WINTER 2015 The Blue Ridge Academic Health Group Report 19 Refocusing the Research Enterprise in a Changing Health Ecosystem Reproductions of this document may be made with written permission of Emory University’s Robert W. Woodruff Health Sciences Center by contacting Anita Bray, James B. Williams Medical Education Building, 100 Woodruff Circle, NE, Atlanta, GA, 30322. Phone: 404-712-3510. Email: abray@emory.edu. Refocusing the Research Enterprise in a Changing Health Ecosystem is the 19th in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2015 by Emory University. 2 REPORT 19 • WINTER 2015 MISSION: The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommendations for academic health centers (AHCs) to help create greater value for society. The Blue Ridge Group also recom- mends public policies to enable AHCs to accomplish these ends. Members and participants (August 2014 meeting) CO - C H A I R S FEATU RED PRESEN TERS S. Wright Caughman, MD* John Z. Ayanian, MD, MPP Executive VP for Health Affairs, Emory University Alice Hamilton Professor of Medicine CEO, Woodruff Health Sciences Center Director, Institute for Healthcare Policy and Innovation Claire Pomeroy, MD, MBA* University of Michigan President, Albert and Mary Lasker Foundation Jeffrey Balser, MD, PhD Vice Chancellor for Health Affairs MEMBERS Dean, School of Medicine Michael V. Drake, MD Vanderbilt University President, Ohio State University Ann Bonham, PhD Michael A. Geheb, MD Chief Scientific Officer Executive VP, Physician Planning and Operations, Association of American Medical Colleges Oakwood Healthcare, Inc.; President, Oakwood Physicians William R. Brody, MD, PhD Gary Gottlieb, MD, MBA Irwin Jacobs Presidential Chair President and CEO, Partners HealthCare System, Inc. Salk Institute for Biological Studies Michael M. E. Johns, MD* Joanne Waldstreicher, MD Former Interim Executive VP for Medical Affairs and CEO, Chief Medical Officer, Johnson & Johnson University of Michigan Health System; former Chancellor and Executive VP for Health Affairs, Emory University; Professor, A D V ISER School of Medicine and Rollins School of Public Health, Emory University Steve Levin Director, The Chartis Group Darrell G. Kirch, MD President, Association of American Medical Colleges Steven Lipstein IN VITED PA RTICIPA N T President and CEO, BJC Health Care William N. Kelley, MD Mary D. Naylor, PhD Professor of Medicine, Perelman School of Medicine, Marian S. Ware Professor in Gerontology and Director of University of Pennsylvania NewCourtland Center for Transitions & Health University of Pennsylvania School of Nursing STA FF Kenneth S. Polonsky, MD Executive VP for Medical Affairs and Dean, Division of Anita Bray Biological Sciences & School of Medicine, University of Project Coordinator, Woodruff Health Sciences Center, Chicago Emory University Mark Richardson, MD Gary L. Teal Dean, School of Medicine Chief Administrative Officer, Woodruff Health Sciences Oregon Health & Science University Center, Emory University Fred Sanfilippo, MD, PhD Director, Healthcare Innovation Program, Emory University ED ITOR Irene M. Thompson, MD Ron Sauder President and CEO, University HealthSystem Consortium Communications Consultant Bruce C. Vladek, PhD Senior Adviser, Nexera, Inc. ED ITORIA L A N D D ESIG N CON SU LTA N TS Karon Schindler Peta Westmaas S E N I O R ME M B E R S Woodruff Health Sciences Center, Emory University Don E. Detmer, MD, MA Professor of Medical Education University of Virginia *Meeting co-planners Arthur Rubenstein, MBBCh Professor of Endocrinology, Diabetes and Metabolism Perelman School of Medicine at University of Pennsylvania Contents Refocusing the Research Enterprise Report 19. in a Changing Health Ecosystem Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The Case for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The Case for Convergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The Continuum of Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Case Study: Doorways to Collaboration with Johnson & Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Supporting Basic Research in a Transdisciplinary Frame . . . . . . . . . . . . . . . . . . . . . . . . 14 Extending the Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Case Study: Emory–Georgia Tech Healthcare Innovation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Case Study: University of Michigan Institute for Healthcare Policy & Innovation . . . . . . . . . . . . . . . . . . . . . . 20 Constructing New Metrics for Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Conclusion: Collaborate and Conquer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Case Study: everaging the Electronic Health Record for Clinical and L Translational Research at Vanderbilt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Previous Blue Ridge Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Executive Summary The research enterprise in academic health centers (AHCs) must respond with energy and creativity to a new set of challenges and opportunities related to cost, effectiveness, and accessibility of health care— even while academic medicine’s traditional mainstay of budget support from the federal government is flat or declining. Academic health leaders must find ways to maintain their commitment to the strong base in curiosity-based science that has made America the world leader in biomedical research. At the same time, they must accept that many of their historical assumptions about funding and organizational structure may be subject to fundamental change. Against this backdrop, the Blue Ridge Academic Health Group (Blue Ridge Group) believes AHCs will best serve society and honor the academic values and commitments that have made them the pace- setters for world science by following these measures: n Taking advantage of opportunities in clinical, translational, and health services research, while pre- serving and continuing to invest in basic science research. n ligning the research enterprise across departments, centers, and divisions within each AHC, being A responsive to its distinctive mission, culture, and strategic priorities, and building on institutional strengths and commitments. n Honoring and rewarding the distinctive skills, educational pathways, and career trajectories that reflect these new realities, even where such approaches may differ from the traditional models of suc- cess for researchers. n Understanding that one significant key to innovation in this new era will consist in partnerships and collaborations. Metrics of competition will need to give way to new measures of collaboration and service, as AHCs look for ways to leverage society’s investment in research across traditional dividing lines between disciplines, schools, and even entire institutions. Implementing the changes proposed in this year’s report may represent a departure for some AHCs; however, some institutions are taking initial steps along this path, and their experiences are described as case studies in this report. The Case for Change bringing new jobs, and the betterment of the na- tional standard of living,” Bush made the case for The appetite for discovery, capacity for invention, sustaining research in defense of national security and vision for improvement that are embodied and the war against disease. He told Roosevelt’s in the American research enterprise all remain as successor, President Truman, that vital as they were in the years immediately follow- ing World War II, when Vannevar Bush, director The responsibility for basic research in medicine and of the Office of Scientific Research and Develop- the underlying sciences, so essential to progress in the ment, wrote his seminal monograph, Science: The war against disease, falls primarily upon the medical Endless Frontier.1 With a provocative declaration schools and universities. Yet we find that the tradi- that the federal government should commit itself tional sources of support for medical research in the to supporting both basic research and directed medical schools and universities, largely endowment research on specific goals, Bush helped set the income, foundation grants, and private donations, are stage for half a century of unrivalled, university- diminishing and there is no immediate prospect of a based, federally financed biomedical research change in this trend. Meanwhile, the cost of medical that became the envy of the world. Addressing a research has been rising. If we are to maintain the charge from President Roosevelt to make recom- progress in medicine which has marked the last 25 mendations about how best to support science in years, the Government should extend financial support the postwar world “for the improvement of the to basic medical research in the medical schools and national health, the creation of new enterprises in universities. 2 Figure 1. NIH Appropriations in Current and Constant Dollars2 With Supplemental Appropriation (ARRA) $40,000 $36,438 Current $ (Millions) $35,745 $35,000 1995 Constant $ (Millions) (Based on Biomedical Research and Development Price Index) $30,861 $30,165 $30,000 $27,167 $30,362 $29,151 President’s Budget Dollars (Millions) $25,000 $21,080 $20,000 $17,699 $16,651 $16,405 $16,406 $15,000 $11,300 $10,000 $5,000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: NIH Office of the Director, Office of Budget: http://officeofbudget.od.nih.gov/ REPRODUCED WITH PERMISSION.2 A half-century of extraordinary growth fol- regardless of size and level of funding, needed lowed, but now, there is no denying the diminish- substantial subsidies from other sources, chiefly ing support for research dictated by the current the clinical enterprise and philanthropy, to cover state of economics and politics. Facing big deficits the gaps in research support—and that is even and anemic economic growth, the engine of big with indirect cost recovery.3 In short, while vital science has stalled. AHCs have felt the chill and to excellence, reputation, and continual improve- are catching cold, if not yet pneumonia. ment, research is not a self-supporting activity for In real dollars, there has been an actual de- any AHC. It can be sustained only by a substantial crease in NIH funding for research, amounting institutional commitment and funds from other to an approximately 25% reduction since its 2003 sources. peak (figure 1).2 And within that total, the focus Within this context, the Blue Ridge Group on finding clinical applications for basic science believes the academic health research enter- has increased. prise must reinvent itself. The current system Compounding the decline in external fund- is unstable and uncertain. Partly as a function ing, careful analysis at a wide range of AHCs, both of health care reform, partly from competitive large and small, public and private, shows that pressures, AHCs by and large anticipate diminish- every dollar of funded research must be matched ing margins from their health systems to sup- and supported by institutional subsidies of 25% port their academic mission, including research. to 40%. A proprietary study of 38 members of Knowledgeable and senior observers are talking the Association of Academic Health Centers about how to find new pathways to “sustainabil- who voluntarily furnished financial data about ity” of the biomedical research system, recogniz- their research budgets revealed that all of them, ing that substantial changes will be required from 3 all major parties—the government, academia, and unaware of the broader financial commitments private industry—if meaningful progress is to be institutions incur to support this research. Se- achieved.4, 5 nior AHC leaders generally recognize that their research enterprise does not break even, though AHCs: Organization and Support the magnitude of the loss is not well docu- The scale of the research enterprise is a signifi- mented or understood. For them, it is sufficient cant asset, but that very size also poses signifi- that research investments generate ample “social cant financial risk for AHCs. In most AHCs, the return,” even if they do not net positive returns research enterprise is several times the size of the on a balance sheet. educational enterprise. For example, extramu- n e ways in which research deficits are funded Th ral research funding in the 50th ranked medical also generally are not well documented or un- school (based on NIH rankings) was more than derstood. Most AHCs provide financial support $100 million in 2014, while it exceeded $500 mil- for the research deficit with explicit transfers lion among the most research intensive medical from clinical, philanthropic, and other funding schools. In comparison, undergraduate medical sources. However, numerous implicit subsidies education represents only a $25-50 million budget typically are provided as well by the depart- for most medical schools (Chartis Group analysis). ments, the dean, and from endowments. A More important, the research enterprise requires better understanding of the costs and funds flow significant financial support. In addition, as noted within AHCs and increased transparency about earlier, careful analysis finds few economies of this funds flow are essential to ensure effective scale in research, with the deficit typically growing use of the funds invested in research. in proportion to the size of the research enterprise. Given the many pressures on AHCs, this The research enterprise has generally not funding gap must be addressed. Federal funding been managed as a strategic investment despite streams for the research enterprise are under ex- its scale and economics. For example, consider treme pressure, at least partially as a result of calls the following: to direct funds to competing national priorities. n Alignment of the research enterprise with the The ability of AHCs to fund deficits is expected AHC’s overall strategy is often limited, de- to become more difficult because of growing spite the significant funds invested to support financial challenges for funding clinical care and research; economic performance is often sub- education, uncertainty about federal support for optimal and is generally worsening because of disproportionate share hospital and graduate funding constraints. A recent review of basic medical education payments, and the challenge of science departments at one AHC found that providing care to the newly insured. about two-thirds of the basic science faculty’s At the same time, there are opportunities for research was in areas that were identified as growth and new resources, but success in the com- one of the AMC’s strategic program priorities. ing years requires that we change strategies, struc- However, most of the faculty members whose ture, and interrelationships (both organizationally research is in the priority programs were not and academically). We can and must use the tools actively involved in those programs; there was of “Big Data,” statistics, and informatics to support no discussion among those doing research in new kinds of research and become more effective a specific field across departments, e.g., all the and efficient. neuroscience researchers, and little or no dis- The development of the Clinical Translational cussion with clinicians (Chartis Group, propri- Science Awards and the genomic sciences them- etary client research, 2013). selves are refocusing academic institutions from n Research economics often are not well under- being isolated research universities to becoming stood by the faculty, including department much greater collaborators. Advances in infor- chairs. Many faculty and chairs believe the re- mation technology and “team science” also are search enterprise is self-sufficient, and they are driving this transition. As methods for collabora- 4 tion improve and inter-institutional partnering in- research enterprise through sensible changes to creases, however, the additional burdens of federal policy and regulation. These efforts deserve great and state regulations are becoming very apparent. attention and support from AHCs as legislative This is particularly true for sharing and manag- proposals come forth in Congress. All research ing patient data needed for research. In addition institutions should read these documents carefully to burdens and costs associated with Institutional and identify where additional regulatory clarity Review Boards, which have differing institutional and/or relief would result in less expensive and practices, state laws intersect with federal poli- more efficient research operations. cies and procedures. Conflicting and burdensome federal regulations involving multiple agencies One Person’s Waste increase administrative overhead, at a minimum, The U.S. health care system embodies a tremen- and can preclude some research efforts altogether. dous amount of inefficiency. In a widely noted Some researchers continue to feel a tension study,8 PricewaterhouseCoopers found that the between HIPAA, passed in 1996; the potential U.S. wastes about $1.2 trillion in health care for improving health from the Human Genome spending every year, slightly more than half of Project, which was not even concluded until 2003 the total $2.2 trillion spent on health care. And but has made despite spending more per capita than any other great progress developed nation, the U.S. achieves only about the The ability to since then; and 27th-greatest life expectancy at birth.9 To be fair, maturation this must be understood against a relatively lower capture and real- of the Inter- ranking among developed nations in the social net from its determinants of health. As analysts at the Organ- locate just a few development in isation for Economic Co-operation and Develop- the mid-1990s ment put it, percentage points onward, which now allows The slower progress in life expectancy in the United of total revenue at large health-re- States is due to gaps in health insurance coverage and lated databases proper primary care, poorer health-related behaviours the margins would to be studied and poor living conditions for a significant proportion on a scale that of the U.S. population.9 make a tremendous was impos- sible previously. This crucial context for understanding our na- difference for the NIH efforts to tion’s health indicators was addressed in the Blue improve policy Ridge Group’s Report 14.10 research enterprise relating to hu- The research enterprise must help solve the man subjects problem of waste in health care through organiza- at most centers. has been incre- tional and cultural change. mental, rather Three specific subcategories alone added up to than looking more than half the total waste: defensive medicine at what would support scaling of databases while ($210 billion), inefficient claims processing ($210 also offering appropriate security for the data. billion), and caring for the preventable conditions Until recently, there was little appetite in either of obesity and overweight and their health conse- Congress or the Department of Health and Hu- quences ($200 billion).8 (p 1) man Services to do anything about these barriers. Reducing waste, in this sense, is highly con- However, the 21st Century Cures Initiative of the gruent with the aims of health services research Energy and Commerce Committee in the House itself and also with value-added health care. of Representatives introduced in 20146, 7 and a few Whether a given AHC’s combined academic other efforts within Congress seek to enhance the and clinical budget is $500 million, $5 billion, 5 or somewhere in between, there are tremendous and the agility to move with them. For example, opportunities to use creativity and courageous in many cases, the capacities and perspectives we leadership to re-envision its strategy and opera- need will be found in engineering schools, which tions. That is our challenge and our necessity. The typically have expertise in systems thinking. ability to capture and reallocate just a few percent- At the same time, AHCs cannot abandon basic age points of total revenue at the margins would research, which will remain a defining component make a tremendous difference for the research of university-based research, as compared with enterprise at most of our centers. It is the thesis of free-standing institutes, national laboratories, this report that this is both feasible and impera- and private industry, to name three. Fundamental tive. And by leveraging the opportunity, we have discovery research is the foundation for break- the capacity—or can develop the capacity—to do throughs that translate into clinical innovations. so while investing in our own ability to perform The heart and soul of America’s decades-old health services research. supremacy in biomedical science and research Health services research reflects the growing has been the close inter-relationship of the best necessity to examine what we do and how we do research with the most intense education at the it, so that we may produce improved outcomes undergraduate, graduate, and professional levels, for the betterment of our patients, our communi- and we must never relinquish that understand- ties, and society as a whole. AHCs must embrace ing—both for the sake of AHCs and for the sake and ensure funding for the complete spectrum of the nation. of research, from discovery to implementation, Expanding the research budget has historically to accelerate improvements in human health and had strong bipartisan backing. However, AHCs address the drivers of excess cost. A recent article must acknowledge the reality that the current in JAMA by Moses and colleagues,11 argues that congressional climate is marked by disagreement the relative neglect of health services research, on how to reduce deficits and provide resources amounting to $5 billion per year overall in a total to support the essential federal role in research. U.S. research base of $116.5 billion, This environment necessitates ongoing, non- partisan advocacy for federally funded research represents a major missed opportunity to improve based on economic vibrancy, medical advances many aspects of health, especially as the burden of for all, and international competitiveness—values chronic illness, aging populations, and the need for that historically have polled strongly across both more effective ways to deliver care are appreciated. parties and a wide range of American voters. This also underlines a continuing obligation for AHCs However, the study also finds that such funding and research universities in general to effectively has grown 37% over the past decade. communicate the value of research findings and their impact. Supporting the Full Spectrum of Research See “Principles” (page 7) for a summary of The growing emphasis on the complementary conclusions in making the case for change. role of health services research provides consider- able opportunities for AHCs. However, taking advantage of the growth areas may require AHCs to recruit faculty with new and different skills. It will also require significant cultural change, along with supporting infrastructure for a different type of research, in some ways resembling engineering or business analysis more than it does the health sciences as traditionally defined. AHCs must have the courage of purpose and the clarity of mind to understand the seismic shifts that are occurring 6 Principles Underlying the Case for Change n Research is an indispensable part of the efficiency, and effectiveness. As large, critical, academic health center’s tripartite mission of and indispensable engines of discovery, AHCs’ improving health through research, educat- domains of inquiry must include themselves. ing health professionals, and providing care to We must continually interrogate the proposi- patients. Discovery science is embedded deeply tion that society’s investment is being well in the DNA of every academic health system spent, patients are being well treated, students (AHC). Indeed, discovery-based science and are being well educated, researchers are being innovation is the principal justification for cre- well supported and directed, and the future is ating and maintaining AHCs in the first place. being well primed with the seeds of advance- A sophisticated, ongoing program of research is ment, even if some of those seeds may not bear inextricably linked and woven into all teach- fruit for years or decades. ing of health professionals that is worthy of the n G reater transparency should be the default name, and equally so, into all clinical care that position for AHCs. Building a well-earned represents the state of the art of health science. reputation for candor, beginning with finance n Accordingly, AHCs must continue to priori- and operations, will enhance the ability of tize research as part of fulfilling their social AHC leaders to engage in the kind of strategic contract. Each AHC will need to determine decision-making that is necessary to focus the optimal balance of basic science, transla- and sustain the research enterprise in an era of tional and clinical science, and health services limits. Transparency with internal constituents, research based on their unique capabilities and especially with faculty, is essential. resources. All discovery science that improves n HCs A must model and embody the changes care, leads to greater efficiency and effective- they recommend. AHCs educate and train the ness, and enhances the utility of AHCs to pa- health professionals of the future and are usu- tients and the greater community is important ally among the largest health care providers in and worth doing. their region or state. They must not only share n Every AHC must be engaged in some pro- their research findings and recommendations gram of active research at a level and with a with others, they must build meaningful feed- focus commensurate to its mission. The scale, back loops into their own education, training, mix, and focus of research programs at various and health care delivery activities so that they AHCs will naturally vary with their age, heri- exemplify the very best practice standards in tage, level of funding, capabilities, and commu- quality, safety, care, and access that they recom- nity expectations and needs. mend to others. This requires seamless and n A HCs’ funded research programs must increas- continual interaction between “academic” and ingly include a focus on their own operations, “clinical” sides of the AHC enterprise. 7 n Improve the health of our communities The Case for Convergence n Enhance our societal impact The research and clinical enterprises need to converge to speed the translation of discovery Obviously, this has major implications for organi- to clinical application and better meet the social zation and systems: the status quo must change. responsibility of AHCs to do the following: Convergence should help AHCs maintain strong economic performance and achieve greater ef- n Accelerate value-driven health care ficiency by demonstrating better outcomes and n Create new, more effective therapies clinical improvements for managing episodes of care and complex conditions. See table 1. n Improve outcomes Table 1. Comparison of Perspectives on Common Challenges Encountered in Fostering Convergence12 (pp 5-7) Common Multi-Institution Report* National Research Blue Ridge Report (2015) Challenge (2004) Council Report (2014)12 Establishing n nstitutions should I n lternative structures A n High-performance effective organi- explore alternative must harmonize with cultures are needed to se- zational cultures, administrative structures the existing culture of lect, promote, and reward structures, and and business models that investigator and labora- both faculty and staff for governance facilitate interdisciplinary tory autonomy. Con- the right qualities and research (IDR) across tra- vergent science fields achievements in this new ditional organizational provide a starting point environment. structures; institutions to organize around n New organizational struc- should develop equitable compelling scientific tures—such as centers and flexible budgetary and societal challenges. and institutes—must be and cost-sharing policies n actors such as differ- F developed to facilitate that support IDR. ences in cost recovery collaborative interac- n llocations of resources A models among schools tion, and they must be from high-level adminis- of science, engineering, supported with core/ tration to interdisciplin- and medicine can com- shared facilities and open ary units, to further their plicate intra-university environments designed to formation and continued partnerships. Laborato- foster interaction across operation, should be ries and core facilities disciplines and groups. considered in addition to are expensive to start resource allocations of up and maintain. discipine-driven depart- ments and colleges. *Facilitating Interdisciplinary Research (From the National Academy of Sciences, National Academy of Engineering, Institute of Medicine.) 8 Table 1. (continued) Common Multi-Institution Report* National Research Blue Ridge Report (2015) Challenge (2004) Council Report (2014)12 Addressing faculty n ecruitment practices, R n romotion and tenure P n Departments or divi- development and from recruitment of is still obtained through sions remain the basis of promotion needs graduate students to a primary departmental disciplinary integrity, but hiring of faculty mem- affiliation for many fac- centers and institutes may bers, should be revised ulty members undertak- be equally important in to include recruitment ing convergent research hiring, promoting, and across department and or associated with retaining faculty and college lines. convergence institutes. talented teams focused n he traditional practices T n ifferences in faculty D on largest-magnitude and norms in hiring of research and service research questions and faculty members and in expectations among sci- areas of need (such making tenure decisions ence, engineering, and as quality, safety, and should be revised to take medical faculty may personalized or precision into account more fully complicate collabora- medicine). the values inherent in tions, although mul- n Tenure must be recog- IDR activities. tiple journal authors nized and understood as and diverse research entailing bidirectional contributors are already obligations between fac- a norm within many ulty and institution and science fields. substantive contributions to the work of teams. n Faculty must have career paths that allow mean- ingful transitions to men- toring, lab management, community outreach, and other forms of service as research productivity wanes. Creating educa- n ducators should fa- E n urricula at the under- C n University-wide or tion and training cilitate IDR by providing graduate level need to trans-school courses can programs educational and training meaningfully integrate foster understanding of opportunities for under- relevant physical, math- convergence and holistic graduates, graduate stu- ematical, computa- comprehension of issues dents, and postdoctoral tional, and engineering at the undergraduate and scholars, such as relating concepts and examples graduate level. foundation courses, data into life science courses n Internal impediments re- gathering and analysis, and vice versa in order lating to calendar, credits, and research activities to to provide a solid foun- and prerequisites may other fields of study and dation for undertaking need to be addressed. to society at large. convergence. n Student interests, enthu- n nstitutions should sup- I n pportunities are O siasm, and creativity are port interdisciplinary needed to effectively important institutional education and training fill in gaps in training drivers of change. for students, postdoctor- and expertise or to al scholars, researchers, learn fundamentals of and faculty by providing a new area to foster such mechanisms as un- a common language dergraduate research op- and understanding. portunities, faculty team These opportunities are teaching credit, and IDR needed at the gradu- management training. ate, postdoctoral, and faculty levels. 9 Table 1. (continued) Common Multi-Institution Report* National Research Blue Ridge Report (2015) Challenge (2004) Council Report (2014)12 Forming stake- n cademic institutions A n Establishing extramural n reat opportunities lie in G holder partner- should develop new and agreements is complex closing the gaps between ships strengthen existing poli- and may be affected by academic and clinical cies and practices that factors such as different sides—schools and health lower or remove barri- leadership, fund- systems—within the AHC ers to interdisciplinary ing, and cost-sharing to focus on the largest research and scholarship, models, or different questions of health ser- including developing traditions and expecta- vices research—patient/ joint programs with tions around issues such community engagement, industry and government as patent development quality, safety, cost and and non-government and intellectual prop- access. organizations. erty protection. n qually great opportuni- E n ontinuing social science, C n Taking full advantage ties lie in pooling efforts humanities, and informa- of the possibilities en- of AHCs, both within tion science–based stud- abled by convergence states and in multi-state ies of the complex social increasingly draws compacts. AHCs and and intellectual processes upon contributions industry can collaborate that make for success- from fields such as the to their mutual benefit ful IDR are needed to economic and social in areas of AHC expertise deepen the understand- sciences, which have and industry need or ing of these processes their own cultures and market opportunity. and to enhance the norms that must be prospects for the creation considered. and management of successful programs in specific fields and local institutions. *Facilitating Interdisciplinary Research (From the National Academy of Sciences, National Academy of Engineering, and Institute of Medicine.) Columns 1 and 2 reproduced with permission from the National Academy of Sciences. Courtesy of the National Academies Press, Washington, DC.12 The success of the transformations outlined in new or enhanced positions that must translate, table 1 will hinge on strong and sustained leader- guide, and implement the changes needed to ship and an ongoing commitment to organiza- achieve meaningful integration between the tional change that recognizes the scale of the chal- academic enterprise and the health system as lenge and the vital need for shared information, well as enduring changes and improvements in analysis and timely communication at all levels. A patient care. They include the positions of chief recent report from the Association of American quality officer, system chief medical officer, group Medical Colleges (AAMC)13 reminds us that the practice president, and chief medical information challenges faced by AHCs will by no means yield officer to lead physicians, nurses, and other health to top-down decision-making alone, no matter professionals and direct clinical processes across how firm the hand on the tiller might be. Rather, hospitals and networks.13-18 coordinated leadership at many points and levels See “Findings and Observations” (page 11) for in our organizations is required, including at the a summary of conclusions in making the case for department chair level. Also critical are several convergence. 10 Table 1. (continued) Common Multi-Institution Report* National Research Blue Ridge Report (2015) Challenge (2004) Council Report (2014)12 Obtaining sustain- n unding organizations F n overnment support G n AHCs must continue able funding should recognize and is one component of to work through AAU, take into consideration obtaining funding for AAMC, and others in their programs and convergence. Many to press the case for processes the unique convergence programs sustained basic research challenges faced by IDR have also obtained funding, which can come with respect to risk, critical support from in sufficient quantities organizational mode, sources such as private only from the federal and time. philanthropists and government. n unding organiza- F foundations interested n AHCs must enhance their tions should regularly in advancing science. own efficiency and effec- evaluate, and if necessary n ncome from start-up I tiveness to maximize their redesign, their proposal companies and venture value to government and and review criteria to capital investors, which industry sponsors in areas make them appropri- may be part of conver- of mutual interest. ate for interdisciplinary gence ecosystems, may n AHCs must continue to activities. also provide support. work hard and creatively n ongress should continue C to identify and cultivate to encourage federal philanthropic sources of research agencies to be funding—both individuals sensitive to maintaining a and foundations—who proper balance between can help supply criti- the goal of stimulating cal missing margins and interdisciplinary research jump-start new initiatives. and the need to main- n AHCs should continue tain robust disciplinary to aggressively pursue research. technology transfer and licensing opportunities to sustain their research enterprise and to maxi- mize their contributions to their communities and to society. Findings and Observations n The traditional funders of basic science are varying their approaches, requiring adapta- n Government, industry, and the public all look tion on the part of institutions and research- to university-based researchers to continue ers. While capacity expands for clinical and their distinguishing enterprise of basic science. translational research, implementation science, Everyone wants the AHC’s goose to keep laying and health services research, our collective golden eggs. The debate is over who pays for commitment to the basic science which fuels food, drink, and shelter. breakthroughs must continue. The pharmaceu- n However, the golden age of the “endless fron- tical industry cannot replace large-scale public tier” that followed World War II and continued investment in research and, in fact, is becoming for about half a century is over and will not less likely to fund broad-gauged institutional return in the near future. Funding from all grants. sources has plateaued, at best, and will remain n Private philanthropy cannot replace large-scale flat or decline in real dollars. public sector investments in research—though 11 Findings and Observations, continued it may provide an indispensable margin. First, n AHCs accordingly must look to their own the scale of philanthropic contributions is ap- organization, culture, and administrative proximately an order of magnitude less signifi- overhead to find new efficiencies and become cant. Second, and equally important, many of more competitive. The fact that AHCs are often the new mega-philanthropists will insist on di- too slow and cumbersome to produce results recting their investments to research, diseases, on the time scale industry can achieve18 leads and causes that are important to them and, in to the growing industry preference for striking any event, generally will not invest in the requi- one-off deals with individual researchers focus- site indirect cost base to keep the lights on and ing on specific molecular targets or pathways. the heating bill paid. n T alent management is a critical part of the n cross all AHCs, small and large, research costs A research continuum and must be done more the institution money above and beyond what efficiently and more strategically at every stage any outside payer will support. AHCs must find of the process. AHCs must improve hiring, sources for the significant cross-subsidy that is promotions, and strategic direction across needed at every size of institution, according to the active lifespans of faculty, and they must careful analysis. improve processes for admitting, training, sup- n linical margins and health care cross-subsi- C porting, graduating, and placing students and dies of research are at risk and in some degree trainees. These critical investments of time and already diminishing in the new competitive money are increasingly too important to be left landscape of health care and given the new exclusively to departments in a time of global pressures on graduate medical education and resource constraint. Every hire into a tenure- other missions. While some specialties cur- track position is an institutional commitment rently remain highly profitable, the enterprise and must be made with a clear recognition of increasingly is balancing its budget by the posi- institutional opportunities, needs, and strate- tive margins of just a few key specialties. This gies. Similarly, the student-to-postdoc-to-first- cannot be regarded as sustainable for the long grant pipeline is far too long and costly and term.13 must be shortened and made more efficient. The Continuum of Research One of the peculiarities of basic science is the variety of paths which lead to productive advance. Many of Government, industry, and society all look to the most important discoveries have come as a result AHCs for “basic” discoveries. New drug/vaccine of experiments undertaken with very different pur- development timelines are decades long, but all poses in mind. Statistically it is certain that important start with fundamental discovery (e.g., Gleevec, and highly useful discoveries will result from some Gardasil).19 While there is a growing belief that fraction of the undertakings in basic science; but the computational biology will shorten the lag time results of any one particular investigation cannot be between discovery of a genetic marker and its predicted with accuracy. effective targeting by a therapy, it is nevertheless true that serendipity plays a large role in some of It is sobering to consider that the health our most important advances, and the progress and livelihood of our descendants in the 22nd of science is not linear. As Bush1 pointed out 70 century may depend in ways we cannot imagine years ago: on findings being made in obscurity by unknown researchers in university labs today. 12 However, support for “basic” sciences— to serving patients and bettering society. But the whether from NIH or industry—is stagnating, company also believes it can meet its vision of if not diminishing. Researchers and AHCs must “transformative innovation” more effectively by increasingly be opportunity-driven to collaborate working with specific investigators who have deep with industry (e.g., J&J Innovation Centers—see expertise and interests, rather than with institu- Johnson & Johnson Case Study, this page). NIH tions. The company has increased its funding for funding for basic science amounts to more than externally conducted basic science, looking for the $15 billion but has declined by 16.8% over the creation of “win-win” collaborations with external past decade.20 The Blue Ridge Group strongly scientists around the world. supports maintaining the baseline of national “We still have some big academic collabora- investment in basic funding. No other single actor tions, where we give money to an institution to has the capacity or the ability to wait years, if nec- collaborate in an area of mutual interest, but we essary, for tangible returns, to the degree that the may do fewer of those,” says Waldstreicher. “We federal government does.21 Everyone who partici- have some good lessons learned. We have learned pates in biomedical R&D needs a robust founda- the real value of working with individual research- tion of serendipitous, curiosity-driven discovery ers, working on specific problem statements or science, which will pay off in unpredictable but targets we are interested in, more so than with the dramatic ways, years or decades from now, just as big institutions.” it has historically. As analysts from the Federation Asked why, she says: “We found that with big of American Societies for Experimental Biology grants, there might be less accountability, col- said recently, referring to the impact of sequestra- laboration, and shared vision for the outcome and tion on the research community: “For biomedical sometimes a misunderstanding in the concrete research, 2013 was a terrible year to have a great deliverables.” idea.”2 One notable successful academic collaboration is the Yale Open Data Access (YODA) project in Case Study: Doorways to Collaboration with which J&J is collaborating with Yale to make ano- Johnson & Johnson nymized clinical trial data accessible to research- With more than $71 billion in annual sales, John- ers unaffiliated with either institution in an effort son & Johnson (J&J) is the world’s largest health to serve independent evaluation and outcomes care company, divided into three chief divisions: assessments.23, 24 The researchers at YODA have a consumer products, medical devices, and phar- specific passion for and expertise in transparency maceuticals. In a transition that is typical of the and data sharing, a common passion of research- pharmaceutical industry in general, J&J is chang- ers at J&J. ing the way it has traditionally done business with In J&J’s new approach, the company has universities and academic health centers. opened four Innovation Centers—in California, The era of the institutional mega-grant is giv- Boston, London, and Asia-Pacific. These centers ing way to a new approach in which J&J strives to each have satellites, along with some associated build close collaboration with individual inves- incubators for early-stage biotech and other sci- tigators working in areas of specific interest. The ence companies. “We want working with us to company will continue to look to academia for be a win-win,” says Waldstreicher. “We are very basic research, especially research that identifies flexible. If you have an interest, we want it to be molecular targets that look promising in defined beneficial for researchers to work with us—so that disease areas such as oncology, immunology, neu- it can lead to financial returns for both of us, and roscience, cardiovascular research, metabolism, importantly, so we can turn their discoveries into and infectious disease, according to J&J’s chief products that meet unmet medical needs.” medical officer, Joanne Waldstreicher.22 Worldwide, J&J is currently involved in hun- J&J believes it shares common challenges and dreds of early-stage R&D projects with external goals with academia, especially when it comes collaborators. Although more than half are with 13 academic or biotech partners, academic collabora- n Innovative therapies require validated molecu- tors alone are only about one-quarter of the total. lar targets—typically genes or proteins. How should universities or AHCs interested in n Academic research labs can accomplish these working with J&J proceed? “Visit or contact our molecular discoveries. innovation centers,” says Waldsteicher. “Under- n Pharmaceutical/biotech funding can contribute stand what our targets are. They would be happy to the development of new molecular-based to see you; or they can come and visit you.”22, 25 therapies.19 This ongoing revolution, or evolution, is being *** driven by new and powerful techniques that allow for molecular-level analysis and precise genetic AHCs increasingly must focus their research manipulation of organisms, from microbes to enterprise so that they differentiate around their man. Molecular biologists and physician-scientists strengths, reflecting their individual histories, now collaborate with engineers, mathematicians, mission, opportunities, scale, and scope. Not all statisticians, chemists, physicists, and computer AHCs will be expert in multiple areas of research. scientists to address the great questions in science Researchers, in turn, must align with their AHC’s and medicine that run the gamut from basic dis- overall strategic direction and priorities.18 covery to the development of new treatments to What role remains for disconnected, funda- sustain health and treat disease. mental, curiosity-driven research? The future will Team-based science can accelerate discovery depend on constructing “win-wins” that protect a and, in fact, will increasingly be the bellwether vital margin for basic science. However, the lim- of advances. AHCs must support this new reality ited availability of external funds for fundamental, by developing new organizational structures to discovery-based research will necessarily result in facilitate collaboration. Appointment and promo- greater selectivity and focus around strengths and tion standards must be able to recognize the team areas of strategic opportunity. contribution of faculty, and physical space must be designed to accommodate collaborative, team- Supporting Basic Research in a based science. Transdisciplinary Frame But the elephant in the room is that our his- torical organizational structures and our metrics We are in an era of unlimited discovery poten- of pre-eminence continue to be anchored in siloed tial in the biological and biomedical sciences, approaches and assumptions.18 Convergence (a the result of decades of fundamental research. A desired approach) will continue to be impeded by seeming paucity of advances in the 1990s was, in AHCs’ guild identity, administrative and organi- retrospect, partly attributable to industry chasing zational structures, reward/recognition systems, “blockbuster” drugs instead of systematically capi- and departmentally based revenue incentives and talizing on what basic science is making possible resource controls. in terms of the acquisition of new targets. Now, In order to meet the extreme demands of the a new alliance between industry and academia, rapidly dawning new era, AHCs cannot afford revolving around these new understandings, to accomplish convergence at the margins while promises to accelerate new drug development— maintaining traditional structures and cultures, against the conventional wisdom that the Human including unaligned incentives. We must keep Genome Project has largely come up dry.26 pushing for the changes that will make convergence New therapies have emerged as the product of the assumption of those committed to research, a long pathway or pipeline of discovery, in some discovery, and application. Sustained and profound cases stretching back decades to early-stage, basic organizational change will require clear vision, research insights. Evidence suggests we are now bold leadership, and motivational communication. at a time of quickening change in the discovery Indeed, as Enders and Conroy13 (p 7) put it, model. 14 Leaders must become agents of change rather and humanly feasible. Figure 2 illustrates one such than protectors of the status quo. The broad gap in construct, thanks to the AAMC’s Advisory Panel readiness to operate as a system, the lack of well- on Research.27 established primary care systems, troubled histories Changes in the funding climate make it of engagement with local communities, limited unrealistic to use the same calipers for individual experience in managing risk contracts, relatively high achievement going forward that have been histori- cost structures and inexperience with partnerships cally applied in the post-war period. Consider the combine to create a significant handicap for even the implications of figure 3,2 for example, at a time most far-sighted and determined leaders. The added when the size, scale, and staffing of the typical complexity of aligning an expanding clinical enterprise AHC have all increased. to educational and research programs also in need of Note in figure 32 that the number of compet- re-engineering creates a further challenge for leaders. ing R01 awards has actually decreased by nearly 15% across the 20-year period, and consider the One critical marker of convergence must be implications for traditional criteria of promo- defining career pathways for faculty that honor tion and tenure. Consider also a recent study that academic values, including the core value of found less than 1% of all scientists published at tenure, but construct models at each phase of a least one research paper every year from 1996 to lifetime that are economically sustainable, flexible, 2011.28 Clearly the terrain has shifted and is con- Figure 2. Research Faculty Career Development Pathways: Respect, retool, change function, adjust salary27 n Balance PI with team n Retirement financial planning contributor roles n Networking events with io n at n Redirectresearch interests emeritus faculty to teach faculty r around institutional assets what to expect in retirement Facilitate collabo and strengths Step-wise retirement Phase-out n n Mini/nano-sabbaticals n Emeritus or honorary status n Certificate programs ol in teaching to Buy-out windows n Re Mid-career Late-career research faculty research faculty Fu Modify salary base/tenure Fu n ct n ct ion guarantee adjustments n ion n Leadership development programs n Administrative roles • Formal mentor • Fundraising • Community outreach • Lead global initiatives Source: AAMC Advisory Panel on Research: Research Issue Briefs, 2013-2014 reproduced with permission.27 15 Figure 3. Number of Competing Awards (with Breakout of R21)2 25,000 RPG plus Supplemental Appropriation (ARRA) RPG Research Project Grants (RPG) 20,000 19,391 R01 Equivalent Awards 16,805 R21 Awards 15,000 Awards 10,393 10,000 9,032 8,997 9,326 7,430 6,758 8,310 President’s Budget 5,436 5,000 5,849 4,902 1,932 1,299 1,771 52 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: NIH Data Book: http://report.nih.gov/nihdatabook/index.aspx and supplemental tables available in RePORTER reproduced with permission.2 tinuing to change for what were once considered time to first independent research.19 career norms. n id-career: focus on respect, recognition, pro- M Of equal concern, from the standpoint of motion paths for faculty serving institutional career pathways and talent management, is the priorities (such as cross-cutting health services success rate for first-time NIH grant applications. research and QI implementation) that do not Across the board, they are down significantly necessarily result in sponsored research grants from 1995, and only about half of what they were and traditional publication. in 2000 (figure 4).2 n ate-career: redefine tenure; find productive L AHCs must be mindful of what is ideal and models for researchers with slowing productivi- what is feasible as they look to their educational, ty to contribute institutional service, mentoring, hiring, and tenure pipelines in an era of funding community outreach; or identify other mecha- constraints and the changing variable of large nisms to improve the financial viability of the research groups and team science, both within overall enterprise and provide the resources to and across institutions. Again, the ecosystem for invest in strategic priorities. researchers is changing, and we must continue to Fortunately, there is evidence from AAMC adapt. that many institutions are beginning to recognize Changes are needed to measure and promote these realities and are in the early to mid phase of success for faculty across the career path: responding appropriately, as shown in a faculty n ront end: shorten postdoctoral fellowships and F personnel policies survey from 2012 (figure 5).27 16 Figure 4. Success Rates for New (Type 1) Applications, Including First-time R01 Awards2 30% 26.2% 25.3% 25% 25.9% 24.1% 20.6% 21.9% 20% 20.4% Success Rate 19.2% 18.6% 16.7% 16.3% 15.3% 14.6% 15% 14.8% 14.9% 14.3% 13.4% 13.4% 10% Research Project Grants (Type 1) R01 Equivalent (Type 1) Awards 5% First-time R01 Equivalent Award 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: NIH Data Book http://report.nih.gov/nihdatabook/index.aspx and supplemental tables available in RePORTER reproduced with permission.2 Extending the Continuum subspecialty areas is expected to disappear. A recent AAMC report,13 warns of the “collapse” of Persistent gaps within and without AHCs must be clinical margins under unremitting pressure from closed—especially the gap between the academic Medicare and Medicaid, (research- and teaching-oriented) and clinical (patient-oriented, clinical revenue-generating) putting enormous tension on the component parts sides of the house. To do that effectively, academic of the AMC [academic medical center] to compete medicine must look to other parts of their own for scarce resources and limiting the ability of clinical universities—including business and engineering services to cross-subsidize the academic missions.13 (p 3) schools. Academic leaders within AHCs need to explicitly recognize and embrace the engineering In this environment, the study warns, AMCs science base underpinning health system perfor- will face only four options: form a system, join mance improvement. collaborative networks, merge into a system, or In addition to the many other aforementioned “shrink in isolation.”13 (p. 5) The bottom line will be considerations mentioned, the out-year pros- to find creative ways to become leaner and more pects for health care reimbursement make it clear efficient, better at providing care, more effec- that academic health systems will come under tive at managing chronic diseases, adept at using increasingly intense pressure. Their ability to shift advanced information technology, and capable of revenues from a few remaining high-premium, improving the health of communities. 17 Figure 5. AAMC Data: Changes to Promotion, Tenure 2008-201227 0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Revised P&T guidelines to broaden the definition of scholarship Revised P&T guidelines to include emphasis on interdisciplinary team science Changed Actively considering change No change No response/NA Source: AAMC 2012 Faculty Personnel Policies Survey Recent Changes Report. Data from LCME accredited institutions (112 respondents) reproduced with permission.27 Case Study: Emory-Georgia Tech Healthcare In- at both Emory and Georgia Tech to see what novation Program lines of health services research already existed. Now entering its fifth year, a novel program Surprisingly, although there was much relevant founded on a partnership between Emory Uni- activity in Emory’s Rollins School of Public versity and Georgia Tech has made surprising Health, there were even more health services discoveries—and resulted in gratifying, unex- research grants at Georgia Tech than there were pected achievements. Fred Sanfilippo, MD, PhD, at Emory. These were based largely in the College executive director, gives credit to the rich health of Engineering, in the discipline of industrial and care and research ecology of Atlanta, as well as the systems engineering. The entire canvass turned strong appetite of researchers within and across up more than 250 funded projects with more than participating institutions to find others with 200 participating faculty. whom they can partner and collaborate.29 That’s a A data-rich website, hip.emory.edu, was need that the Emory-Georgia Tech Healthcare In- developed to promote information sharing and novation Program (HIP) was designed to fulfill. networking. An external advisory board was Institutional goals were to expand the quality, appointed, representing nine AHCs and other scope, impact, and recognition of health services groups from outside the state of Georgia. Ex- research, without creating an expensive new op- ternal members were generous with their time, erating unit at either institution. Health services information, and advice. Other members came research was defined simply and elastically as any aboard. HIP university participants now include research designed to improve the cost, access, and Morehouse School of Medicine and Georgia quality of health care. State University; health systems include Emory Like the proverbial mustard tree, HIP began Healthcare, Children’s Healthcare of Atlanta, with a seeming pittance—less than $150,000 a Grady Health System, and the Atlanta VA Medi- year in operating budget and one-half FTE staff cal Center; and other organizations include the support. Much has grown from that kernel. Atlanta Clinical & Translational Science Institute The first step was to inventory existing grants (ACTSI), the American Cancer Society, Kaiser- 18 Permanente, and the Centers for Disease Control versity of Georgia, and one from Northwestern. and Prevention. Hospital staff from all four participating institu- Within institutions, HIP brought together tions have been awarded grants. schools and disciplines in a new way. For example, Metrics of effectiveness are elusive, but two at Emory, liaisons were drawn from all the health types of measures seem promising. professions schools but also from arts and scienc- One metric is the number of people who have es, business, and law, as well as Emory Healthcare. been engaged in the work of HIP. More than 1,750 Significantly, HIP became an information-sharing persons from more than 50 institutions have been bridge for quality improvement efforts in Emory involved in HIP’s various programs in some way. Healthcare and academically based health services In addition, since 2011 HIP’s website has had research. more than 56,000 visits from all 50 states and 155 Another major form of outreach and activity countries. was creating student activities and symposia and And although it is difficult to prove causation, identifying representatives from each partici- the work of HIP over the past four years is corre- pating institution. “You can get a lot done with lated with a dramatic upsurge in externally funded students,” says Sanfilippo. “Students drive a lot health services research at Emory. From FY11 to of these activities.” HIP offers them not only a FY13, health services research funding increased chance to meet and collaborate with each other by $22.9 million, even while all other sponsored within and across institutions but also the oppor- research was declining (see table 2). The bulk of tunity to identify and reach out to faculty mem- the health services funding is from NIH, and the bers in relevant research areas. bulk of the increase is from NIH. In addition to holding annual symposia on “A 150K annual budget that is associated with the subject “U.S. Healthcare: What’s Broken and a $23 million increase in funding two years later How to Fix It,” the HIP has held six rounds of is probably a good return on investment,” says grants competition and awarded 14 $25,000 seed Sanfilippo. grants to date. The grants are being funded by *** ACTSI and participating institutions. Awards have gone to cross-institutional teams that involve 220 The Blue Ridge Group believes it is past time faculty from Emory, 51 from Georgia Tech, 23 for AHCs to engage in a comprehensive and sus- from Georgia State, 12 from Morehouse School of tained critique of their own research enterprises Medicine, two from Duke, one from the Uni- and health systems (as they regard their academic Table 2. Emory FY 2011 versus FY 2013 Health Services Research Funding29 FY 2011 FY 2013 Change Health services $27.4M $50.3M (9.9%) $22.9M (84%) research (5.1%) p<0.0001 Other $512.2M $456.8M (90.1%) -$55.4M (-11%) (94.9%) Total $539.7M $507.1M -$32.6M (-6%) reproduced with permission.29 19 “partners”)—to wit, our institutions can be too lowing recommended protocols and wearing the slow, too expensive, and too inefficient in their prescribed protective gear, governors responded use of outside dollars as applied to the needs of by ordering quarantines that were neither medi- society.18 cally supported nor politically popular with many However, in every crisis there is opportunity. Americans. In this case, we are awash in new potential to Writing in JAMA online about the Ebola apply academically rigorous health services re- epidemic in West Africa, Boozary and colleagues31 search—defined as research focused on improve- make the case for understanding “quality as a ments in the functioning of the health system cure” in health care, with three important aspects: itself—to our own institutions. Subjects of this safety, effectiveness, and respect for the dignity research can include administrative structures of individuals. Failing to maintain focus on these and services; systems support; and structural, three elements leads to distrust of the health care functional, cultural, and operational separation system, which in turn causes behavior that helps of health care and research, even within the same perpetuate epidemics in places like West Africa, institution. they say. Extending the argument, who is to say Strengthening the whole enterprise bolsters responses in the U.S. would be so different if we basic science and research at every stage of the in this country were ever to witness an outbreak continuum. Health services research itself is of a high-mortality disease with hundreds of increasingly being funded by internal and external new cases per week (much less thousands)? They sponsors, but often the rigor and benefits of health observe: services research are not being applied systemati- cally to the health systems in the same institutions Ensuring that systems are built or rebuilt centered on where the researchers are found. To close this basic principles of quality assessment and improve- circle, right in our own backyards, would un- ment is imperative. Moreover, this must be done in doubtedly be transformative for the provision of ways that build trust with the local communities by health care in America. treating patients with dignity. When people receive As we witnessed the debate over a relative care that is unsafe or ineffective, or they are not handful of Ebola cases in the United States in treated with respect, it is little surprise they avoid fur- 2014, who could not be struck by the fact that this ther care. Preventing such “betrayals of trust” through health crisis—which riveted the White House, the a systematic focus on quality is crucial, for both the national media, the governors of leading states, current epidemic and the next. and the mayors of large cities—reflected two crucial dimensions of biomedical research? Each Case Study: University of Michigan Institute for seemed as important as the other in terms of how Healthcare Policy & Innovation health care is ultimately received and experienced Now in its third year, the Institute for Healthcare by the individual patient and by society at large: Policy & Innovation (IHPI) at the University of 1. The failure of the R&D pipeline to provide Michigan, ncrc.umich.edu/research/initiatives/ us with adequately tested vaccines and drugs— ihpi, has become one of the leading university- even though at least one promising vaccine can- based generators of health services research—for didate had been brought to the point of clinical both the private and public sectors. trials nearly 10 years ago, when it had to be put on IHPI exemplifies how transdisciplinary the shelf for lack of money.30 institutes can work within a school- and depart- 2. Striking disparities in a patchwork of guide- ment-based academic setting, with strong central lines, protocols, training, and preparation that support and unceasing communication aimed at resulted in early expressions of confidence by pub- magnifying its impact on university colleagues lic health authorities being undercut by cases of and external constituencies alike. illness occurring inside the U.S. When health care Launched in 2011 when Michigan took over a workers contracted Ebola despite—allegedly—fol- site adjoining its campus that had been previously 20 owned by Pfizer, IHPI has the mission of studying the waiver, the state was required to commission how health care works; improving quality, safety, an independent evaluation of the expanded Med- affordability, and equity; and advising policy mak- icaid program. Seeing an opportunity to engage ers. Today, IHPI has more than 400 faculty mem- in high-impact work, IHPI applied for the job and bers. Slightly more than half, 58%, come from the was awarded a five-year contract by the Michigan medical school, while the remainder come from Department of Community Health. 11 other schools and colleges and a handful from Additionally, a number of IHPI faculty par- local groups outside the university. ticipate in collaborative quality initiatives funded John Z. Ayanian, director and the Alice by Blue Cross Blue Shield of Michigan designed Hamilton Professor of Medicine, says IHPI was to analyze care and improve outcomes at hospitals founded by the university with strong backing across the state. Data is pooled on a confidential from the Regents in order to have an impact on basis, and Michigan faculty oversee collection and the provision and improvement of health care and analysis. population health.32 Going forward, Ayanian says, IHPI anticipates Reporting directly to the dean of medicine and major new forms of collaboration with its own with a national advisory board, IHPI has a strong University of Michigan Health System, once the core in health services research, including a strong health system completes a multi-year implemen- data analytics hub, and it is organized for outreach tation of the Epic electronic health record that so research findings move quickly into the public began in 2010. That looming prospect points discourse. to the challenges as well as the opportunities in With its own communications and govern- marrying academic research capacities to clini- ment relations staffing as well as support from the cal services business, in academic health systems university in these key domains, IHPI created an housed under the same roof. “impact accelerator,” led by a professor of medi- Other issues, faced by many cross-campus cine with communications staff support, that is centers and institutes, include how to account for “focused on helping members communicate re- indirect cost recovery on IHPI grants brought search more effectively to policy makers, the pub- in by researchers who work both in and out of lic and private sector, and the media and general IHPI-assigned space and how to recruit, promote, public so work we are doing is used by decision and tenure researchers who have their academic makers in the health care system,” said Ayanian. homes in departments but spend much of their The institute is located in 77,000 square feet professional lives in transdisciplinary team activi- of space, representing an investment of about $12 ties in IHPI. An important challenge is how to million, with an additional 10,000 square feet of measure and communicate the impact of faculty newly renovated space being added in September members’ research on health policy and health 2015. It was backed with annual appropriations in care delivery. the $2.5-$3 million range for its first five years. So far, the investment is paying off hand- somely. IHPI researchers garnered more than Constructing New Metrics $82 million in health services research funding for Success during FY13 and published 1,980 articles in 807 journals—including 138 articles in high-impact It is increasingly obvious that current gauges of journals such as JAMA and NEJM. reputation and ranking are unsustainable for all IHPI’s policy efforts, though, are going well but a few universities and AHCs. The corrosive beyond the theoretical. Michigan is one of the effects of a U.S. News & World Report, “Top Ten” 27 states that opted to expand Medicaid under mentality as applied to 141 medical schools are the Affordable Care Act, and the state legislature being widely felt. Just as it is painful and inappro- mandated modifications that required a waiver priate for institutions to all try to squeeze through from CMS. However, as one of the conditions of the neck of a funnel, so it is with individuals. 21 Grant-getting and high-impact journal publica- performance improvement.33, 34 Experience sug- tion are increasingly difficult for individual re- gests that these awards can be locally significant searchers as well. Collaborations and partnerships in enhancing the perceived credibility of member directed to defined needs and outcomes must be AHCs. Other such efforts could be developed, the hallmark of the new order (see table 3). connecting institutions with the needs and goals AHCs must develop new metrics for their own of their internal and external communities of ratings, to reflect their own missions, values, and interest. achievements against meaningful measures of patient outcomes, community health, and societal impact. A side-by-side measure of “traditional” Conclusion: Collaborate and “forward-looking” metrics is provided in table 3. An analogy could be drawn to developments in and Conquer the area of undergraduate education. U.S. News & Growth in the unfunded costs to sustain the cur- World Report pioneered “beauty-contest” rankings rent models of research will require AHCs to do that reward richly endowed, highly selective insti- the following: tutions. Washington Monthly has responded with n ocus their research investments in the areas of F what it calls “a different kind of college ranking,” greatest strategic opportunity. one that turns the U.S. News ranking on its head: n edirect resources away from areas that are not R aligned with strategy or are less productive. Instead of lauding colleges for closing their doors to n educe inefficiencies in the current model. R all but an elite few, we give high marks to institutions n mprove the depth and breadth of expertise I that enroll low-income students, help them graduate, required to provide core services (e.g., shared and don’t charge them an arm and a leg to attend. services in such areas as research administra- tion that historically have been departmentally One promising example in the area of academ- controlled). ic health is that of the Quality Leadership Awards Greater collaboration will be required to given by the University HealthSystem Consortium make best use of scarce resources within each in- (UHC) to recognize member achievements in stitution and as a sector. That will be true across Table 3. Academic Metrics Metrics that Matter to Others27 n ibliometrics B n mpact on institution I n Reputation Changes to clinical workflows, n unding received F n cores, policies, vision n ublications P n mpact on education and training I + n Student, resident outcomes n Collaborations n itations C n Graduate questionnaire responses n mpact on patients, other I n atents/licenses/start-ups P persons, and communities n Outcomes n National/international “ n Quality metrics prominence” n Engagement reproduced with permission.27 22 departments and schools within universities and To begin with, Vanderbilt starts with an ad- also across institutions. vantage, Balser acknowledges: its hospital, clinics, Five CEOs of leading AHCs, writing recently and medical center are all university-owned; there for the Institute of Medicine, concluded as much,35 is not even a separate faculty practice plan. There- as they considered essentially flat NIH research fore, decisions can be made and implemented in budgets from 2010 to 2020, amounting to a pro- an integrated fashion. jected 25% shrinkage in purchasing power: That allows Vanderbilt to run nimble experi- ments in attacking some of the biggest embar- AHSs [academic health systems] will need to forge rassments in health care—with hundreds of partnerships with each other and with those holding deaths from adverse drug reactions every day (the private sector research resources. New research equivalent of a loaded Boeing 747 being lost every capacities and funding streams can take advantage 24 hours) and an estimated $1.2 trillion in waste8 of patient care and related data systems as tools in caused in part by doing wrong and unnecessary developing novel and accelerated clinical research and things. For instance, while genomic testing to en- knowledge translation strategies. sure the suitability of drugs for individual patients is recommended by the labels for more than 200 Underlining the point, the CEOs added: drugs, the FDA mandates such testing for only four of them.36, 37 In addition, the financial constraints that come with “There is a growing disconnect between what shrinking NIH research support compel the AHS we know from basic science and what we actually community to look to alliances within the commercial implement in care,” says Balser. “There is a big community for the sponsorship of research on clinical opportunity here.” interventions. Emerging recognition of the multifacto- By implementing enhanced electronic health rial nature of disease processes and treatments com- records, along with IRB-approved DNA test- pels the engagement of partner investigators across ing for up to 200,000 outpatients and counting, disciplines and institutions. Vanderbilt is beginning to build an extensive de- identified research resource (BioVU) for identify- These are some of the salient considerations ing new genomic biomarkers for drug efficacy and that led to the establishment of PCORnet—the toxicity, as well as disease risk. In a related project National Patient-Centered Clinical Research Net- (PREDICT), patients are being tested preemptive- work—which is a major initiative of the Patient- ly for a panel of individual genetic variants that Centered Outcomes Research Institute (PCORI). warrant prescribing different drugs from those most commonly used. Case Study: Leveraging the Electronic Health For instance, one gene variant, occurring in Record for Clinical and Translational Research about 2.5% of all people, means standard antico- at Vanderbilt agulant therapy with Plavix (clopidogrel) will not An early investment in electronic health records, work. Patients at risk for heart disease are pre- along with one of the country’s largest groups in emptively tested for this genetic variant, and the bioinformatics, numbering approximately 70 fac- information is stored with their electronic health ulty members, is beginning to pay off in changed record. Coupled to this, VUMC physicians have medical practice patterns at Vanderbilt University decision support that automatically notifies Medical Center, says CEO Jeff Balser.36 them at the time they order a drug for a patient As an application of crossover health services re- having the genetic variant, so that doctors see a search that moves seamlessly from academic study “red box” when they attempt to prescribe Plavix to health system application and back again, the for such patients (see figure 6). Doctors are free Vanderbilt experiment illustrates both the potential to override it. “There are times when they still for improvement and some of the inherent tensions decide to give Plavix because there are contrain- as Big Data interacts with physician practice. dications to the other drugs. It’s not ‘thou shalt’; 23 Figure 6. Decision Support for Clopidogrel/CYP2C1936, 38 Clopidogrel Poor Metabolizer Rules Genetic testing has been performed and indicates this patient may be at risk for inadequate anti-platelet response to clopidogrel (Plavix) therapy This patient has been tested for CYP2C19 variants, and the presence of the 2/2 genotype has indentified this patient as a poor metabolizer of clopidogrel. Poor metabolizers treated with clopidogrel at normal doses exhibit higher rates of stent thrombosis/other cardiovascular events. Treatment modification is recommended if not contraindicated: o Prescribe prasugrel (Effient) 10mg daily and stop clopidogrel (Plavix) startdate, 10 AM Due to increased risk of bleeding compared to clopidogrel, prasugrel should not be given to patients: • that have a history of stroke or transient ischemic attack *** Not known; please check StarPanel • that are greater than 75 years of age • whose body weight is less than 60 kg Click here for more information If prasugrel (Effient) not selected, please choose desired action: o Increase maintenance dose of clopidogrel (PLAVIX) 150 mg daily, startdate, 10AM o Maintain requested daily dose of clopidogrel (PLAVIX) 75 mg daily, startdate, 10AM If not using prasugrel, please select a reason: o Contraindicated for prasugrel o Potential side effects o Patient opts for clopidogrel Other (Specify) Click here for more information Cancel Order Note: The Vanderbilt P&T Committee recommends that prasugrel (if not contraindicated) should replace clopidogrel for poor metabolizers; if this is not possible consider doubling the standard dose of clopidogrel (or, use standard dose clopidogrel). However, there is not a national consensus on drug/dose guidance in this population. Published online by National Library of Medicine and by Wiley Online Library. REPRODUCED WITH PERMISSION.38 Copyright 1999-2015. John Wiley & Sons, Inc. it’s ‘please be aware,’” Balser notes. clopidogrel and 305 of whom were classified as This is, self-avowedly, an experiment in “intermediate metabolizers.” Some were pre- progress. One patient had stents placed at five dif- scribed Plavix anyway; how did their outcomes ferent hospitals, racking up $500,000 in medical compare? Rigorous data analysis is needed. bills, before she came to Vanderbilt and doctors Sometimes common sense is wrong. For realized she had both recessive genes that made instance, Vanderbilt invested in one nurse who her a poor candidate for Plavix. They sent her would be charged with preventing pressure ulcers. home with a different anticoagulant, successfully Algorithms were applied to all patients in the hos- treating her at long last. “That’s one patient, and pital to determine which ones were most at risk of you can’t base medical practice on one case,” said pressure ulcers, and the nurse worked specifically Balser. But an outcome study is now under way with them and other nurses to prevent ulcers. At to determine cost savings and medical outcomes the end of a year, to everyone’s surprise, there was in about 1,620 patients who received stents, 32 of no demonstrable difference in outcomes, despite whom were genotyped as “poor metabolizers” of the intervention. 24 Because of Vanderbilt’s expertise in bioinfor- Figure 7 illustrates one way in which basic matics and its ability to handle large volumes of (but most definitely “mission-driven”) research in data, it has become the center of a clinical data re- the new era will be conducted and begin to pay off search network (CDRN), one of 11 in the country through novel partnerships: funded by PCORI pursuant to the Affordable Care Increasingly, it is clear that the mantra of Act. The Mid-South CDRN39 includes Vanderbilt success in the 21st century will have to be “col- University Medical Center, with its owned hospi- laborate and conquer.” The half-century from the tals, more than 100 clinics, 2 million patients, and 1950s through the 2000s was the era of a spirited the Vanderbilt Health Affiliate Network, bringing arms race among institutions, each vying for brag- together eight health systems, 45 hospitals, 350 ging rights on research dollars, velocity of change, clinics, and more than 3 million patients in five Nobel Prize winners and like markers of achieve- states. It will also network, eventually, with Gre- ment. Limited as it may have been, the competi- enway Medical Technologies, representing more tive spirit embodied in that approach could be than 24 million patients nationwide. sustained and harnessed to national good by the In the case of Vanderbilt, its Mid-South rapidly growing resource pool that nourished it. CDRN will serve distinct regional needs as well as Competition is, after all, an American vir- advance science generally and abstractly. Initially, tue. But in a the network will focus on three disease groups: Collaborations steady-state n Sickle cell disease (SCD), era for AHCs, n Coronary heart disease, and and partnerships it is increas- n Overweight/obesity. ingly clear that SCD patients will be recruited through the directed to defined differentiation Comprehensive Sickle Cell Center (a joint effort around mission of Vanderbilt and Meharry Medical College), needs and outcomes and collabora- which sees about 90% of the pediatric/young adult tion around SCD patients in middle Tennessee.39 must be the hall- strategy will be What about getting paid for all this—or the approaches some of it? Evidence shows that both the federal mark of the new most needed government and private payers recognize the by the Ameri- potential impact of prospective genotyping on order. can society their bottom lines and are beginning to reimburse and economy. for it. Balser says Vanderbilt is getting paid “about Metrics of achievement will have to be chosen half the time,” with Medicare/Medicaid reimburs- differently and communicated both internally and ing about $85 for genetic tests and commercial externally. Faculty, staff, and students will have to payers, about $145. be chosen for different sets of characteristics, nur- And payment has also come in the coin of the tured along new pathways of development, and realm in academia—Vanderbilt researchers have rewarded for unique kinds of accomplishments. gotten about 150 publications and more than $75 Money saved, tests avoided, disparities narrowed million in grants directly attributable to BioVU. or eliminated will be badges of honor—and those wearing them will, ironically, help to free up *** scarce money and other finite resources to engage in every kind of research, from “curiosity-driven” Mentioned in the J&J and Vanderbilt case to “mission-driven.” studies were two kinds of major, institutional collaborations that will fuel advances in the 21st century—advances made possible by Big Data, bioinformatics, cooperation across industry sectors and state lines, and wise investment by all payers— commercial, governmental, and nonprofit. 25 Figure 7. Example of a Breakthrough Partnership27 First of its kind collaboration: 234 institutions, including 21 US medical schools and 14 teaching hospitals n NIH n GSK n University of Miami Health System/ Miller School of Medicine/ John P. Hussman Institute for Human Genomics n U.S. Department of Defense n The Michael J. Fox Foundation for Parkinson’s Research n Federal Ministry of Education and Research n 23andMe n PDGene n Cohorts for Heart and Aging Research in Genomic Epidemiology Journal article screen reproduced with permission from Macmillan Publishers Ltd: Nature Genetics. 2014;46:989-993. Recommendations n e Th academic health community must continue structure or totem that prevents the most effec- to partner with and advocate for the NIH to tive use of finite research dollars. The golden sustain the federal investment in basic research. age has ended. Even while advocacy is critical This investment, particularly in basic science, and must be maintained, it is unrealistic to will come from nowhere else in the magnitude believe we will soon return to the sustained that is required to maintain the world’s fore- upward trajectory of the first half-century fol- most research base in the life sciences. In our lowing WWII. It is now incumbent on AHCs to system, only AHCs, supported by the federal adapt and reinvent themselves to maximize the government, have a sufficiently rich pipeline of productive use of any and all funding available. human capital, research infrastructure, scien- n Institutional leadership must be recognized, re- tific expertise, and cultural memory required to inforced, and supported by boards and national perform the basic research that will lead to new leadership in making transformative decisions drugs, therapies, and health advances in 10, 50, to respond to the new realities of steady or or 100 years. Absent a robust continuing federal declining funding for research (at least in the commitment, all of this is at risk because the near term). But leadership from the top, though requisite funding is not coming from other necessary, will not be sufficient for the challeng- areas. es of the 21st century. Leadership from all levels n e academic health community must be Th is critical as well, particularly at the department prepared to rethink any and every traditional chair and laboratory director level. 26 n Universities and AHCs should develop new of thorough, consistent, and ultimately trans- rubrics for evaluating impact based on metrics formative organizational change. System-based that are meaningful to all stakeholders. Quality quality-improvement programs must cooperate and safety metrics, such as those developed by and collaborate with academically based health UHC, are one example, as opposed to U.S. News services research programs, and vice versa. & World Report-style beauty contests that en- n Meaningful collaboration between and among courage wasteful “arms race” spending. Institu- institutions—both within and across states tions should promote, publicize and encourage and regions—must become the new norm. these alternative and more informative metrics Multi-center clinical trials are a well-established for rating institutions and gauging their quality concept, but higher-level and strategically and impact, helping to educate internal and designed institutional collaborations must now external publics about how to measure excel- become just as common. That’s true both for lence in more socially meaningful ways than by positive reasons (research opportunities that counting and ranking research dollars. are made possible by pooling and analyzing n Private philanthropy is a critical source of massive volumes of patient data) and negative support and must be vigorously and creatively (waste reduction, taking total cost out of the pursued by every institution. Institutions must system, which is only possible by system wide look for areas of convergence between their changes).8 own needs and opportunities and the expressed n AHCs must specialize and differentiate around goals and visions of philanthropists, including areas of research, even if this has the effect of individuals and foundations. However, institu- seeming to limit institutional ambition. There tions must also be realistic with themselves and must be no embarrassment in admitting what others about the indirect as well as direct costs an era of constraint now impels. No institution associated with running a university-based can do everything. Especially at the level of research enterprise. Each institution must ulti- basic research, institutions will gain effective- mately direct its own research priorities in ways ness and impact by recognizing their strengths that are consistent with its mission and strategic and building on them. Leveraging institu- plan. tional strengths by combining with partners to n Academic and clinical services businesses— magnify areas of excellence and infill areas of universities and health systems—can no longer need will increasingly be the norm, expected afford the operational abyss and arm’s-length by board leadership and political stakeholders decision-making that have often character- alike. ized their relationship in the past. Meaning- n AHCs must do a better job of educating ful integration of the academic and clinical their own constituencies, beginning with sides, which we have defined as convergence, faculty, but also including senior staff, stu- is required. While health systems have always dents, and others in the university context generated revenue that supports their medical about their financial realities. This must be school partners, this is not enough going for- rooted in greater degrees of transparency ward. Academia needs to learn from health sys- about funds flow within AHCs, including tems by becoming less cumbersome, and health between the academic and clinical sides of systems need to open their arms to academia to the enterprise and between the AHC and infuse high-quality research into every aspect the rest of the university community. There of their operations, from clinical trials to health must be a substantial commitment to inter- services research. 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Accessed January 30, 2015. 30 About the Blue Ridge Academic Health Group The Blue Ridge Academic Health Group (Blue Ridge Group) studies and reports on issues of fundamental importance to improving the health of the nation and our health care system and enhancing the ability of the academic health center (AHC) to sustain progress in health and health care through research—both basic and applied—and health professional education. In 18 previous reports, the Blue Ridge Group has sought to provide guidance to AHCs on a range of critical issues. Previous reports identified ways to foster a value-driven, learning health care system for our nation; enhance lead- ership and knowledge-management capabilities; aid in the transformation from a paper- based to a computer-based world; and address cultural and organizational barriers to professional, staff, and institutional success while improving the education of physicians and other health professionals. Reports also focused on updating the context of medical professionalism to address issues of conflict of interest, particularly in the relationship between academic health professionals and institutions and their private sector partners and sponsors; quality and safety; and improved care processes and innovation through the use of informat- ics. One key report explored the social determinants of health and how AHCs could reshape themselves to address this critical dimension of improving health. The group also issued a policy proposal that envisioned a new national infrastructure to assure ongoing health care reform, calling for a United States Health Board; identified oppor- tunities and the most critical challenges for AHCs and their partners as the Accountable Care Act (ACA) was implemented and examined ways in which AHCs could leverage their unique characteristics and capabilities through the ACA to improve health care, research, and training systems. For more information and to download free copies of our reports, please visit www.whsc.emory.edu/blueridge. 31 Previous Blue Ridge Reports See http://whsc.emory.edu/blueridge/publications/reports.html. Report 18: A Call to Lead: The Case for Accelerating Academic Health Center Transformation. 2014 Report 17: Health Professions Education: Accelerating Innovation Through Technology. 2013. Report 16: Academic Health Center Change and Innovation Management in the Era of Accountable Care. 2012. Report 15: The Affordable Care Act of 2010: The Challenge for Academic Health Centers in Driving and Implementing Health Care Reform. 2012. Report 14: The Role of Academic Health Centers in Addressing the Social Determinants of Health. 2010. Report 13: Policy Proposal: A United States Health Board. 2008. Report 12: Advancing Value in Health Care: The Emerging Transformational Role of Informatics. 2008. Report 11: Health Care Quality and Safety in the Academic Health Center. 2007. Report 10: Managing Conflict of Interest in AHCs to Assure Healthy Industrial and Societal Relationships. 2006. Report 9: Getting the Physician Right: Exceptional Health Professionalism for a New Era. 2005. Report 8: Converging on Consensus? Planning the Future of Health and Health Care. 2004. Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century. 2003. Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center. 2001. Report 5: e-Health and the Academic Health Center in a Value-Driven Health Care System. 2001. Report 4: In Pursuit of Greater Value: Stronger Leadership in and by Academic Health Centers. 2000. Report 3. Into the 21st Century: Academic Health Centers as Knowledge Leaders. 2000. Report 2: Academic Health Centers: Good Health Is Good Business. 1998. Report 1: Academic Health Centers: Getting Down to Business, 1998. 32 Notes 33 Notes 35