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    What's so "magical" about a new
children's center?

For years, the Emory pediatrics department was housed in trailers behind the children’s hospital. Offices, research laboratories, advocacy programs, and outpatient services were all crammed into these temporary modular units, where faculty and staff performed yeoman’s work ensuring that patients and their families received the care and attention they deserved. Plans for a new building remained in limbo for decades, stalled by one impediment after another—including a contentious divide that grew between Emory and the hospital.
     But today one only has to look around to know that things have changed. The new pediatrics building is an apt symbol for a new era for Emory and Children’s.
     Leading medical centers for children all have one thing in common, says Stoll: a strong tie between a children’s hospital and an academic pediatrics program. Emory and Children’s have all the ingredients to become one of the nation’s top five centers.
     “The leaders of both institutions share that vision,” she says. “And we now have an unprecedented partnership to achieve it.”
  A partnership is born

Emory has a long history with Children’s that stretches back to 1928, when Henrietta Egleston Hospital for Children opened on Forrest Avenue in downtown Atlanta. Although privately owned and open to all physicians, Egleston developed a special relationship with Emory from the beginning. Emory’s pediatrics chair served as medical director of Egleston as well as chief of the pediatrics service at the public Grady Memorial Hospital, with Emory trainees getting the benefit of instruction at both facilities.
     In 1959, Egleston moved to a new 100-bed facility next to the university, cementing its symbiotic ties with Emory. As the medical school added new pediatrics faculty with unique and highly specialized expertise, Egleston’s abilities also grew. Emory’s relationships in pediatric care expanded throughout the area, with faculty and residents at Grady (see A Blended Family), then later at Emory Crawford Long Hospital. Egleston, meanwhile, grew into a regional pediatric referral center where community doctors sent their most complex cases. Each time Egleston expanded into new services, this likewise broadened Emory’s teaching programs.
     In the late 1960s, Emory’s pediatric reach began to extend far past Atlanta and achieved several important milestones over the next few decades. Virologist Andre Nahmias, for example, developed the first genital herpes clinic in the world at Grady, in response to the devastating problem of transmission of maternal herpes infection to newborns during delivery. The Poison Control Center at Grady went statewide in services offered and funding received. Emory’s Cystic Fibrosis Center, started by Daniel Caplan, was the first such facility in the surrounding five states and immediately drew children from across the Southeast. Richard Blumberg, Emory’s pediatrics chair from 1954 to 1981, established the first clinical genetics laboratory in Georgia, which eventually led to the establishment of statewide screening of newborns for genetic diseases. Meanwhile, pediatric nephrologist Barry Warshaw set up the state’s first dialysis program serving children at Grady, later moving to specialized kids-only dialysis services at Egleston.
     When George Brumley arrived from Duke to take the pediatrics chair in 1981, the title of a departmental history published that year, “A Department Comes of Age,” exuded confidence. The future looked bright.
     But then a cascade of events caused an unanticipated schism between Emory’s pediatrics department and Egleston.
A custody battle ensues

In the late 1980s, as the specter of managed care loomed on the horizon, Brumley and the hospital together decided to bring in an outside consultant to help both institutions shape their growth. Soon after the consultant’s report was finished, the head of Egleston left, and the consultant, Alan Gayer, was named the new hospital CEO.
     In the meantime, changes were taking place in the structure of the Emory/Egleston relationship. In hopes of strengthening financial performance in the fast-changing managed care marketplace, pediatric cardiology moved from The Emory Clinic into a newly created Children's Heart Center, forerunner of the Sibley Heart Center. Brumley also moved the rest of the pediatrics section out of The Emory Clinic and created a new group, the Emory Egleston Pediatric Care Foundation (EEPCF).
     Things seemed to go smoothly at first. But as the health care climate became more difficult, seemingly irreconcilable differences in priorities grew between hospital and EEPCF leadership. Hospital leadership was more focused on profitability. EEPCF leadership, while also concerned about financial performance, placed higher priority on university missions in teaching and research.
     In this climate, architectural plans for a new building grew yellow around the edges and then vanished altogether.
     At the end of 1994, Brumley stepped down from the chairmanship to devote more time to the work he started with a private foundation on improving care for children in underserved areas. He also hoped his resignation would be a quiet statement of how important it was that Emory and Egleston repair their strained relationship.
     The person selected to replace Brumley was Devn Cornish, a division director in neonatology who had led the successful joint effort between the hospital and department to establish an extracorporeal membrane oxygenation (ECMO) program. A former missionary, Cornish was as soft-spoken as Brumley and, given the success of the ECMO program, someone who worked well with both Emory and Egleston. Named acting chair in December 1994, he focused on holding the department together and improving the relationship between the hospital and the medical school.
     In 1996, working with Egleston leadership, Cornish developed the Emory Egleston Children’s Center, a practice plan that integrated all 181 members of the pediatrics faculty and all other Emory physicians who cared for children.
     In February 1997, Cornish was named permanent chair of pediatrics. But within a month, significant new strains emerged as Egleston’s Gayer unilaterally began recruiting Children’s Center faculty to leave Emory and become direct employees of the hospital.
     With this new breach of faith, the joint clinical organization between Emory and Egleston became unworkable. Cornish worked to convert it into the current Emory Children’s Center, a subsidiary of Emory Healthcare that is parallel to The Emory Clinic. But this new disruption hurt the department and morale.
     Then, almost overnight, everything changed.
  A blended family  

The strength of many of Emory’s pediatric programs comes from their connection with both Children’s Healthcare of Atlanta and the publicly owned Grady Memorial Hospital, which encompasses its own pediatric facility, Hughes Spalding Children’s Hospital.
     A prime example of collaboration among these institutions is the far-reaching Emory Regional Perinatal Center, established in 1977. Emory pediatrics professor Al Brann, then head of neonatology, had been at Emory for only a couple of years when he and then gynecology/obstetrics chair Luella Klein helped Georgia set up the state’s first statewide regional perinatal referral network. Its goal was to lower death and disability among high-risk infants (and high-risk pregnant women) by making sure these babies and women got the highest level of care they needed, no matter where they received it and without regard for their ability to pay.
     The Emory Regional Perinatal Center, one of six in the state, has responsibility for the area from Atlanta to the Tennessee border.
     The center’s success can be attributed to the pooling of the resources of Emory doctors and three different hospitals: Children’s Healthcare of Atlanta at Egleston, Emory Crawford Long, and Grady, says George Bugg, the Emory neonatalogist who directs the program today. Emory pediatrics is the connective tissue. Emory physicians have always headed the center—Brann himself did so for its first 15 years—and they provide the physician services at all three hospitals.
     It works like this. A baby is born in north Georgia with problems beyond the expertise and resources of the local hospital. The doctor calls the Emory Regional Perinatal advice line at Egleston, where a neonatalogist arranges both referral and transportation for the sick baby.
     Where the baby is taken depends on the kind of care it needs. If a severely premature baby needs ventilation and feeding, it may go to either Grady or Emory Crawford Long, where level III neonatal intensive care units and neonatalogists are waiting.
     If the baby requires surgery, it is likely to be sent to Egleston's level IV center. Because of its state-of-the-art heart center, Egleston also receives many babies with cardiac abnormalities as well as many others in need of the hospital’s surgical subspecialties, such as neurosurgery or otolaryngology.
     The perinatal center's work isn't over once the baby goes home. Doctors provide follow-up care as long as is necessary, with clinics based at Grady and Egleston as well as an outreach clinic in Dalton. Outreach education programs are given regularly at many of the 50 hospitals in the region that are likely to use the center's services.

     Anytime hospitals can work together like this, the children benefit, says Brann. And the relationship between Emory, Children’s, and Grady may become even closer. Children’s and Grady are discussing an agreement that would allow Children’s to assume responsibility for the management of Hughes Spalding, to further smooth the way in coordinating services among the hospitals.
     Speaking for many of the Emory pediatricians he has inspired, Brann says doctors who care for children have no choice but to be an advocate for them.
     He also says that doctors in Atlanta have extraordinary opportunities to learn how to help children more. “No one can duplicate the unique set of questions we are presented with by virtue of our location in Atlanta. We are challenged with an urban center that has issues similar to those in developing countries, along with a complex history with respect to race and class and society. But we also have the benefits of proximity to the CDC, the Carter Center, and our own and other public health resources, with all they offer to understand and improve the health of children at home and abroad. Where else could you bring all that together?”
  The ideal patient experience  

What should the ideal patient encounter look like? According to neonatalogist Lucky Jain, it might go something like this:

     8:30 AM: Mary reaches out to check her Blackberry and smiles at the message. “Good morning, Mrs. Smith. This is to remind you of Andrew’s 9:30 appointment with Dr. Vogler at the Emory Children’s Center clinic.

     “We’re on our way,” she replies. “Thanks for the reminder.”
     9:00 AM: Mary wonders why the traffic on Briarcliff and Clifton Road is so light as she pulls into Children’s parking deck.
     “Good morning, Andrew,” chimes the clinic scantron as Mary scans Andrew’s clinic radio-frequency ID card (RFID). “Welcome to the ECC clinic, and thank you for preregistering. Please proceed to the reception desk.”
     9:05 AM: “Hi, Mrs. Smith and Andrew,” greets the front desk staff person. “You will be seen in room 108, the last door on your right down the hall. I have approval from your insurance, and Hillary knows you are a bit early.”
      “How did she know who we were, Mom?” asks Andrew. “I don’t think we’ve met her before.” Mary tells Andrew about the scantron-linked data, including the patient’s picture that pops up on the screen at the reception desk when his card is scanned.
     Mary is happy that Hillary is back from her honeymoon. Life is so much easier for her and Andrew now that Hillary has become their “health solutions coordinator.” When Andrew was initially diagnosed with systemic rheumatoid arthritis, Mary had spent a great deal of time coordinating his care with different providers. How close she had come to losing her job! Now the clinic is a one-stop shop for patients with complex health problems.
     11:00 AM: Andrew has already seen Dr. Vogler and the new physical therapist. Ever since Andrew started being treated with the nanomedicine approach, he is a different child. The side effects of the steroids have disappeared, and he has regained all of his joint mobility. Mary looks at her watch and is amazed that they are done.
     “Don’t forget your flu shot while you are here. And we have a special parent workshop on childhood obesity starting at 11:30,” says Hillary. As Mary looks over the consent form for the flu shot, she wonders how any health care facility could be better than this.
     Last year, Woodruff Health Sciences Center CEO Michael Johns made a presentation in which he challenged the Department of Pediatrics to create the “ideal patient experience,” combining state-of-the-art care with state-of-the-art service. Jain, a pediatrics professor who also holds an MBA from Goizueta Business School, is working with a group of faculty and administrators to make that happen.
     The days are long past when an academic medical center could focus solely on the most up-to-date care and neglect the patient (and parent) experience, he says. And independent centers, focusing on customer service as a way to compete, are starting to pull ahead.
     Providing the best in service means more than just scantron wizardry and Blackberry reminder messages, he says. Techno bells and whistles aside, the real focus is on examining the entire patient visit to find out where problems occur. Is a backlog at the reception desk throwing off the schedule? What causes that? How can techniques like preregistration and embedding data on RFID cards help, and what’s the best use of such technology? Does miscommunication among specialists caring for the patient contribute to delays or less than optimal care? How can this be eliminated?
     “We are now looking at every step of a patient’s visit to see where bottlenecks and problems occur and where we need to make changes.”
     The team also is examining ways to make visits more efficient and optimize the time physicians spend with patients, he says.
     Asked how high the scantron cards and wireless reminder messages were on the group’s wish list, Jain says the electronic improvements could happen sooner than many people think.
     “If Wal-Mart can use this technology to track packages, certainly we should be able to do this for our patients.”
An attempt at healing

In addition to his difficulties with Emory, Gayer had been waging an intense rivalry with Scottish Rite Children's Medical Center across town. Once a small orthopaedic hospital for children, Scottish Rite had begun a growth spurt in the 1980s, expanding both the size and diversity of its services under CEO Jim Tally. Competition in marketing and fund-raising had exploded between Egleston and Scottish Rite throughout the late 1980s and into the 1990s.
     By 1997, the boards of both hospitals had had enough. Atlanta had a growing pediatric population, and the increasingly bitter competition was distracting both institutions from their mission. The boards announced that they would merge to form Children’s Healthcare of Atlanta and that Tally would be the CEO of the new system.
     At the time, it seemed that this merger might make Emory’s pediatrics situation even more difficult. Emory had few connections with Scottish Rite. But behind the scenes, Tally and the new CEO of the Woodruff Health Sciences Center (WHSC) had been getting acquainted and talking about possibilities.
     When Michael Johns arrived in Atlanta in 1996 to head the WHSC, he and Tally had reached out to each other and liked what they found. Having seen managed care in full force in Baltimore, Johns had found Gayer’s approach to partnering problematic.
     He felt that Tally understood the value of academic medicine. With a doctorate in higher education administration, Tally had held previous positions as assistant dean at Southern Illinois University School of Medicine and as vice chancellor for administration and finance at the University of Arkansas for Medical Sciences before heading Scottish Rite.
     Tally recalls that immediately following the merger, members of the hospital board, including founding board chair Larry Gellerstadt and current board chair Joe Rogers, spelled out the new CEO’s principal responsibilities: “Focus on vision, on new possibilities—and forge a new day in the relationship with Emory.”
     When the merger was announced, the pediatrics faculty too had been pulling for Tally, and their instincts proved right.
     “Dr. Tally turned out to be a real healer,” remembers Barry Warshaw. “He understood health care, and he understood what we at Emory were trying to do.”
     Within three months of the merger, Tally and Johns signed the Aflac Cancer Center agreement. A team of leaders were designated from both institutions to meet regularly and spell out shared goals and the road map to achieve them.
     Six years after Emory and Children’s mapped out their strategic plan, most items on the must-do list have already been checked off or are well under way, according to Johns and Tally. Desperately needed new facilities have been built for pediatrics, and new facilities are under construction for Children’s. A national search culminated in the appointment of Stoll to lead the department after Cornish stepped down to pursue his interest in children’s health in developing countries. Increased investments are beginning to bear fruit in programs and initiatives to benefit both Emory and Children’s.

  New(er) kids on the block  

Pediatric ophthalmologists around the world are eagerly awaiting the results of a new national study on treatments for infantile cataracts conducted at 12 centers across the country and led by Emory eye specialist Scott Lambert. His Infant Aphakia Study, funded through the National Eye Institute, is the first to evaluate the two main treatments for this condition, which affects approximately 1,000 babies each year in the United States. But Lambert might never have obtained the support needed to pursue federally funded research into this rare disease without the help of an innovative grant program at the Emory Egleston Children’s Research Center.
     Established in the early 1980s and jointly funded by the medical school and Children’s Healthcare of Atlanta, the center is a powerful catalyst for pediatric research, fostering studies in new areas and encouraging cross-specialty collaboration.
     The seed-grant program gives clinicians like Lambert the resources to explore new avenues for study and develop them to the point that they can compete for federal funding. The center’s seed-grant recipients sign a contract requiring them to write an NIH proposal within a specific time period—or their division must repay the seed money.
     No one has ever failed, says Ron Joyner, the center’s scientific director. About a third of the seed grants go on to generate federal funding, with $13 million in NIH dollars awarded in just the past six years on projects begun with seed-money grants.
     Many of the most highly funded researchers in the department can trace their start back to these seed grants, says Joyner. For example, Ben Gold, division director of pediatric gastroenterology, used one of the early grants to gather preliminary data on the impact of childhood infection with Helicobacter pylori bacteria, a research area in which he has become a major contributor nationwide.
     And as Lambert’s work demonstrates, the grants are not limited to the pediatrics department. If research will benefit children, it’s
eligible, says Joyner. A panel of Emory researchers with no connection to pediatrics makes decisions about who gets funded.
     As research expands into studying diseases at the molecular level—blurring the lines between pediatric and adult medicine,
collaborations that include pediatric research in broader areas of study also are being emphasized.
     Lung researcher Lou Ann Brown, who helped pioneer the development of synthetic surfactant for use in premature babies, is working with Mark Moss, chief of pulmonary medicine in the Department of Medicine to study whether clinical use of the antioxidant glutathione can help prevent lung damage in premature babies exposed to alcohol during pregnancy or if it can help patients who have become ventilator dependent as a consequence of alcohol abuse.
     The center also encourages collaboration between researchers
and clinicians to get cutting-edge treatments to patients as quickly
as possible.
     In the hematology/oncology division of pediatrics, gene therapy researcher Trent Spencer is taking special aim at neuroblastoma, an aggressive tumor that arises in the sympathetic nervous system and tends to metastasize rapidly. Although survival rates have improved in recent decades, long-term survival for children with metastatic disease at diagnosis remains poor.
     Spencer and his colleagues at the Aflac Cancer Center and Blood Disorders Service based at Children’s are genetically engineering immunotherapeutic cells to make them impervious to toxic
chemotherapy regimens and thus able to help the body’s own immune system attack the cancer, bolstering the effects of chemotherapy while lowering the dosage needed.
     Spencer says the easy communication between clinicians and scientists at Emory is one of the reasons he came here. That and the fact that he, like his colleagues, is firmly convinced that “Emory has everything it needs, from the vision to the will to the resources, to become a major translational research center for pediatric diseases.”
Growing up at last

Achieving Emory’s and Children’s new goals will take more than just good will and good planning, of course. It will also take money. Stoll sees fund-raising as one of her biggest responsibilities as chair. She knows that the country’s leading children’s medical centers and pediatric programs all have large endowments, whereas Emory pediatrics has virtually none.
     But the financial picture is changing. The Woodruff Foundation provided almost half of the $42 million cost of the new building, and another $2 million came from various donors, including the foundation established by the late George Brumley’s family. Children’s contributed $8.5 million to the new pediatrics building in return for a parcel of Emory land adjoining its hospital. Construction is already under way on a new hospital addition there.
     The joint Emory Egleston Children’s Research Center, founded in the early 1980s, is seeing new growth in translational and collaborative research. (See Newer Kids on the Block, opposite page.) A $2.85 million gift from the Marcus Foundation will enable the department to recruit national leaders in six pediatric subspecialties. The money will fund new division leadership positions in four of the subspecialties—endocrinology, nephrology, infectious diseases, and pulmonology—and add support to the department’s existing strengths in gastroenterology and neonatal-perinatal medicine.
     “We want to recruit new talent to the department,” Stoll says. “To build a truly world-class department, we need nationally recognized programs in key areas.”
     Meanwhile, Emory’s and Children’s shared goal of becoming one of the top five pediatrics centers in the nation is off to a good start. This spring, Child magazine released its rankings of the nation’s top 10 children’s centers. Children’s Healthcare of Atlanta was number 6, and four of its specialties—cancer care, cardiac care, neonatology, and orthopaedics—were ranked 3, 4, 3, and 3, respectively.
     “Those services feature the combined efforts of Emory, community physicians, and Children's,” Tally points out, “so we all can be equally proud.”
     Light pouring in through the windows in Stoll’s new office provides almost miraculous illumination, considering her previous environs. Like her faculty, she is in love with the new building: its grace, its flow, the still-empty spaces that promise recruitment and growth. And like her faculty, especially those who have been through pediatrics’ hardest years, she sees it as a "no-excuses" facility.
     “It used to be easy to say, ‘We aren’t as successful because we don’t have any money, we live in trailers.’ But now,” she says, gesturing at her surroundings, with the corner of Children's at Egleston visible through her window, “now, we have an awesome obligation to be successful. All the pieces are in place. The children are the center of attention. Failure is not an option.”

Sylvia Wrobel is the former associate vice president for Health Sciences Communications at the Woodruff Health Sciences Center.

Jon Saxton is special assistant for health policy and communications, Office of the CEO, and the executive editor of Momentum.



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