History of Healthcare in Roanoke & New River Valleys Volume IV

THE

HISTORY OF HEALTHCARE

IN THE ROANOKE VALLEY PRESENTED BY THE PUBLISHER OF OUR HEALTH MAGAZINE

The Resource for Healthy Living in Southwest Virginia

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history of healthcare of the roanoke valley • volume iv

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COMMENTS/FEEDBACK/QUESTIONS We welcome your feedback. Please send all comments and/or questions to the following: U.S. Mail: McClintic Media, Inc., ATTN: Steve McClintic, Jr., President/ Publisher/Editor-at-Large: 303 S. Colorado Street • Salem, VA 24153. | Email: steve@ourhealthvirginia.com | Phone: 540.387.6482 Information in all print editions of OurHealth and on all OurHealth’s websites (www.ourhealthvirginia.com and www.ourhealthrichmond.com), social media sites and emails is for informational purposes only. The information is not intended to replace medical or health advice of an individual’s physician or healthcare provider as it relates to individual situations.

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TABLE OF CONTENTS 15.

Introduction

16.

Healthcare Development

45.

Epidemics

53.

Heroes

60.

Nurses

65.

Technology

ABOUT THE AUTHOR

Rick Piester’s

career has included successful experience as a musician, a newspaper reporter and magazine editor, a healthcare communications executive, a symphony orchestra executive and a freelance writer. He has worked in healthcare communications for more than 30 years, including service as executive communications officer for a large New England health system, and providing communications counsel for the Massachusetts Medical Society, publishers of the New England Journal of Medicine. He is now semi-retired, living and writing in Lynchburg, VA, while he and his wife Patricia make their way through their bucket list. the history of healthcare

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acknowledgements Projects of this nature are actually put together by scores of people, with the writer being merely one of the last links in the process.

This history is the brainchild of Steve McClintic, president of McClintic Media of Salem, VA, who for some reason thought that I would do a creditable job of researching and writing it. I hope I have not disappointed him.

Jennifer Hungate, vice president of production at McClintic Media, has been a creative master at photo research, keeping the wheels of production turning and keeping yours truly on track.

For his inspiration to become involved in this project initially, my deep gratitude goes to Darrell Laurant—author, longtime Lynchburg News and Advance columnist until his recent retirement, and indefatigable master of ceremonies for The Writers Bridge (www.writersbridge.net), a collective of writers of various types intent on mutual aid and inspiration. I also want to mention with deep gratitude my role model as historian and author - Peter Houck, MD, of Lynchburg.

For their invaluable assistance with my research, not enough can be said about the staff at the Roanoke Public Library’s Virginia Room, and the authors of previously printed histories of Carilion Clinic and LewisGale. Much credit also goes to the group of writers at the Roanoke Times who have covered healthcare in the region. They include Paul Dellinger, Charles Hite, Sarah Bruyn Jones, Sandra Brown Kelly, Brian Kelley, Jeff Sturgeon, Laura Williamson and others.

Their labors over the years have been both prolific and invaluable.

The physicians and nurses, the employees and board members and the patients of Roanoke Valley hospitals are really at the core of this history, and I hope I have done their stories justice.

The advertisers you see in these pages are the companies whose faith has financed the product you are reading now.

Above all, thank you a million times to my wife, Patricia Hardwick Piester, for her personal support and great patience. Her research assistance, her first reading and her work as whipcracker-in-chief has made all the difference in my getting my work done reasonably on time.

For any inadequacies or errors you may find in this work, the responsibility is entirely my own.

Rick Piester LYNCHBURG, VA

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DOWNTOWN ROANOKE | Photo Courtesy of Shawn Sprouse

INTRODUCTION

W

elcome to the final volume - Volume 4 - of our history of healthcare in the Roanoke Valley.

Healthcare has undergone previously unimaginable change since the 1990s, when this volume begins. The limitations of these pages do not allow an exhaustive, complete and detailed history of healthcare in our region.

We at OurHealth hope that we have instead captured the thrust of the past two decades. We hope that we have successfully explained some of the major forces driving health activities in our region, and we have tried to capture and chronicle the key people and events that have shaped the superb level of healthcare that we enjoy on this day.

When we embarked on this mission—this adventure—we wrote that “we believe that to truly appreciate how far we have come, we have to go back to the beginnings. We have to measure exactly how far we have progressed as a community, and some of the paths taken to get us here.”

Please let us know whether you think we have achieved what we set out to do. But the job isn’t over. There are plenty of stories yet to happen, and yet to be told. With your continued readership and your support, we’ll be there to tell them.

Here, then, is Volume 4.

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HEALTHCARE DEVELOPMENT

T

he news, when it came, was almost anticlimactic. On a sunny, unseasonably warm Thursday, April 26, 1990, the U.S. Justice Department announced that it was abandoning its fight against the merger of Roanoke Memorial Hospital and the Community Hospital of the Roanoke Valley—the merger that created Carilion Health System.

leaders—working under Thomas Robertson at the helm of Roanoke Memorial and Carilion and William Reid as president of Community Hospital and senior executive vice president of Carilion—were free to plan the merger and postmerger activities.

The announcement marked the end to a legal battle that began almost three years earlier, when the two organizations announced that they intended to become one under the Carilion banner. The merger, officials of the hospitals said, would serve to improve efficiency and hold down health costs in the region. The U.S. Department of Justice, however, seeing the makings of a local healthcare monopoly in the merger, filed a lawsuit to halt the plans.

It was the first time that the Department of Justice had attempted to block the merger of two nonprofit hospitals on antitrust grounds.

“We’ve let the government drag this thing on long enough,” said Robertson. “We can no longer afford to stand still.

That’s the bottom line.” So while the lawsuit was moving through the courts, teams of hospital management forged ahead with plans that assumed a legal victory for Carilion.

Over the next three years, the hospitals prevailed in complicated legal wrangling that burned through about $2.5 million in legal costs. The struggle ended only when the Department of Justice had one last option—to go to the U.S. Supreme Court to appeal rulings from a year earlier by lower courts favoring the merger, in an effort to get the lower court rulings overturned. The Department of Justice chose not to pursue the case further.

Although the hospitals had been prevented from actually merging until the lawsuit was resolved, hospital 16

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And plan they did.

As a result, months before the Justice Department’s final announcement, Roanoke Memorial announced preliminary plans for what would open four years later as the hospital’s landscape-altering $70 million South Pavilion. And the hospitals were also planning the postmerger allocation of beds between the hospitals. By the time the merger was official on July 18, 1990, plans had been laid to begin moving all pediatric health activities to Community Hospital by the end of that year, and to relocate obstetric service to Community within 12 to 18 months.

The new hospital system in Roanoke, along with other healthrelated organizations in the region and in the country, was on the brink of a new medical arms race that would bring far-reaching and permanent change.

Multiple pressures in the Roanoke Valley would play out in the form of unrelenting competition among healthcare

PRESENT DAY CARILION CLINIC CAMPUS | Photo Courtesy of Ed Hamilton and Carilion Clinic

organizations—sometimes fierce, sometimes gentlemanly, but always played in dead earnest. Attempts to rein in healthcare costs in America, climbing at twice the rate of inflation, would give rise to new forms of payment for health services and introduce such terms as “managed care,” HMO and “capitation.” A storm of technological achievements would save lives and improve lifestyles immeasurably, but at the same time would further feed what seemed to be uncontrolled growth of health costs.

And a new president, William Jefferson Clinton, would make the reform of the American system of healthcare a cornerstone of his new administration, but that effort would fizzle under the weight of political grandstanding.

A HEALTHCARE HUB As the ’90s dawned, the Roanoke area was already the hub of healthcare in western Virginia. Three major community hospitals, a Veterans Administration Medical Center, many smaller and more specialized facilities and more than 400 physicians in 40 medical specialties made the Roanoke Valley a healthcare powerhouse.

Carilion, the dominant force in the region’s health organizations and the largest single employer in the

Roanoke Valley, also owned four community hospitals in the region and provided contracted management to four others.

Roanoke Memorial Hospital, one of the largest community hospitals in the state, was—and still is—the region’s Level 1 Trauma Center. At nearly 700 beds in the early 1990s, the hospital also included capabilities for open-heart surgery and cardiac catheterization, treatment of cancer, kidney dialysis, alcohol and drug treatment and more.

Roanoke Memorial was affiliated with the University of Virginia School of Medicine and trained medical residents from UVA and other schools. It also had schools for radiologic technology and medical technology.

Carilion partner Community Hospital of the Roanoke Valley at the time was a 400-bed hospital that offered a broad range of health services, including a laser surgery center, coronary care and extensive obstetric services.

Community Hospital and Roanoke Memorial together operated sophisticated diagnostic services, primarily on an outpatient basis.

The hospital operated the Roanoke-based College of Health Sciences, which provided two-year degree programs in nursing, respiratory therapy and other fields. the history of healthcare

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A second major healthcare provider was Lewis-Gale Hospital in Salem, which since 1968 had been owned by the Nashville-based, for-profit hospital company HCA. The 406-bed Lewis-Gale Hospital had recently been renovated to include expanded space and equipment for intensive and coronary care, physical therapy and an augmented heart surgery program. The hospital’s capability included magnetic resonance imaging, a way to produce diagnostic images without using x-rays or dyes. The hospital also operated a radiation therapy center for treating patients with cancer, as well as lithotripsy for treating patients with kidney stones using sound waves, rather than surgery.

Separate from Lewis-Gale Hospital, although closely allied with it, the Lewis-Gale Clinic was a large, physician-owned group practice that shared a campus with the hospital.

The 90-bed Roanoke Valley Psychiatric Center would shortly consolidate its services with Lewis-Gale Hospital to become the Lewis-Gale Psychiatric Center.

Also in Salem, a 600-bed Veterans Administration Medical Center was in the midst of a $66 million construction program aimed at replacing outdated medical, surgical and outpatient facilities. Originally a facility to treat psychiatric patients, the VA Medical Center was being

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expanded to become a general medical and surgical facility for the benefit of veterans living in a broad region of central and southwestern Virginia. The facility also included 100 nursing home beds.

With these major healthcare providers, and a score of smaller institutions and organizations, the Roanoke Valley was about to embark on a two-decade period of growth that would be as tumultuous and frustrating as it was exciting and productive. Every major healthcare organization in the region would at one time or another be drawn into controversies and conflicts, largely created by the winds of change that were buffeting the world of healthcare.

THE COST QUESTION As Carilion was coming into being, a major dose of economic medicine was emerging, and it would change the nature of healthcare delivery; almost everyone involved in healthcare—the government, employers, patients and healthcare providers themselves—was seeking solutions to the growing burden of health costs.

One of the first salvos in what would prove to be a long struggle came from the well-established healthcare insurance company Blue Cross. The insurer tailored a

PRESENT DAY LEWISGALE MEDICAL CENTER | Photo Courtesy of LewisGale

health insurance product called a preferred provider organization (PPO), which it hoped would be attractive to employers. Under the plan, hospitals and physicians would cut their fees for employees of enrolled businesses.

Hospitals and physicians would benefit by having those employees directed to their practices. Employees would be able to go to other providers, but they would pay more. The PPO, named KeyCare, had already signed on Roanoke Memorial and six additional hospitals in the Carilion system, but ran into a roadblock when it came to signing up Roanoke-area physicians.

When KeyCare was being established in Northern Virginia, about 1,200 physicians agreed to participate. But in Roanoke, after six months of recruitment, Blue Cross had received commitments from only about 90 physicians, not enough to implement the program.

The difference? Physicians in the Roanoke area worried that the PPO would restrict the freedoms of both physicians and patients—physicians in terms of the specialists to whom they would be able to refer patients, and patients in terms of the physicians they would be able to choose. In addition, many Roanoke-area physicians were already swamped by patients, and they saw little incentive in a scheme that promised to bring even more patients to their practices.

Overarching all this, however, was a lawsuit against Blue Cross filed the previous year by Lewis-Gale Hospital,

seeking to prevent Blue Cross from excluding Lewis-Gale and its HCA sister hospitals Montgomery Regional and Pulaski Community from KeyCare. Physicians and potential business enrollees in the region were unwilling to join KeyCare until the lawsuit was resolved.

Blue Cross ultimately relented, admitting the HCA hospitals into the PPO. The settlement re-leveled the playing field, but left many wondering what cost advantages would be realized from having the same players on the field. One benefit was that companies with employees in various parts of the state would have the option of joining KeyCare.

The standoff was resolved, after a fashion, but it was a harbinger of the state of competition—and occasional contention—that would prevail between Carilion and Lewis-Gale for years to come. It also signaled the constant presence of the struggle to pay for healthcare that continues to this day.

UPGRADING FACILITIES The presence of the two large systems in the Roanoke Valley gave rise to some odd speculation early in the 1990s. When the company that at the time owned LewisGale, Hospital Corporation of America (HCA), merged with Columbia Healthcare Corp., there was conjecture that the combined Columbia/HCA parent corporation may have had designs on the purchase of the then-new Carilion the history of healthcare

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NEWLY RENOVATED MATERNITY CARE SUITE AT LEWISGALE Photo Courtesy of LewisGale

Health System. In other quarters, there was gossip that Columbia/HCA executives were contemplating the sale of Lewis-Gale to Carilion.

While we know now that neither of those scenarios came to pass, hospital leaders in the region were working on plans for facilities that would serve patients in the coming years.

Targeted especially were facilities for maternity services.

Both Lewis-Gale Hospital and the Community Hospital of the Roanoke Valley were preparing for direct competition for expectant mothers, among medicine’s most coveted patients.

For hospitals to vie to provide these services was a testament to the decision-making muscle of women, found in studies to make healthcare choices for their family more than two-thirds of the time. Give a new mom a pleasant birth experience, the thinking went, and you capture the whole family’s healthcare business for a lifetime.

Increasingly, the trend was to create an environment reminiscent of the home. The birth center movement, with its emphasis on childbirth as a natural occurrence rather than a medical procedure, helped popularize the change.

What had been called labor and delivery rooms were now referred to as birthing rooms. Hospitals were offering [education programs] ranging from classes on baby basics to classes and tours for siblings age 2 to 12.

At Lewis-Gale, the entire maternity care unit had been renovated at the end of the 1980s. Looking more like a floor in a hotel than a hospital, with muted colors and carpeted floors, the maternity floor featured rooms outfitted with large chairs that converted to single beds for the comfort of expectant fathers.

It was Community Hospital, however, that would see sweeping change—not just in the physical layout of the maternity area, but also in the hospital’s entire approach 20

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NURSING STUDENTS AT JEFFERSON COLLEGE OF HEALTH SCIENCES | Photo Courtesy of Jefferson College of Health Sciences

to its services for babies, children and their families. With the merger of Roanoke Memorial and Community, all pediatric health services would be moved to Community by late 1990 to early 1991, and all maternity services and personnel would be shifted from Roanoke Memorial to Community by the end of 1991.

With the shift of maternity services, the neonatal unit at Roanoke Memorial, specializing in the care of premature and medically compromised babies, would move to Community. Community Hospital had also recruited a physician specializing in perinatal medicine, a subspecialty focusing on care of the mother and fetus during pregnancy, labor and delivery, particularly when the mother or fetus is at a high risk of complications.

The move of pediatric services to Community included a new pediatric emergency department (pediatric trauma continued to be treated at the Level 1 trauma center at Roanoke Memorial), a pediatric intensive care unit, specialists in pediatric cancer and lung diseases in children and the addition of 100 pediatric staff members, nearly 90 of whom made the move from Roanoke Memorial.

As 1990 came to a close, Lewis-Gale Hospital launched $2.4 million in construction projects that would allow the hospital to offer open-heart surgery, coronary intensive care and other high-tech heart procedures. The expansion included a 2,300-square-foot open-heart surgery suite and a new location for the hospital’s existing 12-bed coronary care unit. A special surgical intensive care unit was also created to serve heart-surgery patients as well as other surgical cases.

The new services meant that Lewis-Gale would not lose patients to Roanoke Memorial or other regional hospitals for certain heart procedures. Lewis-Gale estimated that it would perform nearly 200 open-heart surgeries during the first year it offered the procedure, compared to about

700 open-heart procedures that were done each year at Roanoke Memorial.

The largest newsmaker in hospital construction of the period, however, came when Roanoke Memorial announced in 1990 that it would seek a $156 million tax-exempt bond issue for construction of new facilities at its location and at others in the fledgling Carilion system.

Of the total, about $70 million would be tagged for what was arguably the Roanoke Valley’s most celebrated healthcare construction project of the decade—a new medical tower at Roanoke Memorial that, when it opened in 1994, would usher the hospital into the 21st century. In addition, money would be set aside for upgraded equipment at all Carilion hospitals ($16 million), facilities for pediatrics and obstetrics at Community Hospital ($6 million), a new outpatient wing and renovated facilities at Franklin Memorial Hospital ($4 million) and $52 million in interest costs.

The bond issue would be one of the largest such bond issues in Virginia at the time, and it would draw the attention of investors nationwide.

In preparation for the long-term construction period at Roanoke Memorial, early site work began in the spring of 1991, with construction scheduled to begin in earnest the following January.

In the end, the two leaders agreed to disagree, but the debate did prove illuminating to many residents of the Roanoke Valley, who in the past likely did not know the difference between the two types of organizations, and the benefits that each felt they returned to their communities.

CARE FOR POORER PATIENTS Some progress was being made in bringing health services to the poorer areas of Roanoke, however. About 38,000 people in northwest Roanoke—about a third of the city’s population—found themselves suddenly without a nearby doctor’s office in early 1992 when the internist who had practiced there for eight years left town. Residents of the neighborhood, many of them without transportation, were elderly. Incomes in the area were below the federal poverty level, unemployment was a major problem and the infant mortality rate was high.

Years before, health officials in Roanoke had attempted to have the area declared a federal manpower shortage area, a designation that would have helped with funding for a community health center. The designation also would have helped the internist then practicing there to work off federal loans he had received to attend medical school, making it easier for him to have a financially successful practice.

TAXING HOSPITALS? Another finance-related issue arose in early 1992, when Virginia Gov. Douglas Wilder proposed a tax on hospitals, nursing homes and pharmacies. The tax was intended to ease the rising cost to Virginia of medical care for the state’s poor and elderly. It was one of a broad range of measures that the governor hoped would help prevent the state budget from bleeding red during the recession of the early 1990s.

Virginia’s hospital industry was able to lobby the support of enough legislators to kill that part of the governor’s plan, but the issue revealed another bone of contention between the nonprofit Carilion system and the for-profit Lewis-Gale Hospital. Leadership of the two organizations became involved in a prolonged public debate over the relative merits of their respective institutions’ tax status. Carilion, primarily through system president Thomas Robertson, argued that the nonprofit and tax-exempt status was well deserved, more than balanced by the level of free care and medical education activities conducted by nonprofit hospitals. Lewis-Gale, primarily through hospital president Karl Miller, countered that the taxes paid by for-profit hospitals, along with the value of free care they provide to indigent patients, outweighed the nonprofits’ contributions to the community. the history of healthcare

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building on McDowell Avenue in 1955.

Burrell affiliated with Community Hospital of the Roanoke Valley in 1968, but by that time it was suffering, ironically, from the effects of the passage of Medicare and the Civil Rights acts. Combined, those pieces of landmark legislation gave both African American physicians and patients the right to practice and be hospitalized in formerly white-only hospitals. The number of physicians and patients using Burrell plummeted.

Burrell became a nursing home in 1979, but a portion of its former emergency department was set aside for use as a physician’s office. Burrell’s board of directors was successful in recruiting one internist in 1984, the internist who practiced in the northwest community until his departure in 1992. (A few years after arriving in Roanoke, the internist and his pediatrician fiancée moved their practice to an office on Melrose Avenue.)

TOP BURRELL NURSING CENTER | Photo Courtesy of Carilion Clinic BOTTOM JOHN (LUCKY) GARVIN, MD WITH THEN FIRST LADY BARBARA BUSH AT THE DEDICATION OF THE BRADLEY FREE CLINIC BUILDING, APRIL, 1990 | Photo Courtesy of Bradley Free Clinic

But the federal government rejected the proposal, arguing that patients in the area had adequate access to physicians in other parts of the city.

They didn’t. Buses ran from the northwest section of the city to the downtown hospitals, but elderly people simply did not have the stamina—and some did not have the money— to negotiate several transfers on their bus ride and then walk several blocks to a physician’s office. Healthcare was available, but it was not accessible.

And health officials worried that the lack of a local doctor would encourage northwest residents to postpone getting healthcare, forcing them to rely instead on expensive episodic care at emergency rooms or urgent care centers.

A solution was found at the Burrell Nursing Center, a facility that was now part of the Carilion health system. Burrell had a storied past, and it would have an even more storied future.

It was founded in 1915 as Burrell Memorial Hospital, the only hospital in Roanoke dedicated to serving the African American community. The hospital moved to a modernized 22

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Working with the Roanoke Health Department and area physicians, Carilion president Thomas Robertson was able to announce the opening of the Northwest Medical Center, located at Burrell and staffed with a specialist in internal medicine who would also supervise resident physicians training there.

This was not the only facility demonstrating Roanoke’s leadership in providing healthcare services to the uninsured.

The Bradley Free Clinic, for example, had been in operation since 1974 and in 1990 moved into its new location at 1240 Third Street, SW, which is still its home.

At its opening, then-First Lady Barbara Bush dedicated the building and announced the renaming of the clinic in memory of Harry Lynde Bradley, father of principal donor Marion Bradley Via. The clinic was designated a Presidential Point of Light in the same year.

Since the clinic’s first full year in 1975, more than 335,000 patient visits with treatment have now been recorded and 785,000 services have been provided, with a total value of $55 million.

HOSPITALS DIVERSIFY While Roanoke Valley hospitals were concentrating on their medical-related activities, some were also seeking ways to support their traditional patient activities by developing

income from allied activities not directly related to inhospital patient care. They needed additional income to offset declining revenues, as government and private insurers demanded discounts from patient care.

Many hospitals in Virginia established freestanding urgent care centers, pharmacies, home health care providers and physician billing services. A 1990 survey showed that 94 hospitals in Virginia operated a total of 217 subsidiary companies.

In Roanoke, one example was Sterile Concepts, a Richmondbased surgical supply company operated by Carilion.

Profit from Sterile Concepts ($2.2 million in 1990) more than made up for a drop of $1 million in profit at Roanoke Memorial Hospital.

psychiatric hospital in Radford, became the first such facility in Carilion’s chain of 11 acute care hospitals. Saint Albans, Carilion officials said, would strengthen the offerings of Carilion health services in the New River Valley. It would join Carilion partners Radford Community Hospital and Giles Memorial Hospital in the region. The partnership would also bring a psychiatric residency program to the new partner, and extension of the residency program already in place at Roanoke Memorial.

As healthcare moved progressively toward favoring outpatient care, inpatient facilities such as St. Albans found themselves becoming obsolete. After staff layoffs at the hospital, Carilion transferred the building and its property to Radford University in 2004.

Not all hospital subsidiaries produced a profit, but they were felt to be worthwhile because they functioned as feeder mechanisms for their institutions. An office building owned by Community Hospital and housing about 40 physicians’ offices was not viewed as a big moneymaker for the hospital, but hospital leaders believed that the physicians in the building would feel heightened loyalty to the hospital and refer their patients there.

Stonewall Jackson Hospital in Lexington also came under the Carilion umbrella, with a five-year management contract announced by the two organizations in 1993. It would prove to be an on-again, off-again relationship, however. At the end of the management contract period in 1998, the Lexington hospital decided to affiliate with a group of independent hospitals in the Shenandoah Valley, named VaLiance Health. Hospital leaders at the time said that the break was not the result of dissatisfaction with Carilion’s management. It was, they said, the hospital’s desire to remain independent that led to the new alliance.

Stonewall Jackson, however, decided to be acquired by Carilion in 2004, after suffering several years with heavy financial losses.

CARILION EXPANDS

EMPLOYERS UNITE

The Carilion system also grew by adding partners during the early 1990s. Saint Albans Hospital, a 75-year-old

The issue of healthcare costs, never far from dead center on the public radar screen, came to the fore again in late 1992, when a coalition of Roanoke Valley employers

A total of 10 Carilion subsidiaries—including a pharmacy and medical supply company, a fitness center, an ambulance service, a home health provider and a real estate management company, were grouped under a taxpaying holding company.

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PRESENT DAY SALEM VETERANS AFFAIRS MEDICAL CENTER | Photo Courtesy of Salem Veterans Affairs Medical Center

teamed up with a company specializing in negotiating lower healthcare costs for member companies’ employees.

large health systems in the state exploring methods, such as group purchasing, to help hold the line on costs.

The Blue Ridge Regional Health Care Coalition selected the Buyers Healthcare Cooperative of Nashville to negotiate reduced fees that hospitals and physicians would receive from the 55,000 employees of the 31-member coalition.

Lewis-Gale Clinic, which at the time was the state’s largest physician practice, with 135 physicians and more than 1,000 employees, sold its assets in mid-1966 for $47 million to PhyCor Inc., a Nashville-based physician practice management company. The clinic, nearly 90 years old in 1996, had long been associated with Lewis-Gale Medical Center and shared a Salem location with the hospital, but had remained an independent entity. It proved to be a short-lived, rocky relationship. Within the first three years of its contracted 40-year relationship with PhyCor, the clinic staff had decreased to some 90 physicians, the others leaving to establish independent practices.

The employer co-op was but one of the new forms of insurance coverage—and new terms in the healthcare vocabulary—that appeared in the 1990s. Others were PPOs—short for preferred provider organizations, under which hospitals and doctors cut prices to businesses that encourage employees to use their services (employees pay more if they choose providers outside the approved list)— and HMOs—health management organizations that require employees to go to preselected hospitals and physicians.

And as the 1990s wore on, hospitals began to respond to pressures from insurers, government, businesses, and each other for high-quality care at lower cost. Lewis-Gale and the four other HCA-owned hospitals in the region beefed up outpatient services in response to insurance companies that were pressing for fewer hospitalizations when outpatient treatment worked equally well. The Carilion health system worked with other 24

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The Salem breakup was not unique. Groups of physicians and their management companies across the country had come to realize that they simply did not see eye-to-eye.

Practice managers kept their attention glued to the bottom line while physicians considered the well-being of their patients first. Those close to the Lewis-Gale Clinic troubles believed that the clinic was within several days of closing entirely if the remaining physicians took no action.

The physicians, having negotiated a loan, bought their clinic back, for an undisclosed amount.

THE SOUTH PAVILION The demarcation line between past and future of healthcare in the Roanoke Valley was made clear with the opening of Roanoke Memorial’s nine-story South Pavilion in the spring of 1994.

Seven years in planning and with construction and equipment costs totaling about $70 million, the South Pavilion encompassed much of what had been learned to date about how people heal—the esthetics as well as the technology involved in faster healing.

Where hospitals had once been filled with cramped, dark and dull spaces, the new South Pavilion was open, airy and stunning. Where hospital buildings had once telegraphed weight, mass and impenetrable solidity, the new South Pavilion showed the world a glass façade that reflected the colors of its mountain setting, actually looking smaller than its 336,000 square feet. On the inside, the glass walls allowed in bright daylight and natural, soothing views.

More than sheer appearance, however, the building also housed a replacement facility for much of the work going

on inside the old, outdated hospital. It included emergency and trauma care facilities for the 28,000 patients who were then seeking care each year. The pavilion connected to a new rooftop helicopter landing area, new surgical facilities and new intensive care and progressive care units.

The building was also designed to be more welcoming to more visitors, because hospitals were evolving from strictly inpatient care providers to complexes for community health counseling, wellness and prevention programs and outpatient services.

It also proved to be a good buy for Carilion. As construction was getting underway, falling interest rates and creative financing options saved millions in interest costs. Construction began during a nationwide recession-era low point in construction activities. This meant that materials and labor costs were very favorable and scheduling problems that typically crop up in a construction boom era were minimized.

TURMOIL AT THE VA MEDICAL CENTER There was plenty of other health-related construction going on in the region as well. The Veterans Affairs Medical Center in Salem opened a new $57 million building in late 1992, a celebration almost obscured by the controversy

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that nearly crippled the hospital at the time.

The new building was intended to be the medical center’s stepping-off point in a transformation of what for the previous 60 years had been a psychiatric hospital—a dramatic makeover into a modern, comprehensive medical center. Designed to echo the graceful Georgianstyle architecture of the 11 existing buildings on the ELBRYNE GILL, MD medical center campus— Photo Courtesy of Carilion Clinic but housing modern, high-tech healthcare services—the new building was being prepared to open following months of chaos among hospital employees and patients.

The storm began in early 1992 as a dispute between a government employees’ union and hospital management, over what the union claimed were poor management practices, poor staff communication about the move into

the new hospital and the creation of stressful working conditions on the 220-acre campus. A later VA investigation into the allegations concurred, in part, that management communications had been lacking.

But the turmoil raged into the national limelight when the bodies of three medical center patients were found on the grounds.

The union called for the resignations of the center director, the chief of the hospital’s medical staff and the center’s chief of nursing services. Within a few months, all three were gone. A new center director, who had a track record of correcting management shortcomings, was assigned to Salem. Insiders spoke of the challenges at Salem as the toughest in the VA system.

Many observers said that the old regime’s departure spurred the healing process. Before the year was out, the new director, John Presley, and the new top management he installed were receiving high marks from staff and patients alike, including the head of the union that a year before had been in pitched battle with hospital leadership.

Support from the medical center’s patients did not falter, however, and the new building now anchors the medical services provided for thousands of veterans in Virginia west of Richmond.

At the Lewis-Gale Clinic on the campus of Lewis-Gale Hospital, a $6.5 million, six-story addition opened in 1993 to house physicians and staff in popular specialties, including allergy; dermatology; ear, nose and throat; fertility and reproductive health; obstetrics and gynecology; and pediatrics. And in 2000, the hospital’s emergency services moved into a new $4.8 million home, part of $15 million in improved facilities that also included the renovation of two floors and a 500-car parking deck. Later, a three-story addition above the new ER added 11 new operating rooms, replacing the ORs that were native to the original 1972 building. The $37 million project was the largest upgrade in the hospital’s history.

While hospitals built and expanded, driven largely by changing healthcare patterns and the need to replace old, outdated facilities, they also contracted, closing units, trimming personnel and shaving costs wherever they could.

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In the course of about 18 months, Carilion eliminated jobs in nearly every corner of the growing health system. A 15-member intravenous therapy team at Roanoke Memorial was eliminated, its duties assigned to staff nurses. Separate healthcare staff for leukemia patients were eliminated, with leukemia patients blended with other oncology patients.

Even a three-person public relations staff was laid off. The number of administrative personnel at Roanoke Memorial was reduced from 14 people to seven. The total of 73 departmental directors was reduced to 56, and cuts were made in the numbers of nursing managers.

HOSPITALS PLAY HARDBALL

The cutbacks marked the end of 70 years of activity at the downtown Gill Memorial Hospital, established in 1926 as a for-profit hospital by Elbyrne Gill, MD, and believed to be the first eye, ear, nose and throat specialty hospital in Virginia. An internationally known physician, Dr. Gill sponsored periodic gatherings of physicians that drew such luminaries as penicillin pioneer Alexander Fleming, MD.

And it would take more than two years to settle the question.

By the 1980s fewer than half of the hospital’s 40 beds were in use, the result of declining inpatient stays in favor of outpatient surgery. In mid-1996 a truck pulled up to the hospital building to transfer the hospital’s equipment to Community Hospital.

Pressures from health insurers to rein in healthcare costs contributed directly to one of the decade’s most bitterly fought struggles between the region’s top two health providers—the Carilion system and the hospitals in southwest Virginia owned by the national for-profit hospital juggernaut Columbia/HCA. On its surface, the battle was which of the two rivals would win the right to build a new hospital to replace the aging Radford Community Hospital.

But underlying that competition was the larger question of who would control healthcare in the region.

In the fall of 1995 Carilion filed for state permission to build a new hospital to replace Radford Community’s 53-year-old building in downtown Radford, something that the health system had been promising and planning for several years. The new hospital was to be located on a parcel of land away from downtown Radford, alongside Interstate 81.

Before the state could take the Carilion application under review, Columbia/HCA subsidiaries Montgomery Regional Hospital and Pulaski Community Hospital (Columbia/HCA was also the parent of Lewis-Gale Hospital in Salem) filed the history of healthcare

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VISTAR EYE CENTER PHYSICIANS IN 2005 | Photo Courtesy of Vistar Eye Center

a plan to build a replacement for the Radford hospital. All three existing hospitals were within a 15-mile area along the I-81 corridor.

The maneuver carried echoes of a similar scrap that began a year earlier, involving competing applications from Pulaski Community and Radford Community over which, if either, would get to build a cancer treatment center in the New River Valley. Pulaski won that contest, but no construction had begun by the time the competing applications for a Radford hospital replacement were filed.

After a year of hearings, charges and countercharges and behind-the-scenes maneuvering, the Carilion plan for a new Radford Community Hospital prevailed. The question of where the new cancer treatment center would be, however, was not settled until 2003. That was when the state denied Carilion’s persistent requests to install cancer treatment equipment at the Radford hospital, which had been completed in 1999.

NRV MEDICAL CENTER By the time the new hospital opened, the name of the facility had changed to New River Valley Medical Center, reflecting its expanded medical capabilities and to signal the expanded service area that hospital planners believed would result from the highly visible spot along I-81, where the highway intersected with Virginia Route 177.

Reflecting national trends to outpatient services, the new hospital had 97 beds compared to the old facility’s 175 beds. Total floor space, however, was 239,000 square feet, compared to 147,000 square feet when it was in downtown Radford. The New River Valley Medical Center also included a three-story medical office building and a rehabilitation center on its 112 acres.

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Completion of the hospital also represented the end of a long career for Radford’s longtime president, Lester L. “Skip” Lamb. Lamb, who had been at the head of the hospital since his arrival in Radford in 1970, completed his plans to retire soon after the new hospital came on-line in 1999.

At the end of 2000, Carilion president and chief executive officer Thomas Robertson announced his planned retirement for early the following year, and that he would be succeeded by Edward Murphy, MD, who had served as chief operating officer for the previous two years.

In his 15 years at the head the health system, he had orchestrated the transformation of a small regional group of hospitals into one of Virginia’s largest health systems, with more than 9,200 people providing health services for much of the western half of the state.

He had guided Carilion through some of the most stressful periods in its still-young existence, during a time of rapid and profound change in the way healthcare was organized, delivered and paid for.

One of the more prolonged stressful periods in local healthcare lore began in 1998, when a group of 13 ophthalmologists (physicians who specialize in the diagnosis and treatment of eye problems) planned to establish an outpatient surgery center in their Salem offices.

The physicians’ group—Vistar—ran afoul of Carilion, which claimed it would lose $3 million a year in revenues and that no more surgical facilities were needed in the region. Carilion asked the state to deny permission to create the facility.

Vistar eventually won state permission after a two-year debate, but ill-will simmered for years until, in 2007, physicians from the Vistar Eye Center announced they would no longer be staffing the Roanoke Memorial Trauma

Center, and that they instead would see emergency patients at Lewis-Gale Medical Center.

Carilion and the physicians arrived at a solution of sorts several months later, when the Vistar ophthalmologists realized that their refusal to consult with other physicians and patients at Roanoke Memorial was potentially damaging to patients.

“A day didn’t go by that I didn’t get a call” from physicians at Carilion hospitals seeking a consultation, said Frank Cotter, MD, the head of the ophthalmologists’ group. “We felt we had an ethical obligation to take care of patients.”

The ophthalmologists agreed to see patients on an on-call basis at both the Carilion hospitals and Lewis-Gale.

Four years later, however, Carilion reversed its position and signed an agreement with Vistar that would place independent ophthalmologists in the Roanoke Memorial emergency department for round-the-clock coverage. The arrangement was a response in part to Roanoke Memorial’s standing as a Level 1 trauma center, which would have been imperiled without the on-site availability of the specialists.

At the heart of the issue was the resistance some physicians were feeling to Carilion’s preference for employing its own physicians, rather than contracting with independent physicians and physician groups.

According to Dr. Murphy’s plan, the process would take up to 15 years to complete, at a cost of more than $100 million. Carilion’s chain of eight owned and affiliated hospitals would stay open, but the focus would shift from hospitals to specialized physician services; physician training would expand dramatically; and doctors and scientists would partner on medical research.

Carilion would hire EDWARD MURPHY, MD scores of doctors and Photo Courtesy of Carilion Clinic build a large, outpatient medical clinic and a combined medical school and medical research institute.

Major elements of the trinity of patient care, medical research and medical education were coming into place.

ONE CLINIC IS BORN, ANOTHER DIES In mid-2006 Carilion president Edward Murphy, MD, unveiled a long-term plan to restructure the organization, transforming it from a well-organized chain of hospitals into a multispecialty group medical clinic to be renamed the Carilion Clinic. It would be modeled in part on the Mayo Clinic, the worldfamous physician-led healthcare and research center headquartered in Minnesota.

The new strategy was in response to internal forecasts that Carilion’s operating surpluses would dry up by the year 2012, to be replaced by multimillion-dollar losses. The health system’s cash flow would dry up, the forecast predicted, unless Carilion did something to reverse the trend.

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CARILION CLINIC LIFE-GUARD 10 | Photo Courtesy of Carilion Clinic

The Carilion Biomedical Institute was beginning to show results.

Established in 1999 by Carilion, Virginia Tech and the University of Virginia, the goal of the institute was to conduct research that would lead to the creation of new companies that would place new medical products on the market.

Continuing the partnership, Virginia Tech and Carilion had just announced plans for a medical school that, after it opened in 2010, would train about 40 physicians per year.

And another element of the transition had been underway for several years: all inpatient care at Community Hospital of the Roanoke Valley would be shifted to Roanoke Memorial Hospital, which was in the midst a $105 million expansion project that would add two five-story additions.

Some outpatient services would remain at Community, but the bulk of the building would be converted for use by the Jefferson College of Health Sciences, which was owned

by Carilion.

But the tide toward creation of the Carilion Clinic met one major obstacle shortly after its announcement: the legendary independence of physicians. Physicians feared that Carilion, by assembling an organization that depended upon physicians becoming employees, was attempting to grab the bulk of power and money involved with healthcare in southwestern Virginia. Carilion countered that the plan put physicians and patients at the center of the 32

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process, and relieved physicians of the risk and headaches of medical practice in America.

The debate raged for years.

Physicians who opposed the plan organized themselves into the Citizens Coalition for Responsible Healthcare Inc., hired a publicist and erected billboards to state their side of the controversy. They took a vote of no confidence in the plan, and voiced their predictions that scores of physicians would either leave the Roanoke Valley to practice elsewhere, or at least shift their allegiance to for-profit HCA and its flagship hospital in the Roanoke Valley, the Lewis-Gale Medical Center.

Physicians did indeed leave Carilion for Lewis-Gale, but they were replaced by physicians hired by Carilion, and by other independent physicians who became part of the Carilion Clinic.

The op-ed pages of the Roanoke Times carried frequent submissions from proponents of one side of the debate or the other.

Even newly inaugurated President Barack Obama gave an indirect endorsement of the clinic approach. During a roundtable discussion with several newspapers, including The Roanoke Times, he echoed statements he made earlier

that organizations such as the Mayo Clinic and other clinic systems are the way to provide the best medical care while lowering costs. The president did not make specific reference to the Roanoke situation.

dies or the community’s grief when a leader dies. But this is one of national proportion; so it’s everybody’s loss.”

In the end, the Carilion view prevailed. The name of the organization now is the Carilion Clinic. Healthcare in the Roanoke Valley was not ruined. But that did not mean that there would be smooth sailing ahead for the Carilion Clinic.

Patients, visitors and even expectant parents in the region’s hospitals were glued to in-room televisions. New parents on the north side of Community Hospital could look into the distance and see airplanes queued up to land at Roanoke Regional Airport following the decision to ground all air traffic in the nation.

Nor was the sailing smooth for the Lewis-Gale Clinic, whose physicians staffed the Lewis-Gale Medical Center in Salem.

Carilion’s Lifeguard 10 medical helicopter was grounded by the FAA until the flight ban was lifted.

In February 2006 the Lewis-Gale Clinic, once a national model for all similar physician practices and a brand widely believed to be untouchable, filed for bankruptcy.

With about $15,000 in the bank and about $18 million in debt, it was bought by Lewis-Gale Medical Center’s owner, HCA Inc., and renamed Lewis-Gale Physicians, hiring the 64 remaining physicians and 350 remaining employees.

TWO NATIONAL TRAGEDIES September 11, 2001, was as beautiful a Tuesday morning as one could imagine in the Roanoke Valley, until about 8:46 AM. That’s when American Airlines Flight 11 flew into the north face of the World Trade Center’s North Tower at about 466 miles an hour.

The events that spun out during that day and the days after produced affects that were felt everywhere, including Roanoke.

People who normally slept soundly were plagued with insomnia. Mental health professionals worked long hours helping people cope with the surreal images coming from their televisions.

Not since the assassination of John F. Kennedy in 1963 had America shared such emotions of collective shock and loss. A psychologist at Lewis-Gale Medical Center described the impact in a newspaper story: “Usually in grief situations, there are boundaries.

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PART OF THE JEFFERSON COLLEGE OF HEALTH SCIENCES CAMPUS IN DOWNTOWN ROANOKE Photo Courtesy of Jefferson College of Health Sciences

Professionals in mental health prepared to see an influx of people suffering from post-traumatic stress disorder, severe anxiety that shows itself in many ways and that’s brought on by exposure to violently traumatic events.

At the Veterans Affairs Medical Center in Salem, psychologists kept watch for veterans and employees who needed counseling. Veterans there who were alive at the time of Pearl Harbor said they didn’t remember themselves feeling as badly the day after Pearl Harbor as they did on the day after the terrorist attacks.

Roanoke residents Stephen Hill, MD, a surgeon and chief of the medical staff at Roanoke Memorial and Community hospitals, and his nurse anesthetist wife, Susan Hill, were in New York City on that morning. He was attending a medical conference and she went along to visit old friends.

In 1978, they had been married atop the South Tower of the World Trade Center, and the structure always held a special meaning for them.

But then, at 9:58 AM, the South Tower collapsed in front of a horrified worldwide television audience. The tower fell

56 minutes after having been hit by United Airlines Flight 175, the second passenger jet to be hijacked and flown into the World Trade Center.

A call went out for medical help. The Hills were steered to what was to be a medical triage center at Manhattan Community College, about four blocks from the disaster site.

They pitched in setting up tables, medical supplies, drugs and other things that would be needed for the thousands of casualties that they expected to assess, treat and send on to further care elsewhere in the city.

The waves of casualties never came.

They did see some injured people—primarily first responders who appeared at the triage site with cuts, respiratory trouble from the smoke and dust in the air and other minor injuries.

But there was nothing they could do for the thousands of people who could not get out of the towers in time.

In the Roanoke Valley, hospital officials and first responders—fire departments, rescue personnel and police—were inspired to revisit their plans for how their hospitals would handle disasters involving mass casualties.

JEFFERSON COLLEGE OF HEALTH SCIENCES STUDENTS LEARNING LAB AND IN CLINIC TRAINING Photos Courtesy of Jefferson College of Health Sciences

Although no one thought that it was likely the Roanoke Valley would ever be attacked by terrorists, everyone involved in disaster response learned that anything is possible.

Hospitals have frequent drills to prepare for disasters involving mass casualties. In the Lewis-Gale emergency room early on a Friday morning in July 2006, the disaster plan became reality. A carbon monoxide buildup in three dormitories at Roanoke College in Salem killed one person and sent more than 100 people to local hospitals. Some of the victims had been attending a Lutheran conference and others had been involved in a college preparatory program.

patients between on-scene medical personnel and emergency medical staff at receiving hospitals.

Early that morning, two gunshot victims had been sent to area hospitals, before college officials had any inkling that they were on the leading edge of a tragic disaster. One person was sent to Montgomery Regional Hospital, to be pronounced dead on arrival. The second was sent to Roanoke Memorial, where the victim died. In the next couple of hours, 17 people were sent to the hospitals. Although more than 30 would die that Monday, hospital staffs in those five hospitals worked to be sure that the rest would live.

A total of 62 people were sent to Lewis-Gale, and another 49 were treated at Roanoke Memorial. It was the first time the Lewis-Gale ER had faced an actual mass casualty incident. The patients at Roanoke Memorial were the most that ER had treated at one time in recent memory.

Because it is a trauma center, Roanoke Memorial typically is the regional control center for mass casualty incidents, but more people went to Lewis-Gale first because of its close proximity to the college.

Staff at Lewis-Gale quickly realized that they were running short of oxygen and oxygen masks. The hospital’s vendor quickly supplied more oxygen, and Carilion shipped 150 additional masks to Lewis-Gale.

The planning and the drills over the years came into play most noticeably on April 16, 2007, a Monday morning, when a gunman at Virginia Tech opened fire and carried out a massacre that would kill 32 people and wound 17 others before killing himself. (Six people were also wounded escaping from classroom windows.) It was the deadliest shooting by a single gunman in U.S. history.

Early in the massacre, five hospitals— Montgomery Regional, Roanoke Memorial, New River Valley Medical Center, Lewis-Gale Medical Center and Pulaski Community—logged on to a software program designed to handle disaster response, coordinating the conditions and transport of the history of healthcare

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A MAJOR ADDITION AT ROANOKE MEMORIAL In September 2007 both Roanoke Memorial and Community Hospital were ready for a major relocation of patient services with the completion of a $105 million construction project at Memorial.

In the shift, all new obstetric, gynecologic and neonatal patients would be treated at Roanoke Memorial, and those services ended at Community.

What had been a 24-hour emergency department at Community closed, with the hospital instead operating an urgent care center during extended daily hours. The trauma center at Roanoke Memorial, expanded as part of the construction, would see all emergency patients.

revamping its curriculum as it moved into a new home. The school shifted its emphasis from associate degree programs to programs leading to a bachelor’s degree. The college now offers master’s degrees in nursing, occupational therapy and physician assistant, and bachelor’s degrees in nursing and a range of other healthcare fields. It also continues to offer associate degrees in several fields. Jefferson College received a renewed 10-year accreditation in 2011. In recent years, enrollment at the college has nearly doubled.

TRYING FINANCIAL TIMES FOR CARILION, AND SCATHING NATIONAL NEWS

In total, the move added 137 beds to Roanoke Memorial, including the 60 in the neonatal intensive care unit, bringing the hospital’s total bed count to 825. At the time, Roanoke Memorial was the third largest hospital in Virginia.

At the same time as the expansions at Roanoke Memorial came online, Carilion was deeply involved in nearly $130 million in additional construction projects — a $70 million office building to house the offices and practices of the physicians being brought aboard to flesh out the organization’s plans for its transition to the Carilion Clinic, and a $59 million building to house the new Biomedical Institute and the Carilion Virginia Tech School of Medicine.

The building that had housed Community Hospital would become the home of the Jefferson College of Health Sciences. Dating back to the early 1900s and the oldest hospital-based college in Virginia, the college was also

The structures were to occupy what had been named the Riverside Centre for Research and Technology, a stone’s throw away from Roanoke Memorial on property just south of downtown Roanoke.

TOP LEFT VIRGINIA TECH CARILION SCHOOL OF MEDICINE AND RESEARCH INSTITUTE Photo Courtesy of Virginia Tech Carilion School of Medicine BOTTOM LEFT VIRGINIA TECH CARILION SCHOOL OF MEDICINE AND RESEARCH INSTITUTE Photo by Jim Stroup

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VIRGINIA TECH CARILION SCHOOL OF MEDICINE’S FIRST GRADUATING CLASS, MAY 2014 | Photo by David Hungate

In addition, Carilion was bringing waves of physicians and other new employees onto its payroll, and medical records software was being installed to integrate its information systems. And the cost of caring for low-income patients grew substantially, to about $99.7 million, a 39 percent increase.

Those growing expenses were at the core of a steep decline in operating income for Carilion’s fiscal year ending September 30, 2007. The financial environment was serious, but not fatal. As time would show, Carilion was feeling the impact of a national economic meltdown.

The national downturn and recession struck just as Carilion’s capital spending was being ramped up, putting 38

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severe limits on what had been highly admirable surplus revenues at the end of the fiscal year.

Spurred in part by the dismal financial climate, Carilion for the first time ever moved to seek public donations for its Carilion Foundation, which pumps funding into charities in the region, and which had been funded completely by corporate money.

Less than a month after announcing the fundraising effort, Carilion was hit with a one-two punch of newspaper stories that brought the system’s bill collection policy under sharp attack.

THE VIRTUAL ANATOMY TABLE AT THE VIRGINIA TECH CARILION SCHOOL OF MEDICINE OPERATES MUCH LIKE A GIANT IPAD Photo by Jim Stroup

A front-page Wall Street Journal article on August 28, 2008, raised questions about whether healthcare savings promised by the creation of the Carilion system had been realized. The article also examined the tension between the health system and its physicians that arose early in the formation of the Carilion Clinic, and suggested that business relationships between the Carilion board and businesses owned by board members were less than arms-length. But the Wall Street Journal devoted its sharpest scrutiny for bill collection practices that drew so many patients into court that local court officials usually reserved one court day a week for Carilion collection activity against delinquent patients.

A Roanoke Times article in mid-September covered much the same territory, but pointed out that mechanisms existed for low-income patients to be treated at the hospital without being sued. The problem, it seemed, was that the patients didn’t know of the mechanisms.

NEW ACCOUNTABILITY Carilion responded by looking into their own billing and collection policies and announcing a drastic change that would give deeper discounts to lower-income patients just when the steadily worsening economy was battering more and more family budgets. the history of healthcare

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The new policy, announced in early 2009, applied retroactively to unpaid medical bills dating to the previous October 1, the date upon which the health system also suspended taking legal action against unpaid bills until a new policy could be crafted.

The new policy called for increased use of electronic databases to identify families living at or below the poverty line, and automatically writing off bills of $1,500 or less. Carilion also raised the amount of equity they could have in their homes and still qualify for charity care, along with other steps, such as offering deep discounts to those who could afford to pay some of their bill, but not all of it.

In mid-2010 Carilion Clinic brought its intentions into sharper focus by taking steps to help keep people healthy, rather than waiting to treat people when they become ill.

Fueled by the national conversation surrounding healthcare under President Obama’s new health law, the Affordable Care Act, the clinic focused its efforts on what it would take to become an ACO—an “accountable care organization,” a relatively new term for groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated high-quality care to the Medicare patients. It fit very well the model that Carilion had had its eyes on for years.

During the previous summer, as the national debate over healthcare legislation seemed about to boil over in “town hall meetings” across the country, Carilion was already talking with insurance companies to arrange a new payment system. Carilion had become a pilot site for studying ACOs aimed at finding an alternative to the prevailing fee-forservice payment model used in healthcare.

At about the same time that Carilion Clinic announced its new direction, 42 students were preparing to become the first class of the Virginia Tech Carilion School of Medicine, the result of nearly six years of discussion, planning and construction. The new medical school, the 131st to open in the nation, took its place as a significant link for Carilion Clinic, for Virginia Tech and for the Roanoke Valley, not

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only as a site to train physicians that many hoped would stay on to practice in the region, but as a major boost to the region’s economy.

It is not the only school of medicine in the Roanoke Valley, however. Virginia Tech and the Harvey W. Peters Research Foundation worked together to found the Edward Via Virginia College of Osteopathic Medicine. Closely affiliated with Virginia Tech and located in Blacksburg, the college recruits heavily from the rural sections of central and southwestern Virginia, piedmont North Carolina and upstate South Carolina. Its mission is to work to ease critical shortages of physicians serving Appalachia. The college also has a campus in Spartanburg, SC, and in 2012 announced that it would be opening a second branch, in Auburn, AL. In March 2011 the person who had shaped the Carilion Clinic into its modern form announced that he would be leaving the organization on July 1, to be replaced by Nancy Agee, who had been Carilion’s chief operating officer.

Most observers agreed that it was an inspired transition.

Murphy was seen as the visionary behind the Carilion as it has developed today, and Agee was recognized as the person who could most effectively put Murphy’s vision into practice.

And that’s where we will leave this history of healthcare in the region. There’s a lot more to be done, and a lot more to be told. Healthcare in America still has a galaxy of unanswered questions and unmet challenges. And everyone has a vested interest in the outcome. Within just the past year, hospitals, physicians and other healthcare providers have worked hard to try to prepare their organizations and the public for whatever the healthcare landscape will look like in the coming years. They are trying hard to balance America’s access to healthcare against political posturing in Washington and widespread resistance to change. Our job at OurHealth Virginia is to help you understand what’s going on in healthcare in our region, and to provide ample evidence of the excellence in the health services we are fortunate to have.

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EPIDEMICS

N

o one knows beyond a doubt the origin of HIV—the human immunodeficiency virus that causes AIDS.

Most researchers now believe, however, that a similar virus—the simian immunodeficiency virus (SIV)—was present in monkeys and chimpanzees in a corner of Cameroon, in western Central Africa. Native hunters, researchers believe, killed the chimps and butchered them on the spot, with blood and gore everywhere to infect humans. This may have been as early as the 1930s.

Researchers further believe that the virus infected humans some time before the 1930s and was gradually spread by river travel. All the rivers in Cameroon run into the Sangha River, which joins the Congo River running past Kinshasa, in the Belgian Congo. The first recorded sample of HIV was discovered in 1959 in a blood specimen obtained at Kinshasa; this was the first known AIDS death.

In 1981 physicians began seeing unexplained cases of a rare form of parasitic pneumonia in healthy young men in metropolitan areas of the United States. Before that, the pneumonia had been seen only in the very old or the very young, or in people with compromised immune systems.

Physicians also began reporting an increase in Kaposi’s sarcoma, a rare skin cancer, also previously seen only in people with weakened immune systems. The common factor in these patients was that they were almost exclusively gay, and predominantly promiscuous.

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CARING FOR PATIENTS AT CARILION CLINIC | Photo Courtesy of Carilion Clinic

PHYSICIANS AT CARILION CLINIC REVIEWING PATIENT DATA | Photo Courtesy of Carilion Clinic

The disease was named Acquired Immune Deficiency Syndrome in 1981. That same year, a young man in St. Louis died as a result of AIDS, the first of what would be an estimated 619,000 U.S. deaths.

It quickly became clear, however, that AIDS was not limited to gay men. It started appearing in hemophiliacs, intravenous drug users, female partners of bisexual men and children of women who had become infected. It slowly became evident that all bodily fluids, including saliva, could carry the virus.

The disease that at first seemed to be confined to a somewhat isolated community became a plague that could affect anyone and everyone. Before many years had passed, it would blaze into a global pandemic that would sicken as many as 50 million people globally, killing 20 million.

In the Roanoke area, three or four people were believed to have had HIV in 1981. In 1991 the four infectious disease specialists in the area were following dozens of patients each. And by 2001 health department statistics reported a total 1,848 cases of HIV and AIDS in southwestern Virginia.

In Roanoke, according to the AIDS Council of Western Virginia, 34 people had died of the disease.

Initially, much of Roanoke ignored the disease. Public information forums went unattended. A tale was told of a Roanoke dentist turning away a patient with HIV, proclaiming in his waiting room, “We don’t want people like you.”

A lone first voice in the Roanoke Valley to bring both attention and help to people with HIV and AIDS was 46

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Charles Schleupner, MD, an infectious disease specialist on the staff of the Veterans Affairs Medical Center in Salem.

He established one of the early clinics in southwestern Virginia where people could be tested for the HIV virus anonymously. He helped educate other healthcare professionals in the region about the disease. He also formed a weekly journal club of infectious disease specialists, a microbiologist and others to review advancements in the detection and treatment of a range of infectious diseases, including AIDS. In late 2001 the NAACP declared a health state of emergency in the Roanoke Valley. The NAACP and its partners in the project—the Roanoke Health Department, the AIDS Coalition of Southwestern Virginia, the Kuumba Health Center and Planned Parenthood—were alarmed at statistics showing that African Americans made up more than half of the reported HIV/AIDS cases locally. The national NAACP also made AIDS prevention a priority.

Nationally, African Americans made up 13 percent of the overall population, but 47 percent of all HIV/AIDS cases.

More recently, public health officials worry that people have become complacent about the disease and its risks.

AIDS has become something close to a routine part of American culture over the past 30 years. Having HIV or AIDS is no longer necessarily a death sentence. Instead, it’s become a chronic disease. Since it takes so long to show itself in most people—up to seven years—many younger people don’t see themselves at risk until they become older and begin to sicken. Not long ago, 41 percent of people

with HIV or AIDS in the region were diagnosed between the ages of 41 and 49. Healthcare professionals were also seeing alarming increases in the numbers of people diagnosed with HIV/AIDS in their mid-20s.

And in 2012 local health offices started seeing increases in the numbers of people diagnosed with AIDS. Roanoke City and Roanoke County had the largest number of cases, with 591. Lynchburg followed with 208 cases, Danville with 158, Montgomery County with 79 cases and Martinsville with 58.

Quick and anonymous HIV and AIDS testing is offered at a number of sites in the region, including the health department.

Legionnaires’, named for the 1967 outbreak at an American Legion convention, is a strain of pneumonia that is often traced to air-cooling systems. The Centers for Disease Control and Prevention said that the Virginia victims are believed to have inhaled bacteria-laden air circulated by the hot tub. No one actually entered the tub, which was filled and on display in the home improvement store.

The flu season makes its regularly scheduled annual appearance in the Roanoke Valley, usually peaking in January and February. In some years, the outbreak is relatively mild.

Although AIDS was by far the most horrifying and enduring of the epidemics and breakouts of illness to affect the region, it was not the only one.

In 1991 a dozen or more cases of rarely seen dysentery were reported to the Roanoke Health Department in the space of a few days, mounting to a total 42 cases over the course of the outbreak. In normal years, one or two cases of the disease are reported. The highly infectious disease causes diarrhea, fever, nausea, abdominal cramps and vomiting. During the War Between the States dysentery was the cause of as many or more deaths as battle wounds were.

The disease was found at two daycare centers and a preschool in Roanoke, as well as at a daycare center in Botetourt County. Five elementary schools in Roanoke also reported youngsters with the disease.

Dysentery became a problem at least once more, in 1997, when eight young people and possibly a grandmother fell victims in the Vinton area and in Bedford County.

Virginia’s first outbreak of Legionnaires’ disease—a fatal one, killing two people and hospitalizing 23 others—was traced to a display hot tub at a home improvement store in Christiansburg in October 1996. the history of healthcare

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CLINICAL STUDIES AT CARILION CLINIC WITH VIRGINIA TECH CARILION STUDENTS Photo by Logan Wallace

In other years, however, such as the 2000–2001 and 2003– 2004 flu seasons, it seems to be everywhere. More recently, the annual flu season stories have been accompanied by worrisome announcements that there might not be enough flu vaccine to carry the nation through the next upcoming season. In other years there are frequently worries that the recipe for that year’s flu vaccine may not be the right match for the strain of flu that actually develops.

Memories of the previous flu season carried over to the 2004–2005 season, along with announcements in early October that the U.S. would not have enough vaccine for the season. The problem was a sterility issue at a vaccine manufacturer in Liverpool, England, causing it to be unable to ship its planned tens of millions of doses of the vaccine.

That cut the U.S. supply of vaccine roughly in half.

During the winter of 1999–2000, for example, a persistent and severe strain of flu—called the Sydney strain—had healthcare professionals in the region very busy. Not only that, but officials at the Centers for Disease Control and Prevention in Atlanta were late issuing their authoritative weekly flu report because they were too busy taking care of their own patients who had come down with the flu.

Vaccination clinics that had planned to treat all comers shelved those plans, restricting vaccinations to high-risk people. Physicians’ offices adopted a federal directive to vaccinate only the young, the old, pregnant women and medical caregivers. Leaders of local hospitals declined their own vaccinations because they were not among highrisk people, and the Carilion system made doses of its vaccine available to other providers.

In the 2002–2003 flu season, a hard-hitting outbreak of both flu and severe colds had schools in the region reporting from two to five times the number of usual absences, and forced physicians to cancel well visits to concentrate on caring for their sick patients.

Luckily, the flu season peaked later than it normally does, allowing health agencies time to reallocate and direct the vaccine to those most in need—the elderly and children— staving off what many thought was shaping up to be a catastrophic flu season.

An early appearance of the illness during the 2003–2004 season depleted supplies of flu vaccine at the same time that the country’s top health officer called the flu an official epidemic. Physicians’ offices, health departments and community clinics reported short supplies of vaccine, and some reported that their supplies were exhausted.

The 2009–2010 flu season brought a new phrase into the healthcare lexicon. The H1N1 “swine flu” strain became more widespread in the region, causing hospitals to ask visitors not to bring children to see patients and again spiking demand for vaccines in the face of dwindling stocks.

And the flu itself packed an especially strong punch. LewisGale Medical Center rescheduled elective surgeries to free up beds for flu patients. Nationally, that flu season proved to be one of the deadliest on record, with a national toll of 48,614 deaths attributed to the flu.

The appearance of the flu complicated Election Day 2009.

With the flu virus able to survived for prolonged times on various surfaces, elections officials offered plastic stirring sticks for voters to use to touch voting screens. Cotton swabs were used for the same purpose in other localities. And the

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Virginia Department of Health and the Centers for Disease Control and Prevention provided 2,000 bottles of hand sanitizer for use in polling places.

The prescription painkiller OxyContin became a public health threat at the turn of the 21st century. Overdoses of the drug had killed more than 35 people in southwestern Virginia by 2001, driving healthcare providers to announce stepped-up efforts to curb prescription fraud and to treat abusers.

In 2005 five female residents of the Lakeview Assisted Living Center in Roanoke became sick and tested positive for the Group A streptococcus bacteria, a cause of necrotizing fasciitis, the so-called “flesh-eating bacteria.”

Two of the women died, and a third was forced to have a leg amputation. After the outbreak, a health department investigation found another 18 residents and staff who tested positive for the bacteria. The health department investigation reported that the bacteria were likely transmitted by an employee who displayed no symptoms.

MRSA, a bacterial skin infection that most often occurs in hospitals, began to move into the healthy community in the middle of the decade, believed to be a side effect of the overuse of antibiotics. The hard-to-treat infections are the result of methicillin-resistant Staphylococcus aureus. The overuse of some antibiotics, such as penicillin, allows the bacteria to develop a resistance to control. An infection occurs when the bacteria enter the skin through an abrasion or open wound, transmitted through skin-to-skin contact.

In late 2007 MRSA showed up in Bedford County and Roanoke County athletes. In the previous year, five cases were documented in the Roanoke and New River valleys.

At the same time that the infections were being reported in the community, cases of hospital-acquired MRSA also were on the rise. Nationally, MRSA infections in hospitals tripled between 1995 and 2005.

Late in the year, the death of a 17-year-old Bedford County boy underlined the dangers of the infection. The MRSA infection, undiagnosed until late in his illness, had spread to his kidneys, liver, lungs and the muscle around his heart. His death caused all 22 Bedford County schools to be closed for thorough cleanings.

Ironically, his death came on the same day that the federal Centers for Disease Control and Prevention announced the results of a study establishing that “invasive MRSA disease is a major public health problem,” more prevalent than originally believed.

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HEROES

S

ome of the people whose careers have made a huge difference in healthcare in the Roanoke Valley

CAROL SEAVOR, EDD Carol Seavor spent the first 15 years of her healthcare career as a nurse, and then moved into academia. In 2002 she left her post as associate dean for academic affairs at the University of Tennessee’s College of Nursing to become president of the Jefferson College of Health Sciences in Roanoke.

In that role over the next seven years, she led the college through a period of unprecedented growth in both curriculum and enrollment.

During her tenure, enrollment at the college expanded from just over 600 in 2002 to over 1,000 in 2009. She led the college in expanding to 14 the academic programs offered, including the addition of four bachelor’s-level programs and three graduate programs.

She also guided the college’s expansion into the Roanoke Community Hospital building after Carilion Clinic consolidated services at Roanoke Memorial Hospital in August 2007.

Dr. Seavor retired at the end of the 2009 academic year, leaving a legacy of continued growth and academic excellence in a broad range of programs.

CAROL SEAVOR, EDD Photo Courtesy of Carilion Clinic the history of healthcare

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WILLIAM REID At the helm of the former Jefferson Hospital since 1953, Reid guided that hospital during an ill-fated joint venture with Lewis-Gale Hospital, when Jefferson became Community Hospital of the Roanoke Valley.

He then served as president of Community Hospital, a key player in the formation of the Carilion Health System, and after the establishment of Carilion in 1990 continued to head Community, while at the same time serving as senior executive vice president of Carilion. Reid retired at the end of 1992.

When he first considered his career in 1948, “you could go to school for fishing and deep sea diving, but not hospital administration,” he said. When he retired as president of Community Hospital of Roanoke Valley, he had served 40 years in hospitals.

A graduate of Virginia Tech, the Bluefield, WVA, native did find a college program for hospital administration in 1948, a fledgling one at the Medical College of Virginia in Richmond. As part of the MCV program, he did an internship at Jefferson Hospital in Roanoke. “It was the closest hospital to Bluefield,” he said. He got his master’s degree in 1952 and became administrator at Waynesboro Community Hospital. He said he learned to appreciate the role of a small-town hospital administrator.

“I was the total administrative staff,” he wrote in a personal essay about his year in Waynesboro, working in a small basement office.

“I served as director of nursing with staffing responsibilities.

I purchased the drugs; I purchased the radiology equipment and supplies as well as those for laboratory, housekeeping and dietary.” He remembered a time he had to drive around trying to find a replacement for a switchboard operator who had been on duty for 14 straight hours during an ice storm. In Roanoke, he had a lot more help.

But he never lost the feeling of what it was like when you had to do it yourself.

CHARLES BRAY, MD, AND LOUIS RIPLEY, MD In 2006 the medical community in the Roanoke Valley paused to honor two of its own, in large part for the important roles they had played more than 55 years earlier. Retired by 2006, Dr. Bray and Dr. Ripley each received the Roanoke Valley Academy of Medicine’s lifetime achievement award.

Both were young physicians during the summer of 1950.

They were orthopaedists. And their choice of specialty put them on the front lines during the “Summer of Terror,” the 10-week rage of polio through southwestern Virginia when 54

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WILLIAM REID | Photo Courtesy of LewisGale Medical Center

they and other physicians treated 450 patients with polio, most of them young children. Forty-five of those patients died that summer.

Young people from all over the region were brought to Roanoke Memorial and Crippled Children’s Hospital. It was still a segregated nation, however, and African American people with polio were forced to travel to Richmond for help, if they got any help at all. Later, Look magazine would call the Jim Crow practice “medically inexcusable.”

The 120 beds in the Roanoke hospital were almost completely filled with polio victims. The young patients needed care 24 hours a day, seven days a week. Some patients recovered, others became paralyzed before the young physicians’ eyes. Some died.

“We practically lived together,” at the hospital during the period of the epidemic, Dr. Ripley told the Roanoke Times.

The number of cases dwindled as the summer wore on, and

by October, it was declared over. By 1955, Dr. Jonas Salk’s polio vaccine received widespread distribution and now polio has all but disappeared from the American landscape.

The two physicians continued their work with children as well as adults, visiting field clinics twice a year over decades to treat patients for free. And they helped develop a residency program in their specialty at the University of Virginia, training young physicians who might someday be needed to serve on the front lines of some new threat to health and lives.

[ www.ourhealthvirginia.com ]

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DOUGLAS MARTIN | Photo by Shawn Sprouse

DOUGLAS MARTIN For many of his 55 years on the job, he has held the unofficial title of the “Mayor of Roanoke Memorial Hospital.”

His official title is clinical support supervisor, but his service has been much broader than the title might imply. He is a greeter at the hospital’s main entrance, a kind and reassuring hand on a gurney for patients being transported, a source of knowledge and wisdom for all things great and small.

His first day on the job was January 27, 1958, when Dwight Eisenhower was president, the Internet had not been developed and the U.S. had yet to put its first satellite into space. Carilion did not yet exist.

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Everyone at the hospital in those days called each other “Mr.” or “Miss” or “Mrs.” So he was called “Mr. Martin.”

The name stuck.

You’ll recognize him if you should be there. Look for an athletic-looking fellow with roses peeking out of the pocket of his lab coat. He loves them, grows them at home and they oftentimes show up in patients’ rooms— an anonymous gift.

And when you hear the sound of a medical helicopter transporting a patient to or from the hospital, look for the fellow with his hat over his heart, saying a silent prayer.

That will be Mr. Martin.

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NURSING

A“It’s a tough time to be a nurse.”

headline on a Roanoke Times article in late November 1996 got it right:

The article dealt specifically with some of the frustrations that nurses were feeling during a nationwide cutback of nurses as well as other health workers in America’s hospitals. The trend in many hospitals looking to cut costs was to reduce the number of licensed nurses, reassigning some tasks to lower-paid aides.

In the latter part of 1996 the Carilion health system had embarked on just such a course. To position its hospitals for what Carilion expected to be the new face of hospital care in the country, the system had launched a major restructuring.

Carilion was implementing a “patient care model” that reduced the number of nurses by relegating many chores that had traditionally been performed by registered nurses to “clinical partners.” Taking temperatures and blood pressure readings, changing bandages and many other less-technical tasks would now be the task of licensed practical nurses and nursing assistants. The work that would be passed along to nonlicensed employees also included inserting needles for intravenous medications and inserting catheters to collect urine.

Nurses were vocal and clear about expressing their fears that the new patient care model would damage the quality of patient care and conceivably put patient lives in danger.

The cutbacks were not limited to nursing jobs. But nurses felt that they were to bear the brunt of the changes, and it was the strength and numbers of nurses who were slated to lose their jobs that drew the attention of nurses’ unions.

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NURSES IN 1996

Organizers from the Kentucky Nurses Association and from the Service Employees International Union (who saw the possibility of organizing non-nursing personnel) conducted meetings with Carilion employees. A local group, Virginia Nurses for Change, was formed as a local contingent of nurses examining the possibilities of organizing a union.

of their time training for the new patient care system would return to their units.

Carilion backed down.

Ironically, while the issue of reduction in the numbers of nurses was being played out on the one hand, on the other hand hospitals were finding that nurses were in short supply. At the beginning of 1997, nurses were looking at the possibility of their ranks being thinned out to an extent that alarmed them. Before 1997 ended, healthcare organizations in the region were struggling to attract and retain more nurses.

Faced with the prospect of union representation battles on two fronts, Carilion abandoned some portions of its restaffing plans and postponed other parts indefinitely.

One phase of the postponed nurse staffing plan was the provision that required noncertified assistants to take over some of the duties that had been performed by registered nurses.

Carilion also announced plans to hire a temporary nursing service to help it meet the acute need for staff—the Roanoke hospitals had been forced to defer patients to Lewis-Gale Medical Center on several occasions. The company said that 72 inpatient nursing employees who had been in orientation would move into patient areas.

Also, 101 nursing employees who had been spending part

The unions ended their organizing efforts, saying that it appeared that the employees’ aims had been achieved without the assistance of a union.

Studies had shown that as the numbers of staff nurses declined, patient accidents and infections increased. Nurses left hospital-based nursing for jobs in-home healthcare, community health services and other health-related organizations. This further depleted the supply of RNs. Hospitals in the region went into vigorous recruiting mode.

They worked to attract nursing students to work as nursing assistants or nurses’ aides while they were in school, and the history of healthcare

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CARILION CLINIC NURSES Photo Courtesy of Carilion Clinic

they established internships for junior and senior nursing students. Young nurses who established early relationships with hospitals would turn into RN employees, the hospitals hoped.

Lewis-Gale advertised for nursing employees in communities where there was an overabundance of nurses and where nurses had indicated a willingness to move to Virginia. As time went on, Carilion and Lewis-Gale started offering sign-on bonuses ranging from $750 to $2,500 for nurses who agreed to stay with the organization for a specified length of time. At Carilion in 1999, 70 newly hired nurses were paid a bonus of $2,000 each for an 18-month commitment and by mid-2000, 14 of those had left after fulfilling their promise.

Carilion needed a total of 85 additional nurses at the time, and declared a number of its beds inactive to even out the ratio of nurses to patients. It was the early phase of a nursing shortage expected to stretch into the future as far as 2006.

Nursing schools in Virginia stepped into the brink, ramping up their programs, in some cases doubling the number of

students they were admitting. The supply of new nurses did not appear to meet the continuing demand until a faltering economy in 2009 and 2010 brought a temporary halt to widespread hiring, although most still believe that there are plenty of employment opportunities for new nurses. Some nurses, planning retirement several years ago, have decided to continue working and tough out times of economic uncertainty. This will likely delay a more pronounced nursing shortage.

A major point of pride for the nursing profession in the region was reflected in the selection of Nancy Agee as president and CEO of Carilion in July 2011.

Born at Roanoke Memorial Hospital, she started her life in healthcare as a candy striper and started working as a nurse with Carilion 40 years ago. She now heads up the large health system in which she has spent her working career, making a place for her organization in the new world of how healthcare is provided and paid for.

NANCY AGEE Photo Courtesy of Carilion Clinic

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PET-CT IMAGING SCAN AT LEWISGALE MEDICAL CENTER Photo Courtesy of LewisGale Medical Center

TECHNOLOGY

T

he rapid advancements in healthcare technology that began in the 1950s gave rise to a constantly accelerating pace of research and further development. By the end of the 1990s, anyone would have been challenged to find many similarities, in terms of equipment and methodology, between the then-modern face of healthcare and that of mid-20th century America.

At the time of World War II, the physician typically had access to a stethoscope, a thermometer, a blood pressure cuff and meter and perhaps hospital-based access to an x-ray machine and an electrocardiogram. The physician’s medications were limited, with sulfa drugs and penicillin then considered the height of the pharmacist’s art.

Research and development of new equipment, spurred by wartime efforts, produced a flood of new instruments—new and more effective centrifuges, mass spectrometers, electron microscopes and more.

Greatly fast-tracked work in microelectronics and semiconductors during the war spurred the development of computers for use in diagnostic imaging techniques, monitoring equipment and recordkeeping. Quantum leaps in biomedicine paved the way for advances in immunology and pharmacology that today see application in organ transplants, joint replacements and the clinical development of medications.

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DIGITAL MAMMOGRAPHY AT LEWISGALE MEDICAL CENTER | Photo Courtesy of LewisGale Medical Center

But the lifesaving power of medical innovation comes at a price. In almost every corner of American enterprise, the development and application of new technology serves to drive costs down. Not true for healthcare. New technology raises costs. Medical technology, moreover, is a major factor in the annual 10 percent growth rate of healthcare spending.

The United States leads the world in healthcare spending—$2.7 billion in 2010, an estimated $8,000 a year for every man, woman and child living in the nation.

Spending on healthcare is at the root of the long and winding national debate on how best to rein in costs while at the same time making all this technology available to the greatest number of people.

During the 1990s healthcare in the Roanoke Valley kept apace with the technological change happening elsewhere and, in at least one instance, set the pace. A dramatic shift from inpatient hospitalization to outpatient treatment, the desire on the part of major providers to adopt new technologies and the fierce and unrelenting competition that developed in the formerly sedate world of healthcare were all contributing factors in the southwestern Virginia race to add new technology.

Transplantation surgery came to Roanoke in 1993, when a 41-year-old man received a kidney donated by his sister.

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from the Cleveland Clinic to establish the transplant program, which had been under development at Roanoke Memorial Hospital for the previous year. He and his team expected to conduct about 40 kidney transplants a year.

The program was to be short-lived, however. After four years and 76 transplants, Dr. Hayes decided to stop doing kidney transplants when the program was unable to meet the predicted number of 40 transplants a year.

The program was successful in terms of patient results. As of the time the program was canceled in 1993, 93 percent of the patients had survived and 90 percent had retained the transplanted kidney, which compared well with national statistics.

Dr. Hayes went into private practice with Physicians CareJefferson Surgical Clinic. The 20 patients on the hospital’s transplant waiting list were transferred to the list at the University of Virginia Health Sciences Center.

Sometimes new technology itself was enhanced by the surroundings in which the technology was delivered to patients. Such was the case when the Lewis-Gale Breast Center opened in Salem in 1996. Fluffy terrycloth robes, skin lotions and deodorants (women coming in for a mammogram were asked not to wear any before the procedure) and designer colors and décor were all calculated to ease what often can be a terrifying experience for a woman—facing the possibility of breast cancer.

At about the same time the center opened at Lewis-Gale, another opened in Roanoke’s Old Southwest district and a third facility was in the process of becoming a breast center.

Prompting the new movement were findings that only about half of the 1.3 million women in Virginia who should have been having regular mammograms actually had them.

Additionally, the leading edge of baby boomers was then turning 50, the age at which breast cancer often strikes.

Health planners and marketers correctly predicted a significant rise in the demand for health services related to detection and treatment of breast cancer.

Fueling the trend on the technological side was the development of technology that replaced a surgical procedure with one that could be done quickly, in the office, with faster results and readily available specialists to counsel women who learned they had breast cancer.

At the Breast Care Center of the Blue Ridge in southwest Roanoke, minimally invasive stereotactic biopsies employed computer imaging to guide a slender hollow needle into a suspect area of the breast. The needle was used to extract “plugs” of breast tissue, which were then quickly checked for cancer cells.

This procedure was also done at the Lewis-Gale Breast Center and in a similar center at Community Hospital, but at the Blue Ridge center, patients could lie on their stomachs on a special bed while the procedure was performed.

The older alternative was an invasive procedure, with a scarring incision, under general anesthetic. The surgery required a longer time to perform and a longer recovery period.

In 2001 the technology was offered at the New River Valley Medical Center and at other locations.

Still more recently, digital mammography came to the Roanoke Valley. In 2007 Lewis-Gale and the Carilion Clinic—in three of its Roanoke Valley locations—began

using the higher-resolution, more easily manipulated and stored form of mammography. The digital images are returned almost instantly, they can be deleted and reshot immediately and they can be shared electronically.

Leading-edge cancer treatment equipment was unveiled in 1997 at the Columbia Pulaski Community Hospital cancer treatment unit, which boasted a dual-energy linear accelerator to treat cancer victims with precision-controlled radiation beams guided by tungsten blades. The device was able to focus different degrees of radiation on specific areas of cancer, without overlapping and causing problems in other parts of the body. Equipment in the center linked by computer to the one at sister hospital Lewis-Gale in Salem, allowing instant data exchanges.

A technological change of a more conventional nature swept through Roanoke-area hospitals in mid-1998, when they got rid of powdered latex gloves, which had proved deadly to some healthcare workers elsewhere.

Up until then, cornstarch was used to make latex gloves easier to slip on. But when the gloves were sterilized during manufacturing, the cornstarch and rubber combination produced an antigen that resulted in ailments ranging from asthma to life-threatening shock in patients and healthcare workers.

The switch to nonpowdered gloves, which became a national pattern, came largely through the efforts of Richard Edlich, MD, a surgeon at the University of Virginia. His mother fought a 40-year battle with complications from surgery that were finally traced to her reaction to the powdered cornstarch used on the gloves. He chronicled the experience in a book, Medicine’s Deadly Dust. Publication of the book resulted in multiple lawsuits against hospitals and physicians by people who had suffered the complications described in the book.

Hospitals began getting rid of the powdered gloves, with Virginia hospitals in the lead, and Roanoke-area hospital setting the pace for the rest of the state.

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The Veterans Affairs Medical Center in Salem had gone powder-free in mid-1998.

elevator control systems—and replacing everything that was not Y2K compliant.

At about the same time, Carilion began using powder-free examining gloves in patient rooms and offices, and started moving to a powder-free environment in operating rooms.

Lewis-Gale Medical Center in Salem is powder-free in the emergency room, about 99 percent converted in the operating room and moving away from using powdered examining gloves throughout the hospital.

Local and national pharmacy chains said they were prepared for the changeover, with CVS noting that that chain had been preparing since 1996.

The importance of computers in modern healthcare was underscored as the world braced for chaos with the approach of midnight, December 31, 1999.

The problem, as some feared, would be that older computers would break down when the date switched from “99” to “00.” Computers, the fears went, would not recognize the logic of a century change, and to them, it would be 1900, not 2000. This in turn would lead to data loss of incalculable dimensions.

As it turned out, the so-called “Y2K crisis” never materialized.

But the fears were real enough to force organizations and even governments around the world to take preparatory action.

Roanoke area hospitals were ready. Y2K readiness teams at all hospitals spent several years in advance combing through all computer-dependent aspects of the hospital, inspecting computer systems and medical devices—even

Just to be sure, however, many hospital executives planned to be at their hospitals on New Year’s Eve, a Friday night, rather than attending a party to see the old century out and the new century in.

Beginning in 2000, Carilion became a perennial name on the list of the 100 “most wired” health systems and hospitals in the country, according to an annual survey conducted by the American Hospital Association. In 2001, the system became a national test site for paperless hospitals, installing software initially at the system’s Franklin Memorial Hospital in Rocky Mount.

The system worked with the German conglomerate Siemens, installing software that incorporates patient diagnosis, treatment plan, progress notes, laboratory results, x-rays and other images with medical literature online. The system also had the capacity to alert medical providers to dangerous drug interactions, remind them of treatment protocols, evaluate symptoms and suggest known treatments.

The technology of electronic medical records (EMR) has since become the standard for healthcare providers in the

NEW MEDICAL TECHNOLOGY AT LEWISGALE MEDICAL CENTER | Photo Courtesy of LewisGale Medical Center

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country, with the federal government providing billions in stimulus funding to hospitals and physician’s offices that move into EMR by 2015.

From the late 1990s into the infant years of this century, an $85 million hospital building boom was driven not by the need to add beds to hospitals in the region, but by the need to update and modernize the space that hospitals already had, and to prepare them for what one observer called “the inevitable decline in the health of baby boomers.”

Not one new bed was added to hospitals in the region during that surge in construction. In fact, some hospitals gave up beds. They were no longer needed as patients moved into and out of the hospital faster, reporting to the hospitals in the morning for a procedure and going home that afternoon or early that evening. Patients who did need to be hospitalized overnight discovered that they were being treated with sleeker, more advanced equipment.

Patients demonstrated a preference for care in up-to-date facilities, and hospital staff preferred to work in them.

Lewis-Gale Medical Center became the regional pioneer in the use of Prime ECG, an evolutionary step up from the “standard” ECG (electrocardiogram) used to give health professionals a look at the heart’s electrical activity to predict and diagnose a heart attack. The Prime ECG instead takes a more detailed look at the heart, to help diagnose “silent” heart attacks that conventional ECG might miss, saving time, money and lives.

The Prime ECG uses a disposable vest embedded with 80 censors—compared to a dozen sensors on conventional ECG. Information from the sensors is fed into a portable machine that produces a color-coded map of the heart. The device also alerts emergency medicine staff to the fact that a patient is not having a heart attack, reducing the need for unnecessary further tests and providing quicker peace of mind.

Lewis-Gale also brought to the region the hyperbaric chamber, best known as a device to help divers avoid postdive “bends” caused by bubbles of gas developing in the blood and tissue that can cause pain, cramps and possibly paralysis. Treatment is spending time in a hyperbaric chamber, where patients sit in a high-pressure atmosphere that forces oxygen into the tissues. The same science that governs a hyperbaric chamber can also speed healing and reduce infections. In-hospital use of the chamber is primarily to prevent infections that can develop from radiation therapy and to help with the healing of complex wounds. It is also used to combat carbon monoxide poisoning.

Much of the progress of cardiology in the region could have been traced following the care of one single person, a Montvale man who as a 50-year-old was Roanoke Memorial Hospital’s first patient to have open-heart

surgery. On June 29, 1982, a surgical team led by Paul Frantz, MD, replaced the man’s mitral valve with the valve from the heart of a pig.

Ten years later, almost to the day, Dr. Frantz replaced the deteriorating pig valve with an artificial valve. And 12 years after that, the man had a pacemaker installed at Roanoke Memorial. Up to that point, he had experienced the full arc of the heart program at Memorial. In June 2006, at age 74, the man died as a result of complications from an auto accident.

In that span of time, Roanoke Memorial had moved from stopping the 50-year-old man’s beating heart in his open chest while a heart-lung machine supplied blood and oxygen, to performing minimally invasive cardiac surgery through a small “port” in the patient’s chest.

The so-called “port access” surgery debuted at Roanoke Memorial in 1999, and it drew the attention of physicians from all over the world. About 20 percent of Roanoke heart surgery patients qualified for the technique, named for the three-inch port in the chest wall through which surgeons performed multiple bypass operations and heart valve replacements and repaired congenital heart defects. Compared to a 12-inch open incision, the port access surgery allowed faster recovery and less chance of infection and reduced the likelihood of internal bleeding.

Dozens of surgeons from all over the world came to Roanoke to observe and learn the technique.

Later, even smaller incisions were all that were needed for a surgical robot called a da Vinci Surgical System. With it, surgeons use a foot pedal and hand levers to maneuver mechanical arms bearing surgical instruments. Watching on a monitor, the surgeon performs an operation through small ports in the patient’s chest wall. A third mechanical arm controls a video camera inside the body that sends live magnified images to the monitor.

The same equipment has since been adapted for kidney surgery, prostate removal and other types of surgery.

What’s next? The possibilities are limitless. Medical technology will continue to race forward with unprecedented speed. Procedures and equipment that were the norm last month, last year, five years ago will be left in the dust of obsolescence. But what’s ahead is another new universe of medical treatment and equipment that the healthcare world of today can barely begin to imagine.

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TOP STATE OF THE ART Da VINCI SURGERY EQUIPMENT AT LEWISGALE BOTTOM COMPUTED TOMOGRAPHY (CT) SCAN, GENERATES DETAILED CROSS-SECTIONAL IMAGES OF THE BODY Photos Courtesy of LewisGale Medical Center

technology