The years of traveling to the Piedmont, Norfolk, or even farther for the last word in medical treatment were over for the people of North Carolina's easternmost counties. University Health Systems of Eastern Carolina, resting on its sturdy tripod of a medical school, a state-of-the-art hospital, and associated smaller hospitals and physicians in private practice, is one of the state's largest health care systems. It offers the residents of its 29-county service region more than 700 hospital beds in Greenville, and as many more in its affiliated community hospitals. Its 7,000 employees all stand ready to utilize their skills to support the health and comfort of the patients who need them. As a tertiary referral center, PCMH supplies comprehensive acute, intermediate, and outpatient health services to more than 1.2 million people in the east.

Between 1951 and the end of the millennium, there have been radical changes in Pitt County as in the entire nation in what "healthcare" means. It has evolved from waiting for illness to come, then attempting to treat it, with heavy reliance on hospital-based care. Instead, healthcare providers have changed their point of concentration from rehabilitation to lifelong wellness, from treatment of illness to keeping their clients well, encouraging wholesome diet and a healthy balance between exercise and rest. Both because of the emphasis on quality of life and economic considerations, hospitalization is a resort only when a physician or other healthcare worker finds outpatient treatment impractical or inadequate to manage an illness.

PCMH's central objective is still to provide care to citizens of Pitt County according to their need and regardless of their ability to pay. This main goal has never changed as the overall goal of promoting wellness has come to the forefront. The service mission has become less narrowly focused on treating an individual's disorders out of connection with their families and communities. Treatment has always gone on in a caring and compassionate setting, but now caregivers attend more than in the past to the needs of the whole person.
As an academic medical center, PCMH is the teaching and clinical research site for the medical school and the allied health and nursing schools of East Carolina University. Practicing and improving on the methods at the plough point of medical research delivers benefits to all who utilize the hospital's facilities. Improvements in gathering and analyzing information about the provision of patient care make it possible to specify the choice and timing of procedures so as to enhance their effectiveness and lower their cost.

The provision of tertiary care to people referred from outside the immediate area as well as inside it has become almost as important as the local mission of the hospital. To serve the region effectively has entailed helping to make primary care more available, through cooperative programs with smaller hospitals. This not only benefits patients immediately by lessening their need to travel long distances, but ensures that they reach the appropriate specialists when specialized services are needed.

In implementing its role in the region, University Health Systems has since the administration of Jack Richardson developed clearer and clearer strategic plans. Richardson commented that while strategic planning in the health sciences has only recently become widespread in the United States, it has been going on since the 1970s at PCMH. It has moved from periodic and reactive planning to a process of continual formulation and revision of strategic initiatives that are probes into the future as well as reactions to present and past needs. An unobstructed vision of what it means to serve as the core of an integrated healthcare delivery system is the result. It is now possible to formulate, though always tentatively and flexibly in response to changing situations, the roles that the hospital, the medical school, and the private physicians and community hospitals ought to play and are likely to play in the future of the East.

The medical center has been ahead of the rest of the world in two ways that have made it a model of raising the health status of a large geographic region - where there are, in spite of diversity, a number of outstanding common characteristics. There have been and still are sweeping shortages in health care services, varying somewhat between the mostly agricultural countryside and small towns on one hand, and the fairly large urban areas such as Greenville, Goldsboro, New Bern, Wilmington and Kinston on the other. The region as a whole is one of low income, many mediocre schools, and a low literacy rate. It is also an area with a high incidence of heart disease associated with elevated cholesterol levels, of cerebrovascular strokes associated with high blood pressure, and of diabetes. Many of the statistically significant health problems relate to the low income and poor diet - too much fat and sugar, too little protein, fresh vegetables and fruit - in the East.

The culture of planning is the first main difference between PCMH and hospitals elsewhere. As Richardson says, planning is now widespread, but it is still at an earlier stage of development than it is here, where we have been refining it for over 20 years.

The second important difference is the shift that has been taking place also since the 1970s from overriding emphasis on acute care services to emphasis on community health and wellness. As a tertiary care center, PCMH still pays much attention to surgery, inpatient medical treatment, and all the functions needed to support them. This is the face it turns especially to the surrounding region, outside Pitt County. It continues to present that face to the local citizens, while at the same time developing the many aspects of primary care, community health, and wellness initiatives.


Both planning and community initiatives will determine where University Health Systems goes in the future. The centers of emphasis that have grown out of the planning process are all, as far as possible for each, family centered. The planners, working with the hospital staff and administrators, have distinguished several of these centers. Some of these are rehabilitation, adult, pediatric and neonatal intensive care, surgical and medical cardiopulmonary services, trauma, ambulatory care including outpatient surgery, oncology, wellness and prevention.

The earliest centers were the Regional Rehabilitation Center, the Children's Hospital, and the cardiac surgery program that is now a crucial element in the Heart Center.

The administrators of the Regional Rehabilitation Center have worked with the planning staff to project as far as possible where health care, especially rehabilitation, will now go. An important issue will be that of reimbursement for the services actually rendered. Accurate and detailed cost accounting are essential as a basis for negotiation with those who pay for rehabilitation, especially if capitation becomes the dominant mode of payment.

Increasing the range and volume of services is crucial for maintaining the quality of rehabilitation. Offering a full continuum of care, including services from wellness to hospice care and everything in between, is critical for achieving a high level of delivery for the least cost. Continuing involvement in acute rehabilitation will continue to be fundamental, with energetic and imaginative efforts to find ways to decrease length of inpatient stay. At the same time, greater and greater importance must be attached to subacute, long-term care, wellness, day treatment, and prevention, not only at the PCMH center but in shared ventures in community hospitals.

Without diminishing the attention and importance given to the Children's Hospital, the spectrum of perinatal care has broadened to emphasize equally Women's Health Services, prenatal care, and involvement of the whole family in children's health. UHS makes its presence felt before, during, and after an infant's birth. In uncomplicated pregnancies, the Birthing Center affords home-like surroundings for mothers and infants. When the birth is complicated, the Level III neonatal intensive care unit and the pediatric intensive care unit are brought into play. The expanded 50-bed NICU will enhance the ability of the pediatric staff to care for newborn who are at risk.

Into the new century, all of the services centered on the health of mothers and infants must be extended and enhanced, even though many families in the east find it difficult or impossible to pay for the best of care. Up to now, UHS has been forced to pour large sums of money into services for which it has not been reimbursed. It is likely that a major task for the future will be seeking sources of funds to cover the expenses of continuing to supply these services, whether the recipients can pay or not.

The Heart Center, the major cardiac care center in eastern North Carolina, will continue to function in the leading edge of heart surgery and medical treatment of heart diseases. Already, cardiac surgeons are carrying out minimally invasive procedures using the da Vinci surgical robot, principally for mitral valve repair, bypass surgery, and congenital heart ailments. The procedures are being extended to arrhythmias and congestive heart disease. The new instrument system, placing the surgeon "inside the heart," can only increase the number and successfulness of operations beyond the 1,200 open-heart surgeries already being performed each year.
Besides the robotic instruments for heart surgery, there are also constant developments and improvements in diagnostic tools that lead to improved medical treatment of heart disorders. The Heart Center will continue to keep pace with the latest advances here.

Any hospital's emergency department, the one service whose door is wide open 24 hours a day, seven days a week, becomes for many patients their first and often their only healthcare provider. When a family does not have a doctor of its own, emergency physicians must make it their responsibility to decide on immediate courses of treatment that in many cases determine later long-term therapies. The Pitt Emergency Services nurses and doctors who are the first to meet sick or injured persons bring to bear all of the resources of the medical center to respond to their needs. While in disasters the activities of Emergency Services are displayed most dramatically, it is in the handling of day to day, nitty-gritty calls for help that they most clearly reveal their nature.
One result of the constant availability of emergency care has always been its high cost. Also, because the emergency service staff must use their time to deal with anyone who comes, if only by dispensing an aspirin and the advice, "Call your doctor in the morning," the costs often cannot be recovered. The role of gatekeeper has become a major function of emergency services, its significance growing as managed care, with all its regulated delivery of healthcare, becomes more prevalent in eastern North Carolina.

Responding to its changed role and to prepare for the impact of further shifts in the delivery of health care, the Emergency Service of UHS has formulated its mission as providing trauma services, transportation, disaster response and education as well and as cost-effectively as possible. It will inevitably continue to be the portal of entry for many patients, including those with their own family physicians who find it more convenient to make use of the hospital's facilities than to open their offices at three o'clock in the morning. Women in labor will doubtless continue to enter the hospital via the emergency room. Mental health crises know no hours, and both detoxification and mentally ill patients will find their way in the middle of night to the busiest and most brightly lighted entrance to the hospital.

The Trauma Center furnishes a service particularly important in eastern North Carolina. Accidents and injuries are especially frequent in any agricultural area like this one. Operators of farm equipment face a serious risk when they are injured by their own powerful machinery.

The straight, unobstructed rural roads of the region are a tremendous temptation to inexperienced drivers to see how fast their vehicles will go. A recent report of the Trauma Center observed that a 16-year-old, male or female, is four times as likely be involved in a car crash as a 30-year-old driver. A further hazard of the rural setting is that so many highways are only lightly traveled, and a crash victim may not be found for a hour or even until the following morning. Motor vehicle crashes accounted for nearly 41 percent of all the trauma admissions to PCMH in 1998. The Trauma Center has assumed responsibility for educational programs in regional hospitals and local rescue squads. For each patient referred from another hospital a report is sent back summarizing the care that is given and offering education if needed. Such transfers made up 59 percent of patients admitted to the center during 1998, and they are likely to increase in number each year during the coming century.

The Leo W. Jenkins Cancer Center has become one of North Carolina's preeminent cancer centers. During its first ten years, its staff of specialists diagnosed and treated more than 10,000 new cancer patients. It has entered the sphere of public education with its "Buddy Check" program aimed at detecting breast cancer, and prostate and skin cancer screening days. It has been intimately involved in the educational programs of the medical school and PCMH's residency training with periodic one-day symposia on breast cancer, a post-graduate course on sentinel lymph node biopsy, and formation of new tumor boards for breast and lung cancer.
Patients, especially those whose diseases resist conventional treatment, are offered opportunities to participate in national or locally initiated clinical trials of new treatments. Research is being directed toward cancers in women and children, toward use and evaluation of radiation and chemotherapy, and toward leukemia and surgery in breast and bowel cancers.

New programs are continually being developed, and outreach clinics expanded throughout the 29-county service area of University Health Systems of Eastern Carolina.

A Vision

University Health Systems has a vision. Its primary role is to help establish an integrated health delivery system in eastern North Carolina. Responding to both healthcare needs and economic imperatives, the system must further change its focus from treating the sick to improving health status. Through emphasizing primary care, wellness, and prevention of illness, furnishing alternatives to acute care and other more costly services, it will best serve its clients and its own continuing viability.

While physical facilities, especially the most up-to-date equipment for diagnosis and treatment, are absolutely essential, the system must strongly emphasize assembling the most effective possible combination of providers. Primary care physicians, well-trained nurses, and medical and surgical specialists must be ready to deal with acute care and plan subsequent rehabilitation. Home health, nursing homes, and hospice services are no longer "options," but requisites in providing for the whole-life health of the area's citizens.

The providers will function most effectively if they are brought together into networks rather than function in isolation. Private practitioners working out of their own offices and clinics still have a role in a region of many small communities, but they can be productive only if advanced care is available reasonably near by.

University Health Systems' emphasis on the well-being of the population it serves is fully consistent with its mission. This mission is to function as an academic medical center, comprised of a hospital, a medical school, and a network of private physicians. In the hospital, teaching as well as treatment is carried out. The medical school trains specialists along with the family practitioners who are its main charge. The diverse group of private physicians forms a loose network both in the immediate vicinity and across the area. They are themselves connected by a web of clinics and community hospitals affiliated with UHS. During the next century, the system's effect must be felt increasingly from the Outer Banks to the irregular western boundary of its 29-county region of responsibility.