The Cancer Center

It was appropriate that treatment of the second most frequent cause of death, cancer, had been more and more a focus of attention at the hospital and medical school. Radiation treatment had begun at the still unopened cancer center as early as 1985. Dr. Donald Lannin, associate professor of surgery at East Carolina University, announced on June 30, 1992, that Pitt County Memorial Hospital had been awarded credentials as a Teaching Hospital Cancer Center by the American College of Surgeons’ Commission on Cancer. He said that in terms of clinical care, this was as high as the hospital could go, and that the recognition would help it to obtain research grants and doctors’ referrals. It also brought greater credibility to the ECU medical school’s teaching hospital, placing it on the same level with Duke, Chapel Hill, and Wake Forest hospitals, which were also teaching cancer centers. “I think it’s a stamp of approval that (patients) can get as fine cancer care at PCMH as they could get anywhere in the country. It gives them the confidence that they would get the most specialized care. Anything that can be done anywhere can be done here,” he said.

At that time, PCMH treated about 1,100 new cases of cancer each year, along with additional cases of recurrence and patients who needed continued care. The accreditation required the hospital and medical school to establish a cancer committee of physicians, nurses, social workers, and others who worked with cancer patients. The committee met regularly to discuss new developments in cancer treatment. A second requirement was setting up a tumor registry, through which the hospital followed up on cancer patients’ recovery or the recurrence of cancers.

Lannin said, “Now cancer is treated with multi-disciplinary teams. Cancer treatment has evolved from being something you could do at any hospital to something you need to do in a specialized place.” Where traditional treatment relied mostly on surgery, the specialists at PCMH had found that using a variety of approaches worked best.

The New Bed Tower

Meanwhile, work was continuing on the new bed tower, whose first floor would house the Heart Center, expanded nuclear medicine, nuclear cardiology, and ultrasound departments, as well as support space for surgery. On the second floor would be three eight-bed intensive care units and 50 intermediate care beds. The third and fourth floors would each have 24 intensive care beds and 36 intermediate care beds. The present cafeteria and dietary service areas would be expanded into the new building. The project would necessitate hiring about 237 new employees, including nurses and allied health workers, as well as recruitment of 37 new physicians. The addition would bring PCMH’s bed count to nearly 750, making it one of the largest hospitals in the state.

Diane Poole, vice president for administrative services, was in charge of making the bed tower operational. She said the bed tower corridors were designed to segregate patient traffic, visitor traffic, and material transport from one another. Each type of traffic flow would have its own bank of elevators. There would be a sky bridge on the third floor for the convenience of staff and patients, connecting the new tower with the existing ones.

After completion of the bed tower, the present labor and delivery suites were to be converted to an outpatient surgery unit with two operating rooms. The pharmacy and central supply area would be enlarged. In the fall, construction would begin on a 12-bed pediatric intensive care unit to be located in a new floor to be built on top of the Birthing Center. A new entrance for a Children’s Hospital and Women’s Hospital would be added by renovating the storeroom and the Birthing Center, to provide access to the hospital-within-a-hospital that would comprise patient rooms, the Birthing Center, labor and delivery suite, and nursery.

The dedication of the bed tower was postponed from October 15 to October 31, 1993 and its opening delayed until the middle of November by minor construction problems. Governor James B. Hunt, Jr., was on hand for the ceremony, and after touring the new facility said that PCMH was “the hospital of all of eastern North Carolina. We are at the capital of eastern North Carolina.” He commented that economists had estimated that the 450 new jobs brought in by the expansion would add $41.5 million to the area’s economy.

“This hospital, this medical school are a magnet for economic development,” he said. “It helps us to attract into our area the very best. I want us to continue to invest in the future of Greenville and Pitt County. I believe our best days are yet to come.”

Healthcare at a Distance

In the early 90s, the ECU Center for Health Sciences Communication was making a name for itself nationally and internationally in the area of telemedicine. In a February 1993 interview, David Balch, director of the center, described their first year of experience with a telemedicine system designed to enable the doctors at Central Prison in Raleigh to consult about their inmate patients with specialists in Greenville. Two-way television connections with sound and data transmission linked offices at the Brody Building with a doctor’s office at Central Prison. The inmate and the prison’s primary care physician would walk into the office, turn on the television equipment, and see a doctor in Greenville. The doctor in Raleigh faxed the patient’s record to Greenville, so that the consultant could have it before him.

“Our doctor asks the patient a lot of questions, and can use a digital stethoscope to monitor the patient’s heart,” Balch said. Some doctors were skeptical at the beginning. “There was strong resistance at first, extreme skepticism. Some people even said it was ridiculous. Now they see it is saving time and covering them legally, as well.” The patient was virtually present in two places. Both the primary-care physician and the consultant could read the vital signs with a digital stethoscope or other instruments. The Department of Corrections saved about $700 each time it could avoid sending a sick inmate to a doctor outside the prison, and also did not have to spend the large sums of money that it would cost to set up and staff its own diagnostic facility.

By June, 1994, the telemedicine program was working in association with the medical schools at Bowman Gray School of Medicine in Winston-Salem, Duke University Medical Center in Durham, and UNC-Chapel Hill. They were seeking federal and state funding to connect the medical schools to rural hospitals across the state. The ECU School of Medicine and PCMH would be linked with hospitals in Belhaven, Plymouth, and with the Naval Hospital at Camp Lejeune. This would provide a connection with 372,000 people in the eastern region. Without leaving their local hospitals, they and their physicians could consult specialists, be examined, study X-rays, and have their vital signs monitored remotely. During 1993, PCMH physicians carried out 200 consultations, more than at any of the 10 other places in the country that were using telemedicine.

Also in 1994, there were two favorable occurrences for the telemedicine program. First, the publishers of Telemedicine Magazine nominated the program for the Healthcare Innovations in Technology Systems “Partnership in Technology” award to be announced at the Henry Ford Health Systems Conference in Las Vegas in the fall. The Center for Health Sciences Communication was one of five finalists for the award.
The specific innovative use of technology that was being recognized was the design and development of suites for telemedicine conferences. Using them, specialists at PCMH and the school of medicine could consult with patients in rural counties who could not come to the medical center. The suites safeguarded the patient’s privacy during consultations. Utilizing the specialized sound, picture, and computer equipment in the telemedicine suites, each costing about $15,000, the doctor could both talk to the patient and observe him over a high-tech television system.

The second positive happening was the fruition of the joint project with the other medical schools in the state: an award of $2 million in three federal grants to be conveyed during the next three years for expanding and improving the telemedicine system, and to reimburse doctors and other health professionals who provided their services. The grants could be renewed after 18 months, and would enable the communications center to add hospitals in Belhaven, Camp Lejeune, Faison, and Edenton to those in Ahoskie, Williamston, and Central Prison in Raleigh already connected to the system.

During the week of August 6-11, 1995, five ECU-PCMH telemedicine experts presented a demonstration distributed across the country from a national computer graphics and interactive technology convention in Los Angeles. The coast-to-coast consultations were transmitted over the fiber optics lines of Pacific Bell, Sprint, and Carolina Telephone. After making their presentation, the team arranged telemedicine consultations for 84 persons during the last three days of the conference. Thousands of attendees at the Los Angeles Convention Center visited the booth manned by people from PCMH and the Center for Health Sciences Communication at the school of medicine. Television monitors in the booth carried images of physicians in Greenville interacting with “patients” at the conference.

The exhibit was shown on a Los Angeles television station and on CNN, and was taped for later showing on Japanese public television, the Sci-fi channel, and at NASA. Observers from Europe and the Far East talked with the exhibitors about their interest in building similar systems in their own countries. Representatives of the United States armed forces were interested in what the University Medical Center was already providing to Camp Lejeune and to clinics and hospitals in Belhaven, Faison, and Edenton, and discussed extending similar services to the five military bases in eastern North Carolina.

Healthcare Reform

The new bed tower was evidence of the medical center’s ability to prepare for future growth. However, upcoming changes in healthcare delivery were about to test its mettle again. To deal with the challenges that lay ahead, the hospital and medical school devoted their annual planning retreat to the topic of healthcare reform.
They held the 1993 planning retreat in November, at Hilton Inn, with attendance by invitation. Bob Baker, president of the University Hospital Consortium, told the group, “We have to face the changes that are coming and develop some new tactics… or else we’re going to be in the dark.” University hospitals had to lower prices to compete in President Bill Clinton’s proposed healthcare system, in which consumers would pay for medical services on a monthly basis rather than fee-for-service. Healthcare providers had to provide adequate service more efficiently than they were currently doing, while keeping costs down, or fail to attract and retain customers.

Baker, who represented 62 university medical centers, said that 59 hospitals in the consortium charged on the average 22 percent more for services than the Medicare program paid for those services. He pointed out that consortium members must bring their costs down to those of competitors. One way to do this was to emphasize primary and preventive care, and to avoid purchasing unnecessary technology.

A 1994 interview with Dave McRae, PCMH’s chief executive officer, underscored the effectiveness of the hospital’s ability to survive–and even thrive–in the face of obstacles. During the 18 years since he first joined its administration, it had grown from a community hospital serving the citizens of its home county to becoming one of the state’s foremost regional medical centers. It had affiliated with the medical school to make it possible to give residents of eastern North Carolina access to the latest in medical technology and skill. Association with smaller hospitals in the region had given them the means to overcome limitations on resources inevitable in mainly rural areas. The hospital, in cooperation with the school of medicine, conducted 60 medical clinics in rural communities throughout the east. Even more communities had turned to PCMH to handle cases their local hospitals could not handle. The concept of making links between rural communities and the urban medical center to provide better access to medical care had been with the hospital and the medical school from the start. It was among the reasons healthcare officials across the country looked to the University Medical Center of Eastern Carolina for answers on reforming healthcare.

The PCMH-ECU School of Medicine Heart Center was dedicated on Friday, May 20, 1994. The $20 million facility, which had been put into use the November before, occupied 40,000 square feet of space on the first floor of the bed tower that had been constructed between 1991 and 1993. The dedication was attended by Greenville’s mayor, Nancy Jenkins, and by Dr. Bobby Brown, president of the American Baseball League, who was a retired cardiologist. The ribbon was cut by Dr. Randolph Chitwood, executive director of the Heart Center. Dr. Brown was the guest speaker, and spoke on “Pop Flies and Other Subjects of National Interest.”

A focal point of the medical center’s development was its dedication to cardiovascular services. The center had been established to meet an urgent healthcare need. The eastern region had the highest incidence in the state of high blood pressure, stroke and heart disease. It is true that cardiac surgery had been established at PCMH for nearly 10 years. By 1994, the program included the most up-to-date procedures for diagnosis and treatment of heart problems, and for rehabilitation after treatment. However, the various services were provided at different locations, necessitating a great deal of travel inside the sprawling hospital. At the Heart Center, electrocardiograms, ultrasound, and catheterization gathered the data needed for complete electrophysiological study of a patient’s heart function, information essential for both treatment and research.

The centralization of all the cardiovascular functions had brought about many improvements in the care that patients could receive. Where it had been necessary to bring them nearly a half mile from their rooms, the travel had been reduced to about 100 feet, since the heart patient rooms were located in the bed tower above the Heart Center. Also, much less staff time was consumed in traveling from the clinical, research, and educational areas now in the same wing, rather than from five different departments on six different floors of the medical school.

The rehabilitation programs for heart patients, also located in the Heart Center, were a crucial part of the program. Many heart problems that were treated resulted from lifestyles that were unhealthy—the rehabilitation program was also an educational one. Patients were taught how to make their lives healthier through diet, exercise, and learning to handle tension.

Renewal of Affiliation

At this point, the 19-year-old affiliation agreement between the hospital and medical school was due to expire. Representatives from Pitt County Memorial Hospital and East Carolina University began meeting to discuss renewing the contract. Dr. Ernest Larkin, chairman of the Joint Policy Committee that had written the contract, said that the affiliation agreement of 1975 outlined the terms under which PCMH pledged to support the ECU School of Medicine, and serve as its primary teaching hospital. The contract, which would expire in 1995, had many requirements for both the hospital and the medical school, including that the two maintain their accreditations. “It’s been a very favorable relationship for everybody involved,” he said. “The community has benefited from the whole medical center. I feel real confident that that mutual relationship is going to continue.”

The affiliation agreement renewal was commemorated on December 20 with a luncheon followed by a signing ceremony. Except for a few minor changes, the agreement remained the same as the one signed in 1975 that had guided the cooperation between the hospital and the medical school for 20 years.

Responding to Change

Representatives of PCMH held a workshop with the Pitt County Board of Commissioners on January 30, 1995, to explore possible changes in hospital operation to respond to the transformation of healthcare delivery. The almost universal shift to managed care and health maintenance organizations would inevitably force the hospital to change it emphases. Where surgery and other remedial hospital procedures had in the past brought in the most revenue, the accent was shifting to preventative care and preserving wellness. Unless it could adjust to the reform in healthcare, the hospital’s financial health would be threatened.

Dave McRae told the commissioners that the main trend was toward capitation of healthcare. Organizations large enough to define the terms under which they would provide their employees with health plans were moving to managed care systems in which, for a fixed fee per enrollee, they expected their providers to supply all the elements of healthcare—examinations, laboratory services, X-rays, preventative care, and remedial treatment. The provider became responsible for any losses that might be incurred. A main goal was to avoid treatments that required hospitalization. But hospitals had traditionally depended on intensive and expensive inpatient therapy for most of their revenue. It was essential that they evolve new ways of delivering healthcare that would free them from dependence on surgery or intensive care.

Ms. Barger mentioned joint ventures that the hospital was working on with other organizations to build a stratified managed care system that would distribute risks and return insurance profits to the providers. She believed that a program that operated mainly for profit, having to pay stockholders off the top, would put an unacceptable burden on providers. The medical center was seeking a plan that ensured that revenues went back into care, rather than into profits.

McRae described managed care plans in Winston-Salem and Greensboro in which healthcare providers had banded together and acquired licenses to operate a managed-care system. This had taken a long time. PCMH could not afford to wait, but had to begin adapting to the changes that were already coming. It was likely that within five years, indemnity insurance would no longer exist, and most eastern North Carolina residents would be covered by managed care systems.

The hospital was also seeking coalitions with other providers in the region, to have an organization in place with which managed care companies could contract. For example, Pitt and Bertie county hospitals were discussing collaboration in a horizontally integrated network that might also include other hospitals.

PCMH was also working on vertical expansion into home health, hospice, nursing home care, and wellness centers. HealthEast, a hospital subsidiary, would purchase primary care practices and set up a coalition of physicians to guarantee an adequate number of practitioners to serve the area and to act as “gatekeepers” for referrals to specialists when this was appropriate. This was in harmony with the trend for managed care plans to limit direct access to specialists.

East Carolina Health Services, another venture of the hospital, had begun to provide home treatment and administration of intravenous fluids. In November 1994, it had opened University Home Infusion Therapy. Infusion therapy nurses administered various medications directly into veins: nutrients, antibiotics, chemotherapy agents, and drugs to control pain. They also delivered nutrients by tube directly through the esophagus into the stomach. University Home Infusion was a means of shifting services from the hospital and avoiding the cost of long hospital stays.

Women’s and Children’s Healthcare

Among the most urgent needs in the eastern region of North Carolina, with its infant death rate nearly twice the national average and over one and half that of the state average, was better perinatal care. On February 21, 1995, PCMH held a ribbon-cutting ceremony for the new pediatric intensive care unit and the new admissions lobbies for the Children’s Hospital and Women’s Health Services. The changes had cost $3.8 million, and included renovation and expansion of the old Birthing Center lobby to create two new lobbies. The pediatric intensive care unit was on the second floor of the new construction.

Without traveling from the main hospital lobby, pediatric patients were able to enter the hospital directly through the new Children’s Hospital lobby, which also held play areas and an aquarium designed to minimize the stress of hospital visits on children and their families. Once in the Children’s Hospital, patients would receive most of the services they needed without having to be transported to other parts of the hospital. The rooms were private, and space was provided for family support.

Funds raised by the Children’s Miracle Network Telethon had paid for lobby, waiting room, play area, and family conference room furnishings, and for some portable equipment.

The renovations to the Birthing Center lobby and expansion of the labor and delivery area improved the facilities for obstetrical services. There were 12 labor-delivery-recovery beds, 12 private labor rooms, two intensive- care beds and three rooms for Caesarian sections. In the new nursery there was space for 31 newborn and 10 convalescent infants.

In October, the Children’s Hospital opened the Community Pediatric After-Hours Clinic in a space just off the hospital lobby. The clinic was staffed by nurses from the hospital, and by doctors from three private practice pediatric clinics in Greenville. Kathleen Leonard, nursing administrator for pediatrics, said of the clinic’s patients, “They won’t have to go to the emergency room, they won’t have to wait 12 hours to be seen when the pediatricians office opens, and they will be seen in a supportive environment. It’s a better experience all the way around.”

At its June 1995 meeting, the hospital board of trustees had voted to terminate the agreement to purchase the Greenville branch of Home Health & Hospice Inc. Diane Poole said that the federal investigation of the Goldsboro agency for Medicare fraud was taking so much time that hospital officials thought it advisable to end the plans for a joint venture. Other plans to provide Pitt County and the region with home healthcare were already under way.

The Wellness Center

In July, the hospital took a major step toward providing preventive health services when the board of trustees approved plans to build an $8 million wellness center, to be open to the public. The 43,000 square foot center was to be constructed on 29 acres west of the Stanton Square Shopping Center on Stantonsburg Road. The center would include an indoor pool, fitness machines, and areas for aerobic exercise, and would offer a complete wellness program, including counseling on diet and weight loss and on stopping smoking.
Many of its 1,800 members would be in need of therapeutic interventions, so the center would provide more medical supervision than a typical fitness center, many of whose clients were already fit when they joined. The staff would include occupational and physical therapists, and some of its members would come by referral from physicians for pulmonary and cardiac rehabilitation services. It was anticipated that about 15-20 percent of its members would be hospital employees.

In order to clear the way to opening the center in 1998, the hospital had agreed with Athletic Clubs Inc. of Raleigh, who had objected to the opening of a wellness center in competition with the two private ones already in operation, not to market its wellness unit as a fitness center. All members would be required to have health screenings and to follow individualized wellness plans.

A Home Health Agency

With two other hospitals, Bertie Memorial Hospital in Windsor and Chowan Hospital in Edenton, PCMH filed a competitive Certificate of Need with the N.C. Division of Facilities Services to open a home health agency in Bertie County. This would involve purchasing 40 percent of Bertie Home Care, a subsidiary of the Bertie County hospital, for about $110,000. Skilled nursing, physical therapy, occupational therapy and other services would be developed by Bertie Home Care, of which Chowan Hospital would purchase 5 percent. Previously, the home care agency had provided only bathing, feeding and transportation to disabled and elderly residents of the county.

Mrs. Poole said, “We discharge patients from this hospital (PCMH) to Bertie County. We feel an investment in this home health agency enables us to ensure those patients who are sick and require intense levels of home health services will be adequately cared for.” The agency would also be used as a clinical training site for ECU and Martin Community College healthcare students.

At a public hearing on August 15, 1995, in Windsor, Joseph Bazemore, chairman of the Bertie County Board of Commissioners, and Dr. Alden Davis, a surgeon and medical director of Bertie Home Care, spoke in favor of the planned home health agency. Bertie County had a home health agency operated by the county health department, but the state Medical Facilities Plan had already ruled that another home health agency was needed in the county. The Certificate of Need application was a competitive and not an exclusive one, and several other existing agencies had also applied.

The hospital board of trustees decided at its regular meeting on August 22 to submit a second application for a Certificate of Need to open a home health agency. The initial application had been made in January 1994 after a public hearing The certificate had been approved in April of that year, but was withdrawn in the face of opposition from two home-health agencies already operating in Greenville. Tar Heel Home Health of Kinston and Home Health & Hospice of Goldsboro had both argued that a third agency would duplicate those already present. The 1995 State Medical Facilities Plan had found only 141 patients in Pitt County qualified for home health services but not receiving them, where 150 were normally required as prerequisite to a Certificate of Need application.

Mrs. Poole, PCMH vice president for community-based services, said that she did not know if the two existing agencies would oppose the new application, but hoped they would not. The hospital and medical school needed the facility for training purposes, and the hospital was applying under an exemption provided for teaching hospitals.

Although Tar Heel Home Health filed a protest, the Division of Facilities Services gave final approval in August 1996 to the hospital’s application for a new home health agency. University Home Health Care opened in October, offering skilled medical care to homebound patients. The agency could serve Medicare and Medicaid patients, as well as private-paying ones.