientists on problems with clinical relevance, to increase the
department's contribution to advances in medical care
• Continue recruiting new faculty to strengthen the department's research in
developmental biology and physiology
• Strengthen graduate education through better recruiting and reorganizing the
graduate program
• Develop new courses that will integrate the basic medical sciences and bridge the
clinical sciences
66
�CELL GROWTH, REGULATION AND ONCOGENESIS
Accomplishments
• Developed interdisciplinary Cancer Biology Training Program, with
recommendation for support by NIH
• New interdisciplinary course in cellular signalling
• Successful fund raising, with the Cancer Center, for the Levine Science Research Center
Plans
• Become a Department of Molecular Oncology
• Reauit new faculty
• Promote interdepartmental research into questions involving science and medicine,
especially cell growth regulation processes involved in cancer
• Establish Cancer Biology Training Program
• Strengthen the Section's contribution to undergraduate, graduate, and medical
education
67
�COMMUNITY AND FAMILY MEDICINE
Accomplishments
• Expanded primary care: 96,000 outpatient visits, 800 admissions, 60 obstetrical
deliveries, and 3,600 referrals to specialists
• Expanded specialty care in obesity and in occupational and environmental health
• Developed new community primary care outreach proposals
• Developed a new Master of Environmental Management degree
• Established the Research and Development Fund from clinical surpluses to facilitate
research in the department
Plans
Participate in planning for thc new primary care clinic
• Continue to expand primary care services on campus and to plan community primary
care outreach programs
• Request expansion of the inpatient service to 24 beds
• Participate in planning medical school curriculum changes to facilitate education of
generalist physicians
• Plan new Masters and PhD degree programs in Biohazard Science
• Provide research release time for faculty and internal funding for their pilot studies
• Request a position for a PhD research epidemiologist as a resource for clinical research
• Continue planning to return thc chair's office and other administrative offices to
an on-campus location
• Complete the search for thc new departmental chair
68
�GENETICS
Accomplishments
• Reauited two outstanding new faculty
• Genetics course in first year medical school curriculum
Plans
• Create a Department of Genetics
• Reauit new faculty in animal and human genetics, including a senior Howard Hughes
Investigator
• Develop a graduate training program
69
�THE HEART CENTER
Accomplishments
• Continue to be one of the largest referral centers for cardiovascular services in the
state and one of the largest in the country
• Ranked among the top institutions in scientific presentations at the Annual Meeting of
the American Heart Association
• Initiated a second mobile cardiac catheterization laboratory
• Increased the number of in-house cath laboratories
• Opened a pediatric echo laboratory
• Formed a peripheral vascular program that combines medicine, radiology and surgical
physicians
• Initiated a volunteer patient support program
• Implemented a development program
Plans
• Enhance marketing efforts including strengthening local (Triangle area) referrals and
direa patient access systems
• Form an interdisciplinary adult congenital heart disease program
• Expand interdisciplinary clinical research programs
• Integrate quality assurance initiatives under the center umbrella
• Define the concept of quality and cost-of-carc analysis to help frame the health care
cost debate related to cardiovascular disease
70
�IMMUNOLOGY
Accomplishments
• Formed new department and recruited new chairman, Dr. Thomas F. Tedder
• High quality instruction program for undergraduates, graduate students and medical
students
Plans
• Reauit five new faculty over 5 year period
• Enhance graduate and research programs in the areas of immunology and signal
transduaion; animal models of human immunological disease, particularly the use
of homologous recombinations and transgenic animals; T and B cell interactions; and
adhesion molecules and their potential therapeutic uses
71
�MEDICINE
Accomplishments
• Developed clinical and research programs within the Center for Living, and the Sarah
W. Stedman Center for Nutritional Studies, with progress made toward
financial viability
• Maintained strong clinical and research programs
Plans
Develop a program in human genetics
Foster the careers of physician-scientists
Expand the cardiovascular program in the treatment of acute myocardial infarction
and interventional techniques
Develop new programs in allergy
Expand existing programs for invasive gastroenterology, invasive cardiology including
peripheral vascular disease, bone marrow transplant, arthritis, stroke and infectious
diseases
Develop the outpatient programs for all components of the department
Expand the Primary Care Outpatient component of the Division of General Internal
Medicine
Expand clinical research in all divisions
Restructure and reconfigure the subspecialty outpatient programs
Develop training programs in clinical research for both house staff and fellows
Develop a program in human genetics
72
�MICROBIOLOGY
Accomplishments
• Conducted outstanding research and maintained a high level of extramural funding
• More faculty participation in the medical school microbiology course
Plans
• Recruit new Chair
• Replace departing faculty
• Request additional faculty to expand research and training in:
- prokaryotic molecular pathogenesis
- molecular parasitology
- molecular virology
73
�NEUROBIOLOGY
Accomplishments
• Eight new faculty recruited since 1990
• Extramural support for faculty has increased by about one million dollars from 1990 1992
• Improved medical school course by developing new text material
• Added two arts and sciences undergraduate courses
• Received NIH Training Grant in neurobiology
Plans
• Support interdisciplinary research in:
- Brain injury and repair (with Neurology and Neurosurgery)
- Pathological basis of neurodegenerative disease (with Neurology)
- Animal behavior (with Zoology and Psychology)
- Receptor biology and intracellular signal transduction (with Cell Biology,
Medicine and Biochemistry)
- Epilepsy and its cellular and molecular basis (with Neurology)
• Recruit two new faculty, probably in cognitive neuroscience and molecular
neurobiology
• Expand research in brain development, neural plasticity, and neural imaging
• Expand the opportunities for third year medical students seeking research experience
• Increase graduate student enrollment to about 30 students
74
�OBSTETRICS AND GYNECOLOGY
Accomplishments
• Received NIH grant for Gynecologic Oncology and NIEHS agreement to establish a
reproductive endocrine center
• Dramatically increased involvement with clinical practice plan
Plans
• Expand and consolidate laboratory space and strengthen collaborative efforts
• Enhance obstetrics, including fetal diagnostic center and ultrasound
• Make general obstetric/gynecology services more attractive and accessible to area
patients
• Make sub-specialty services more visible nationally, stressing the involvement of faculty
in cutting-edge research
• Increase student involvement in ambulatory care
• Redefine resident and student obstetrical opportunities
• Revise and reorganize the reproductive biology course and expand regional course
programs
75
�OPHTHALMOLOGY
Accomplishments
• Reauited nationally recognized chairman, Dr. David Epstein
• Reorganized clinical programs in terms of subspecialty services
• Developed cross bridging research programs, both within Ophthalmology and with
other departments
Plans
• Expand clinical services, especially in pediatrics
• Develop strong research programs, with more funding by industry and development
• Recruit research faculty, particularly in glaucoma
76
�PATHOLOGY
Accomplishments
• Revised medical school pathology course
• Restructured autopsy service
• Formed Division of Autoimmune Pathology as major diagnostic unit
• Consolidated and improved Duke Hospital Clinical Laboratories
Plans
• Continue to improve the responsiveness and efficiency of hospital laboratories
• Strengthen the clinical and diagnostic service laboratories, including recruiting surgical
and forensic pathologists
• Revamp the graduate program, including recruiting new research faculty, especially in
basic cardiovascular pathology
77
�PEDIATRICS
Accomplishments
• Reauited new Division Chief of Cardiology (Dr. Arthur Garson), Endocrinology (Dr.
Michael Freemark), Rheumatology (Dr. Deborah Kredich) and Medical Director of
Intensive Care Unit (Dr. Jon Meliones)
• Addition of 10 new faculty
• Revised residency training program
• Planned dedicated pediatric cardiac catheterization and Echo laboratory
• Developed contraa with Durham Regional Hospital to provide neonatal care
• Awarded Child Health Research Center by NIH
Plans
• Recruit new leadership for neonatology, nephrology, gastroenterology, infectious
diseases and additional junior faculty
• Integrate children's services, including surgical, medical, nursing and support staff to
ensure that comprehensive high quality patient care is provided in a fiscally responsible
manner
• Enhance off-site pediatric primary care
• Develop research concentrations and grant support in:
- Human genetics, to complement programs in developmental biology and
embryology
- Neurosciences, with emphasis in learning disabilities, developmental behavior,
mental retardation, epilepsy, degenerative diseases of the nervous system, and
neuromuscular disease
- Vaccine development center
- Development of a comprehensive asthma program
- Development of a center for studies of host defenses in children
• Evaluate plans for Lenox Baker Children's Hospital expansion to enhance inpatient/
outpatient rehabilitation services
• Initiate major fundraising campaign to partially fund the construaion of the Duke
Children's Hospital
78
�PHARMACOLOGY
Accomplishments
• Recruited four outstanding faculty in 1992
• Improved graduate student recruitment: 58 applicants, 13 offers and 8
matriculants with an average grade point average of 3.7
• Co-initiated an interdisciplinary course in cellular signalling
• Offered two courses to Arts and Sciences undergraduates
• Improved the medical pharmacology course which received high ratings from medical
students
• Research productivity of more than 7 publications per faculty
Plans
• Recruit 1-2 new faculty
• Develop a graduate program of 35-40 students
• Develop a program in molecular endocrinology strong enough to win an NIH Center
of Excellence Award and to serve as an NIH-funded training program for PhD's and
postdoctoral fellows
• By recruiting new faculty, increase collaborative research and training with other
departments, especially in the application of molecular technology and genetic
analysis
• Help establish a core transgenic animal facility
• Strengthen collaboration with pharmaceutical and biotechnology companies and
increase their support for pharmacologic research and education programs
79
�PSYCHIATRY
Accomplishments
• Reauited nationally recognized chairman, Dr. Allen Frances
• Reorganized inpatient service
• Established a Steering Committee to coordinate research activities in the department
• Recruited full time director for residency program (Dr. Tana Grady)
• Continued accreditation of general psychiatry residence training program
Plans
Integrate and enhance outpatient services
Develop a system of total quality management, including care mapping
Develop a unified clinical database and integrated medical records system
Recruit new leadership for the division of child psychiatry and VA psychiatry, and
recruit new research and clinical faculty
Increase interdepartmental research
Expand continuing medical education programs
80
�RADIATION ONCOLOGY
Accomplishments
• Continued growth of clinical services above budgeted projections
• Strengthened of multidisciplinary clinics
• Substantive research progress in the areas of thermal dosimetry, normal tissue
tolerance, tumor microcirculation
• Development of cancer biology course for third year medical students
Plans
Continue growth of clinical program at rate of 5-10% per year
Continue hyperthermia investigations, including the development of improved
heating equipment, non-invasive thermometry, further quantification of thermal
dosimetry, the exploration of combinations of heat, drugs and radiation for the
treatment of a variety of malignancies
Quantitative studies of normal tissue tolerance to both drugs and radiation and the
molecular events leading to normal tissue damage
Investigate predictors of tumor response to therapy
Develop an oncology track for third year medical students collaboratively with other
faculty of thc Comprehensive Cancer Center
81
�RADIOLOGY
Accomplishments
• New grant support for thoracic imaging and magnetic resonance microscopy
• Clinical volumes exceeded budgeted projections
Plans
• Develop an outpatient imaging facility providing mammography, CT scanning, and
magnetic resonance imaging, with easy access for patients
• Expand research employing magnetic resonance (MR) microscopy to involve faculty
from neurobiology and cell biology
• More collaboration with psychiatry in clinical research employing positron emission
tomography (PET) scanning and develop cardiac applications
• More radiochemistry research into radiolabelled antibody techniques
• Greater collaboration with industry and other departments in developing effective
clinical applications for new technology, especially in musculoskeletal imaging (MR),
oncology and transplant (CT), and neurointervention
82
�SURGERY
Accomplishments
• Reauited Dr. Eli Gilboa, a nationally prominent gene therapist, to strengthen the
surgical virology program and lead the effort in gene therapy
• Reauited Dr. Jeffrey Piatt, a nationally recognized immunologist, to enhance the
transplantation program
• Reauited Dr. William Richtsmeier, new chief of otolaryngology
• Began a federally funded study on the development of clinical practice guidelines for
unstable angina
• Established an endosurgical center funded by US Surgical
• NIH Academic Surgery Research Training Program reapproved and funded
• Increased surgery cases from 17,948 in 1991 to 18,264 in 1992 and moved facilities to
Duke North
Plans
Expand research and clinical programs in cardiovascular surgery, gastrointestinal
surgery, surgical oncology, organ transplantation, and pediatric surgery, with
continued emphasis on multi-model therapy and thc development and clinical
application of new technologies, especially microsurgery and other minimally invasive
approaches
Improve the efficiency and cost-effeaiveness of surgical services, and their
responsiveness to patients and referring physicians
Expand the trauma service and strengthen the Sports Medicine program
Investigate establishment of a Center for Human Appearance
83
�Education
UNDERGRADUATE
The involvement of the Medical Center in undergraduate education is important for undergraduates and the Medical Center. It provides quality training for undergraduates who represent
the future of medical practice and research. In 1992-93, a Biochemistry Concentration, primarily
taught by the Department of Biochemistry, was introduced into the undergraduate curriculum as
part of the Biology and Chemistry majors. In addition, there are undergraduate courses in pharmacology, neurobiology, cell biology, and immunology, and undergraduates do research in Medical
Center laboratories. We anticipate more involvement in undergraduate education and developing
new concentrations and/or majors.
SCHOOL OE MEDICINE
Because Duke is consistently ranked as one of the top five medical schools in the country,
the Medical School continues to attract outstanding students. The positive atmosphere among
current students, the excellence of the faculty, support from the Office of Medical Education, the
third year devoted to scholarship, the financial aid package, and the history of successful application of Duke School of Medicine graduates to postgraduate training, all contribute to the excellent
reputation of the Medical School.
Admissions: Consistently competitive
In 1990 the Medical School received 4,936 applications; this year the Admissions Committee will screen about 5,900 applications (a 20% increase) and will offer well over 700 interviews to
prospective students; 200 offers of admission will be made to achieve an entering class of 100. These
statistics permit an extremely selective admission process. An entering class must have the quality
and diversity that will serve both Duke and the nation well. Thus a class must contain, for example,
students who are interested in primary care, an appropriate balance of women and minorities and
physician/scientists, and in all cases individuals who will become leaders in medicine.
The Established Curriculum
With only two years of required courses, Duke's Medical School curriculum is unique among
North American medical schools. The first year is composed of five blocks of eight weeks each,
when the following courses are taught during one of the blocks: biochemistry, cell biology, genetics, gross human anatomy, medical physiology, micro-anatomy, neurobiology, human behavior,
immunology, microbiology, pathology, pharmacology, and clinical arts. Clinical Arts is a
three-hour a week problem-based learning experience for students in small groups, using standardized patients (patients trained to simulate the physical and psychological symptoms of specific
diseases) and both basic science and clinical tutors.
84
�During the second year, students rotate for eight weeks through the following required
clerkships: surgery, medicine, pediatrics, obstetrics/gynecology, and psychiatry. Students elect
cither an additional eight-week clerkship in family medicine or four weeks of family medicine and
four weeks of neurobiology.
The third year is an elective year of scholarly investigation. Students select a preceptor and
study track in which the preceptor participates. These study tracks include: behavioral neurosciences, biomedical engineering, biometry and medical informatics, biophysics, cardiovascular, cell
and regulatory biology, immunology, infectious diseases, molecular and cellular basis of differentiation, neurobiology and visual sciences, and pathology.
The fourth year is devoted entirely to clinical electives. Among the more popular electives
are the internal medicine subinternship, emergency surgical care, consultative cardiology, basic
radiology, clinical anesthesiology, and principles of orthopedics.
Curricular Changes in 1992
A number of changes were made during the past year both to integrate the curriculum and
to tighten aspects of the curriculum which are considered problematic. These include:
• Developed a mission statement for the Medical School.
• Revamped the physiology course in Year 1, with considerable input from the
Office of Medical Education and a new course director.
• Instituted new student-rated faculty evaluation forms and a more proactive
approach to evaluating courses by the Office of Medical Education.
• Developed a third-year study track which complements a career in primary care
(an emphasis on human population health).
• Refined the use of standardized patients in the Clinical Arts program and in the
Introduction to Clinical Medicine program.
• Developed a standardized clinical evaluation experience at the end of the second
year (through support from the Macy Foundation) in conjunction with three
other North Carolina Medical Schools.
• Reworked the Psychiatry and the Obstetrics/Gynecology Clinical Clerkships
under new course directors.
• Monitored third-year medical students more closely during their independent
study through a systematic review of their experience, three months into the
third year, by advisory deans.
85
�Plans for Additional Curricular Change
Year 1
• Develop a core curriculum for the first year. Major impact: 1994. Developing a core
curriculum for the first year will proceed via two parallel processes.
- An educational/computer specialist will work with first-year course directors to
complete a detailed computerized format of the current curriculum by June of 1994.
- A series of small work groups will devise the core curriculum through consultations
with course directors, course instructors, and clinical scientists by the end of 1993
• Develop a systematic procedure for evaluating instructors in the first year. The Office of
Medical Education will work with course directors to develop a systematic way to evaluate
instruction during the first year. This will give feedback to professor and course directors
about the effectiveness of their teaching.
• Revise the Clinical Arts Program. Two aspects of the Clinical Arts Program will be
reviewed for possible revision.
- The lecture series will be reviewed to determine how lecture time can be most
effectively used.
The Clinical Arts small-group curriculum will be reviewed with basic science faculty
to ensure greater input of basic science material and learning concepts.
• Integrate the Basic Science Curriculum in the first year. The mandate to establish a core
curriculum for the first year takes precedence over integrating concepts across basic
science departments, but the Office of Medical Education will begin to work with selected
basic science instructors to consider whether concepts, such as oncogenesis, can be better
integrated through trial instructional units using instructors from multiple basic science
departments.
Year 2
Review Year 2 for ambulatory and primary care experiences. The current nature of
ambulatory and primary care experiences within the second year curriculum will be
assessed, and the possibility of providing an integrated/cross-disciplinary ambulatory
experience will be explored.
Reconsider the long-standing distribution of time across clerkships. The possibility of a
combined Psychiatry/Neurology clinical clerkship is being considered. In addition,
opportunities for increasing surgical specialty exposure during the second year are being
explored, given that Duke requires fewer weeks on surgical rotations than most medical
schools with comparable experience.
86
�Establish a core curriculum in the Clinical Clerkships. Once a core curriculum for the
basic sciences is under way, setting up a core curriculum in the Clinical Clerkships will be
undertaken.
Explore integrating Basic Science instruction into the second year. Innovative ways for
involving Basic Science instructors in the second-year curriculum will be explored.
Possibilities include Reproductive Biology in the OB/GYN clerkship and Neurobiology in
the Psychiatry/Neurology clerkship.
Year 3
Develop clear lines of responsibility for third-year study tracks. Third-year study tracks
will be reviewed to determine how to establish better responsibility for these tracks. In
some instances, these third-year study tracks may be integrated with a department (such
as moving the neurobiology study track into the Department of Neurobiology, thus
separating it from visual sciences which, in turn, would be moved to the Department of
Ophthalmology). There is consensus that the scholarship year is not to be limited to
Basic Science departments, and we should encourage departmental responsibility where
feasible.
Redefine the study tracks. Plans are underway to add a new study track in Human
Population Health. This track should be attractive to students entering primary care and
will eventually lead to a master's degree (probably a Master's of Health Science) which
could be completed in 12 months of study.
Develop clear objectives for third-year independent studies. The possibility of requiring a
paper from the third-year independent study will be explored with third-year study-track
direaors. In addition, responsibilities of preceptors will be clarified and monitored (to
assure that students are not used as lab technicians). Regular and active interaction
between students and preceptors (not just doctoral fellows) will be essential for
preceptorship.
Further develop the pathophysiology course. This course will likely be continued in its
present form beginning in September of the third year and continuing through May.
Basic science faculty should be better integrated into the course, and interlocutors should
be developed.
87
�Year 4
• The current list of offerings for Year 4 will be carefully reviewed. Some "selectives" may
be added to the electives of Year 4. A selective could be an experience in primary care/
ambulatory care. Other possible selectives could include one of the surgical
sub-specialties.
Minority Affairs
Duke University School of Medicine recruits approximately seven under-represented minority students per year. Virtually all of these minority students are on a Dean's Scholarship. To
enhance the recruitment of under-represented minority medical students, Duke uses: scholarship
funds; a Minority Weekend when qualified minority applicants are invited to return to the campus
at the expense of the medical school; an active Student National Medical Association chapter which
works closely with the admissions office in recruiting minority medical students; and an informal
support network of minority faculty and students. We will continue to recruit minority students
aggressively and to help them succeed.
Financial Aid
Duke University School of Medicine provides an excellent financial needs package for its
students. Of those students needing financial aid, their total indebtedness upon graduation from
medical school less than $32,910 in 1992, compared to average debts of $45,000 for graduates of
public medical schools and $68,000 for graduates of private medical schools. Plans are underway to
increase the endowment of scholarship funds for financial aid over the next five years. An optimistic goal is to double the current endowment for financial aid from ten to twenty million dollars,
which should assure that we can continue our current financial aid package without major difficulties. Medical alumni/alumnae are possible targets for a campaign.
GRADUATE EDUCATION
During the past year, graduate programs have been integrated across the basic sciences,
clinical departments, and the rest of the University. A Graduate Coordinating Committee has been
established with representatives from each basic science department, the University Programs in
Genetics and Cell and Molecular Biology, and the University departments outside the Medical
Center. This Committee coordinates graduate student recruitment, ensuring active collaboration
among departments and programs so that students are recruited to Duke rather than individual
departments. In order to encourage an open academic environment, which should prove attractive,
students will be free to transfer between departments, providing they meet the admission criteria of
the department to which transfer is proposed. Multiple faculty from different departments will
teach courses that are now being developed, and students from many departments will attend.
An annual Medical Center wide graduate student day is planned when students will be able to
present their research as posters and lectures. Clinical faculty will have greater access to secondary
appointments in basic science departments.
88
�The graduate program is expected to inaease in tandem with the planned inaease in
faculty size. Currently there are approximately 260 graduate students, and we hope to achieve an
enrollment of 375 by 1997. This would maintain a student to faculty ratio of about two. Supporting graduate students is the top priority for development activity in the basic medical sciences. An
endowment fund of 20 million dollars has been targeted to support the desired expansion in the
graduate program.
Research programs within the Medical Center compete very successfully for funds, and
outstanding new appointments have been added to our already strong faculty.
Other programs include a Clinical Psychology Internship Program for predoctoral students
and Clinical Pastoral Education. Finally, a program in environmental health leading to a Master's
degree is in the planning stages and may begin as early as the 1993-94 academic year. This program
will be carried out jointly with the School of the Environment.
PHYSICIAN-SCIENTIST PROGRAMS
Duke University is a leader in training physician-scientists. Our NIH supported MD/PhD
program accepts about 5 outstanding students per year and received a very high rating by NIH in its
most recent review. In addition, approximately 5 medical students per year extend their third year
in order to obtain a PhD. The program is one of the three oldest continuing programs in the
country having been founded in 1966. In all, more than 215 students have matriculated in the
program, more than at any other of the 31 existing programs. Because these programs are a source
of extraordinary students, we will seek to attract foundation support in order to expand the number
of participating students. In addition, expanding the third year program to non-laboratory research will produce individuals well qualified to do clinical research. Training outstanding physician-scientists is a high priority for Duke University Medical Center. More than 85% of these graduates enter academic careers.
SCHOOL OF NURSING
The mission of the Duke School of Nursing is to create a center of excellence for the advancement of nursing science, to promote clinical scholarship, and to educate advanced practitioners.
Goals, Accomplishments and Plans:
Academic Programs: Strengthen the curriculum by adding new majors or clinical specialty
tracks which build on the strengths of Duke and respond to societal needs for health care.
To prepare nurse leaders for patient populations with significant health care needs the
School of Nursing added two new clinical areas of specialization: the geriatric nurse prartitioner
program which began in the spring of 1992 and the pediatric clinical nurse specialist program
which began in the fall of 1992.
89
�Specialties which currently prepare clinical nurse specialists will be revised to provide
opportunities for students to become nurse practitioners (pediatric nurse practitioner or adult nurse
practitioner). In acknowledgment of the inaeasing emphasis on the health care team, students in
the nurse practitioner programs will be trained to work collaboratively with physicians to provide
primary health care in a variety of settings including hospitals, clinics, nursing homes and home
care.
We will continue to build the infrastruaure for a doaoral program in nursing through
strong academic programs at the masters level, sustained faculty research and funded grants, and
increased interdisciplinary collaboration.
Rural program initiatives: In response to current maldistributions of health care workers, the
School has received funding from the Fayetteville Area Health Education Center to bring the MSN
program in administration and critical care to nurses in Fayetteville. Twenty-eight students from
nine counties (which are mostly rural and underserved) are enrolled in the program. While classes
are held at FAHEC, students most often do their clinical work at Duke Hospital.
Beginning in spring 1993, every geriatric nurse praaitioner student will be placed in either
a rural or underserved site for clinical experience. Similar clinical rotations will be developed for
students in the pediatric and adult nurse praaitioner programs.
Clinical Scholarship: Duke seeks to be a national leader in clinical nursing research and
significant progress was made toward the goal. There were no funded research grants within the
School of Nursing prior to 1991. Since then, faculty have been awarded four intramural grants
(Duke University); four small extramural grants (American Nurse's Foundation, American Cancer
Society, and the Alzheimer's Association); and three larger NIH grants (National Institutes of Aging,
National Center for Nursing Research and the National Institute of Child Health and Human
Development).
In collaboration with Duke Hospital Nursing Service, a Nursing Research Center will be
established under the direction of Dr. Barbara Turner. The Center will stress interdisciplinary
research with other departments and centers.
Students: The school seeks to increase diversity of the student body and the number of
highly qualified students. Through recruitment efforts, student enrollment increased from 60 (32.3
FTE's) in the fall of 1991 to 122 (49.5 PTE's) in the fall of 1992. Minority enrollment increased from
3% to 9%. A student affairs officer was hired to help with recruitment and streamline the admissions process. A comprehensive national reauitment plan will be implemented to inaease enrollment to 15 FTE's per major (total of 75 FTE's) in the next three years, with a minority recruitment
goal of greater than 10% through hiring minority faculty, increasing financial assistance for minority students, and providing needed academic support. Endowments for student scholarships will be
increased.
90
�ALLIED HEALTH PROFESSIONS
The Graduate Program in Physical Therapy has been a national leader in physical therapy
education for more than four decades. Its primary mission to develop highly qualified physical
therapy practitioners has grown during the past five years to include interdisciplinary research
activities to expand the body of knowledge supporting physical therapy care. The faculty has
received national recognition and grant support to do further research focusing on the problems of
the elderly. Research is now extending into areas of musculoskeletal and neurological disorders.
The physical therapy program has a large, well qualified applicant pool from which to select.
Currently, approximately 28 MS students graduate annually. The possibility of a PhD program in
physical therapy, with about 4-6 students per year who will be supported by this ongoing research,
is being explored.
The Physician Assistant Program at Duke University is fully accredited by the AMA's Committee on Allied Health Education and Accreditation. The program offers a Master of Health Sciences
(MHS) degree. Applicants are all college graduates with a minimum of six months of prior health
care experience. Last year, the program had 267 applicants for the 40 available positions and 70%
of the entering class were women. Currently the program has 44 students enrolled in the first year
and 39 in the second year.
Last year's 41 graduates brought the total alumni to 901. Almost half (48%) of Duke PA
graduates are employed in primary care specialties. Graduates of the program continue to pass
national board examinations at a high rate (90% versus 80% nationally). The program is 90%
financially self-sufficient and could exist without external funding by moderately increasing tuition
fees. The program currently has a 3 year $350,000 training grant from DHHS.
Expanding thc program, improving teaching, and enhancing extramural funding are future
goals. This program is especially important for expanding primary care training and facilities.
The Program in Transfusion Medicine enrolled its first students on August 31, 1992 and has
completed a little over one semester of instruction. Three students, one each from North Carolina,
Washington State and Arkansas, were admitted. The students' progress during the first semester
indicates that admission criteria were largely correct. Although few announcements about the
1993 program have yet been circulated, several partial applications have been submitted and a
number of requests for admission forms have been received. Again, out-of-state individuals have
shown considerable interest. Plans for the program over the next few years are gradually to increase
class size to a maximum of four first and four second year students.
The Clinical Laboratory Science Program (formerly Medical Technology) has been continuously
preparing clinical laboratory practitioners at Duke University Medical Center since 1932. The
training has alternately culminated in a certificate and/or a baccalaureate degree over the years. At
present, this Program awards a certificate from Duke University Medical Center to graduates of the
12.5 month long curriculum. Current approved class capacity is 24 students per program cycle.
91
�This program is formally affiliated with 14 colleges and universities to provide the clinical education
component of their Clinical Laboratory Science majors. Graduates receive their certificates and
baccalaureate degrees simultaneously. Post-baccalaureate applicants are also accepted toward the
certificate from this Program.
The Clinical Laboratory Science Program is part of the School of Medicine, Department of
Pathology, and is supported by Duke University Hospital. The program is acaedited by the Committee on Allied Health Education/Accreditation of the American Medical Association. Accreditation renewal is due in October, 1993, and we anticipate a site visit in May, 1993, in partial fulfillment of the reaccreditation process.
Renewed interest in this field in the last 5 years and avid reauiting by faculty have produced a 3:1 ratio of applicants to class places. Applicants are natural science majors in chemistry,
biology, or clinical laboratory science with co-majors in the sciences. This field has been well
publicized as underfilled, and the U.S. Department of Labor has predicted a consistent growth curve
for available positions through the year 2005. We have accepted our full class for the 1993-94
program cycle.
Because of the increased quantity and quality of applicants and the need in the marketplace,
the program is considering increasing annual class capacity. Long range plans include enhancing
problem-solving and simulation teaching strategies in the curriculum, implementing computer
administered examination procedures, and evaluating potential graduate level programs for the
various clinical laboratory disciplines.
Research
Outstanding research programs are the core of an academic medical center: they ensure the
advancement of medical knowledge and, therefore, diagnostic and treatment modalities. Unfortunately, the support of research will become more difficult. Support from the federal government
will, at best, keep pace with inflation. Whereas the Duke Medical Center competes very successfully
for f ederal funds, ranking 6th in 1991 and 8th in 1992 nationally, money from this source cannot
be expected to increase dramatically. Additionally, all extramural funds received for research must
be subsidized by the Medical Center to underwrite thc full costs of research. The indirea costs
payments are inadequate and are likely to provide us even smaller fractions of the real costs in the
future. Health care reform will decrease reimbursement for the delivery of health care services.
Given that clinical income has traditionally subsidized underfunded education and research,
alternative sources of revenue must be found.
The Medical Center ranks well nationally in support from corporations, with approximately
38 million dollars in 1991-92. In 1992 major research collaborations were established with
Burroughs Wellcome (5 million dollars over three years) and US Surgical (3.3 million dollars over
92
�five years). However, further support is needed for research. To enhance these efforts, a single
Office of Science and Technology, which combined the previous Medical Center and University
offices, was established in 1992 to serve the entire University. This office reports to the Chancellor
for Health Affairs and its purpose is to assist in establishing research collaborations with industry, to
protea intellectual property through increased patent development, and to generate income
through licensing and establishing start-up companies. Although this office currently is subsidized,
technology transfer should eventually provide significant income for research.
INTERDISCIPLINARY PROGRAMS
This planning document cannot adequately summarize the complexity of the research
activities at the Medical Center, nor can it detail the complexity of the necessary administrative
structure. No single administrative element can be regarded as the focal point of a specific area of
research: the overlap between departments, sections, programs and centers is extensive. This is a
reflection of the interdisciplinary nature of modern research in the medical sciences. The matrix
nature of the administrative structure, however, is defined by common interdisciplinary themes,
some of which are discussed below.
GENETICS
Many human diseases are genetic in origin, either directly through inheritance or by environmental modification of genetic material. If the molecular origins of the critical genetic elements
are understood, rational medical treatment can be developed. During the past year, two new
faculty appointments have been made in the Sertion of Genetics, and Dr. Eli Gilboa, a major figure
in genetic therapy of HIV infection and cancer, has joined the Department of Surgery. Among
many research accomplishments, significant progress has been made in understanding how specific
oncogenic proteins are regulated genetically. Oncogenic proteins are crucial in regulating the
growth of cancer cells. Important progress also has been made in understanding the role of genetics
in axonal growth, a crucial problem in neurobiology. A search is underway for a senior animal/
human geneticist in the Howard Hughes Medical Institute as is a plan to enhance our transgenic
animal capabilities, which will provide an unprecedented opportunity for determining the function
of specific genes and developing human disease models in animals.
SIGNAL TRANSDUCTION
Signal transduction describes the communication mechanisms that control biological
processes. It provides a link between molecular events and major diseases such as cancer. Duke is
an international center for studying the receptors on and within cells that regulate cellular events
by binding specific molecules, for example, ephinephrine regulation of heart activity. Major
progress includes isolating an exciting new receptor involved in neuroregulation (proline transporter), and elucidating mechanisms involved in regulating receptors and other signalling mechanisms, especially chemical modifications by enzymes (phosphorylation/dephosphorylation). A
Cancer Biology Training Program for PhD's has received a very favorable review and should begin in
1993. In conjunction with this program, an interdepartmental course in cellular signalling has
93
�been initiated. This area of research will continue to expand, with the Cancer Center playing an
important role, both in supporting the research and in providing a link between basic and clinical
sciences.
NEUROSCIENCES
Duke continues to expand its scientific capability during the Decade of the Brain as designated by the Federal Government. Neurosciences are directly related to signal transduction but
interact with many other interdisciplinary areas and involve complex intracellular networks. The
Department of Neurobiology is looking at how the brain works and has added two new faculty
during the past year (8 since 1990). Among the important research findings has been the discovery
and mapping of neural domains which provides information about the localization of specific
neural functions. Based on experimental work, a novel hypothesis has been developed that relates
the growth and development of cortex to information storage. The Department of Radiology has
continued developing magnetic resonance microscopy, advanced magnetic resonance imaging and
tomography which will be important for visualizing the functioning human brain. The Department of Psychiatry and the Division of Neurology also have active research programs exploring the
link between molecular processes and neurological and mental illness, and the Department of
Pharmacology has active research programs engaged in understanding the molecular events underlying neuro phenomena.
IMMUNOLOGY
Immunology is an important area at Duke University. The immune system is involved in
many diseases, and understanding how the immune system functions on a molecular basis is
critical for designing rational treatments. Immunology bridges the clinical and basic sciences, but
the focus is the newly formed Department of Immunology. The new chair for the Department of
Immunology will provide needed research strength in the area of adhesion processes and leukocyte
trafficking in immunology. These processes are important in regulating the immune response to
foreign proteins. The new chair is expected to recruit five new faculty.
Duke continues to lead in AIDS research including developing a promising AIDS vaccine
which will be tested in clinical trials. A therapeutic program based on the mechanism of action of
the HIV rev protein also is being explored. The rev protein controls the reproduction of the HIV
virus. Duke is considering a broad vaccine program directed at a variety of diseases in addition to
AIDS, such as acute immune diseases. The Medical Center has a strong program in transplantation,
which again links basic and clinical research. Dr. Jeffrey Piatt, Department of Surgery, has been
recruited to this area; his program encompasses fundamental studies of immunological barriers to
xenotransplants i.e. substituting an organ from one species of animal to a different species. Immunology will continue to be a focus for Medical Center research.
94
�STRUCTURAL BIOLOGY
Structural biology, the relationships of structure to function, is becoming a major interdisciplinary area. A Center for Macromolecular Structure has been established and will move to the
Levine Science Research Center (SRC). This Center provides advanced technology for determining
molecular structure by nuclear magnetic resonance and X-ray crystallography. The facility includes
enhanced molecular graphics, which will help in designing drugs and understanding the interactions between biomolecules. Structural biology also includes important advances at the macro
level. The Department of Radiology has been conducting research in imaging which is important
for many areas, especially the neurosciences as described above. One of the remarkable accomplishments this past year has been visualizing developing mouse embryos by magnetic resonance imaging.
95
�Index to Exhibits
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
Exhibit
1:
2:
3:
4:
5:
6:
7A:
7B:
8:
9:
10:
11:
12:
13:
14:
Sources of Support - U.S. Medical School
Composition of Revenue
NIH Extramural Awards
Grants and Contracts
Hospital Volume Trends
Duke Medical Center Service Area Definition
Discharges by Service Area
Total Discharges by Payor
Deductions from Revenue
Total Private Support to DUMC
Capital Uses for Major Initiatives
Capital Sources for Major Initiatives
Summary of General Assumptions
Operating Revenue and Expense Forecast
Operating Revenue and Expenses
(average annual percent increase/decrease)
Exhibit 15: Duke University Medical Center Future Facilities Schedule
Exhibit 16: Duke University Medical Center Facility Expansion Plan
96
7
8
17
17
21
22
23
23
24
51
54
55
56
57
57
59
60
�27710
aPpmwUar for ^*aiii( .Affmt*
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October 27, 1993
Arnold Epstein
Policy Development
The White House
Old Executive Office Building
Room 486
Washington, D.C. 20500
Dear Mr. Epstein:
As a major component of our national health care delivery system, academic health
centers must adapt torapidlychanging policies and needs. Toremainvital and productive they
must increase their cost-effectiveness and provide improved access to health care of measurable
quahty. The viability of academic health centers is not only important to provide a means for
improving health care delivery but is also essential to providing appropriately trained personnel
and for the research needed for continued improvement in health care.
To focus on how academic health centers can positively address these issues, Duke
University Medical Center is organizing a conference to include selected leaders from various
segments of the health care industry for a conference entitled "The Academic Health Center and
Health Care Reform." It is our intention to focus specifically on how academic health care
institutions can become better instruments for effective and rapid change. Questions to be
addressed include: How should academic health centers change to be compatible with HMOs and
managed care networks; how will they maintain balance of core academic missions; how will
they become cost-effective and competitive with other health care providers? Academic health
centers will either be part of the problem or part of the solution of health care reform.
I have the great pleasure of inviting you to attend this conference which will inaugurate
a new phase of the "Duke Private Sector Conference" series originated many years ago under
the leadership of Bill Anlyan. As before, we expect the Private Sector Conference to be a
valuable forum for national leaders and opinion makers in health care to exchange ideas in a
collegial and informal setting. Each invitee will be an active participant, and as in Duke Private
Sector Conferences in the past, we will cover your expenses while you are our very special
guests in Durham. We ask that you beresponsiblefor your transportation expenses to and from
Durham, unless that is a limiting factor in your attending.
�The two-day conference will be held on Monday and Tuesday, April 11 and 12, 1994.
Registration and a welcoming dinner will be held on Sunday, April 10. The proposed program
and list of invitees are appended. My colleagues at Duke and I hope that you will be able to
participate in this metting and look forward to hearing from you soon.
With best wishes.
Sincerely,
Ralph Snyderman, Wl.D.
Chancellor for Health Affairs
Dean, School of Medicine
xc:
William G. Anlyan, M.D.
�DUKE UNIVERSITY MEDICAL CENTER
PRIVATE SECTOR CONFERENCE
"AHC 2000: THE ACADEMIC HEALTH CENTER AND HEALTH CARE REFORM"
Durham, North Carolina
April 11-12, 1994
PROGRAM
THE RAPIDLY EVOLVING ROLES OF THE AHC IN HEALTH CARE DELIVERY: ARE
WE PROBLEM-SOLVERS OR PROBLEMS?
•
The Changing World of Health Care
•
How Will the Core Missions of Education, Research and Patient Care Need to
Change?
•
How Will These Missions be Funded?
•
Health Care Delivery Systems and the Role of AHCs
HOW WILL HEALTH CARE REFORM AFFECT GOVERNANCE, ORGANIZATIONAL
STRUCTURE AND FINANCING OF THE AHC?
HEALTH CARE DELIVERY
•
NETWORKING: What are the Optimal Structures for Health Care Networks?
•
PRIMARY CARE: How Should the AHC Provide Primary Care?
COST-EFFECTIVENESS: How Can AHCs be Converted into the Engines For
the Delivery of Cost-Effective Care of Measurable Quality?
INSURANCE: How Should the AHC Relate to the Insurance Industry?
�AHC 2000; CONFERENCE INVITEES
April 11-12, 1994
William G. Anlyan
The Duke Endowment
Roger J. Bulger
Association of Academic Health Centers
Richard F. Celeste
Senior Adviser to the Clinton Administration
Eugene W. Cochrane, Jr.
The Duke Endowment
The Honorable Robert Dole
U.S. Senator from Kansas
Arnold Epstein
Assistant Adviser to the President on Policy Development
Alain Enthoven
Stanford University
Arthur Garson, Jr.
Duke University Medical Center
Michael E. Johns
Johns Hopkins University
David A. Jones
Humana, Inc.
William N. Kelley
University of Pennsylvania School of Medicine
Nannerl O. Keohane
Duke University
C. Everett Koop
National Ready to Learn Council
�David Korn
Stanford University
Thomas W. Langfitt
The Pew Charitable Trusts
David M. Lawrence
Kaiser Foundation Health Plan, Inc.
Ira C. Magaziner
Senior Adviser to the President on Policy Development
Joseph B. Martin
University of California-San Francisco
J. Alexander McMahon
Duke University
James E. Mulvihill
The Travelers Companies
H. Richard Nesson
Brigham and Women's Hospital
William New, Jr.
Natus Medical Inc.
Herbert Pardes
Columbia University
William A. Peck
Washington University School of Medicine
Robert G. Petersdorf
Association of American Medical Colleges
Mitchell T. Rabkin
Beth Israel Hospital, Boston
Uwe E. Reinhardt
Princeton University
Arnold S. Relman
New England Journal of Medicine
�Roscoe R. Robinson
Vanderbilt University
Mark C. Rogers
Duke University Medical Center
Terry Sanford
Duke University
Steven Schroeder
Robert Wood Johnson Foundation
Donna E. Shalala
Health and Human Services Secretary
Kenneth I. Shine
Institute of Medicine, National Academy of Sciences
Frank Sloan
Duke University
Ralph Snyderman
Duke University Medical Center
Kenneth E. Thorpe
Deputy Assistant Secretary for Health Policy
James S. Todd
American Medical Association
Daniel C. Tosteson
Harvard University School of Medicine
Bernard T. Tresnowski
Blue Cross/Blue Shield Association
P. Roy Vagelos
Merck & Co., Inc.
Robert R. Waller
Mayo Foundation
Gail L. Warden
Henry Ford Health System
�Virginia V. WeJdon
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
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Paper
Dublin Core
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Title
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[Duke University Medical Center Letter] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Arnold Epstein
Identifier
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2006-0885-F Segment 3
Is Part Of
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Box 8
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093086" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
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3/16/2015
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42-t-12093086-20060885F-Seg3-008-011-2015
12093086