26

rangements in meeting the needs of
the people in the Region. The Law
requires that these groups be broad-
ly representative of the major health
resources of the Region. It also insists
that members of the public familiar
with health needs be included. The
Law makes their approval of applica-
tions for operational grants a condi-
tion of Federal grant support.

To ca.rry out the full intent of the
Law, the Program Guidelines and
the National Advisory Council have
stressed the importance of the con-
tinuing role for the Regional Advisory
Group and the necessity for independ-
ence of its functions. As evidence that
the advisory group is performing its
role and is not a pro forma or sub-
servient group, an annual report is
required from the Advisory Group
itself giving its evaluation of the ef-
fectiveness of regional cooperative
arrangements.

The importance and composition
of these Advisory Groups have been
given further attention in a recent
policy statement of the Secretary of
the Department of Health, Educa-
tion, and Welfare on "Medical Care
Prices." This policy calls for special
emphasis to be given to adequate and
effective consumer representation in
the administration of Regiond Medi-
cal Programs. The Regional Advisory
Groups are a logical locus for that
representation.

Continuing Education
for Patient Care

Continuing education is an essential
component of Regional Medical Pro-
grams. It contributes in a most direct
way to the primary purposes of the
Regional Medical Programs. Im-
provements in patient care require
the primary participation of prac-
ticing physicians and other members
of the health team in their daily prac-
tice. Therefore, if the advances of
biomedical research are to be made
available to patients, the means must
be provided continuously to update
the performance of ail health profes-
sionals and supporting personnel.

However, Regional Medical Pro-
grams are not exclusively nor even
primarily a continuing education ef-
fort. Continuing education is one of
a number of means of working to-
ward their total objectives. Continu-
ing education projects, no matter how
meritorious, are supported from Re-
gional Medical Program grant funds
only when they are part of integrated,
comprehensive approaches of en-
hancing regional capability for the
diagnosis and treatment of heart
disease, cancer, stroke, and related
diseases.

The accelerating rate of advance
in the biomedical sciences and re-
lated technology makes the problem

of keeping current increasingly diffi-
cult for all involved in health care.
Regional Medical Programs are pro-
viding new opportunities to develop
the essential linkages between educa-
tion and practice, as an important
means of diminishing professional ob-
solescence which is the inevitable
consequence of rapid scientific ad-
vance. Studies of better ways of pro-
viding health services, demonstra-
`tions of patient care, and educational
and training for all types of health
personnel are joined together in a
unified effort. In continuing educa-
tion, as in other components of the
program, attention is focused directly
on the question, "Will this effort
change behavior and will this change
result, in fact, in the patient receiv-
ing the benefits of advances in heart
disease, cancer, and stroke?"

Progress reports show Regional
Medical Programs are proving to be
a strong catalyst to the entire field
of continuing education and training
of the health professions. They are
providing mechanisms for the coop-
erative relationships that can make
continuing education more effective
in improving patient care.

Latest Advances in
Diagnosis and Treatment

Section 900(b) of Public Law 89-
239 states that the Regional Medical

Programs are to help the medical pro-
fession and the medical institutions
of the Nation make available to their
patients "the latest advances in the
diagnosis and treatment" of heart
disease, cancer, stroke and related
diseases. A narrow and rigid interpre-
tation of this section would seriously
hamper the effective accomplish-
ment of the purposes of the program.
Improved health for patients threat-
ened or afflicted with these diseases
requires  emphasis on prevention
and rehabilitation as part of diagnos-
tic and treatment processes. It re-
quires dissemination and widespread
use of all relevant knowledge in
order to achieve the benefits of the
"latest advances."

The Public Health Service has
encouraged the Regions to consider
health functions as a continuum and
not a set of isolated functions. This
continuum involves the environment
of research and teaching, where the
latest advances in diagnosis and
treatment are most readily intro-
duced, as well as the other institutions
and groups involved in preventing
and caring for victims of these
diseases. To overcome existing gaps,
it is necessary to overcome problems
of organization, distribution, man-
power, cost, attitudes of the public or
the health professions and evaluation
of the effectiveness of activities in


27

changing the health status of the
population.

Limitations on Institutional
and Personal Commitments

A practical issue is raised by the
initial authorization of the program
on a 3-year exploratory basis. If the
program is to succeed, institutions
and organizations must commit them-
selves to participation in regional co-
operative arrangements which may
involve some lessening of their inde-
pendence of function. Many of these
institutions are under continuous
financial pressures. Full commitments
to new patterns of relationships in-
volve changes in attitudes. For these
reasons it is very difficult to obtain
this full commitment on the basis of
a limited authorization of the pro-
gram.

Similar problems apply in recruit-
ing talented manpower. High caliber
people are reluctant to make career
changes when the permanency of the
program is under question. The de-
gree of commitment already achieved
in the initial phases of the program
is the basis of hopeful expectations.
However, it will be difficult to obtain
a valid trial on which to base judg-
ments of the ultimate effectiveness if
the nature of the program authoriza-
tion does not encourage voluntary

and serious commitments of institu-
tions and personnel.

-.--
Relationships to
Other Programs

The great trends of accelerating sci-
entific advances and rising public
expectations in health have gener-
ated many new activities and pro-
grams to stimulate and support con-
certed action for health across the
Nation. Regional Medical Programs
are part of the response to these
forces. Other major actions relate to
financing the costs of medical care,
education for the health professions,
delivery of mental health services in
the community, strengthening public
health services and planning and con-
struction of hospitals and other
facilities.

In the preamble to the most recent
of the major Federal enactments, the
Comprehensive Health Planning and
Public Health Services Amendments
of 1966 (Public Law 89-749)) the
Congress made the following state-
ment of national health purpose :
"The Congress declares that fulfill-
ment of our national purpose depends
on promoting and assuring the high-
est level of health attainable for every
person, in an environment which con-
tributes positively to healthful indi-
vidual and family living;

"that attainment of this goal depends
on an eflective partnership, involving
close intergovernmental collabora-
tion, oficial and voluntary efiorts,
and participation of individuals and
organizations;

"that Federal financial assistance
must be directed to support the mar-
shalling of all health resources-na-
tional, State, and local-to assure
comprehensive health services of high
quality for every person, but without
interference with existing patterns of
private professional practice of med-
icine, dentistry and related healing
arts."

The many and diverse health pro-
grams, both nationally and in the Re-
gions, States and communities, all
contribute to these goals. However
various thrusts must be interrelated
to achieve maximum impact and ef-
fectiveness. Utilizing resources wisely
in the many promising avenues of
health activity calls for planning and
cooperation at many levels and the
recognition of the preponderance of
nonfederal financing for the total
health function.

Two fundamental principles, both
implicit in the Congressional declara-
tion of purpose just cited, govern the
Federal participation in health pro-
grams.

The first is a commitment to local,
broadly based initiative and plan-

ning. A diversity of patterns and
priorities, determined by the people
of a Region, State, or community can
help to match programs to particular
needs. No master plan imposed by a
central authority can be sensitive
or responsive to the multiplicity of
local conditions and requirements.
Planning is to aid foresight and ra-
tional action, not dictate solutions.

The second is that decisions in-
volving health involve the whole of
society, not just a few public or pri-
vate agencies. Rather all those af-
fected by these programs--providers
and consumers, public and private
groups, educators and practitioners-
must participate actively in decision
making. Division and fragmentation
impair progress and effectiveness.

These two principles are demon-
strated with special clarity in two
major new Federal programs designed
to pull together a number of efforts
whose impact has been diffused in the
past: the Regional Medical Pro-
grams,  and  the Comprehensive
Health Planning Program authorized
by Public Law 89-749. The first seeks
to stimulate the development of co-
operative arrangements for programs
directed toward enlarging the avail-
ability and enhancing the quality of
care provided for major disease prob-
lems on a regional basis; the second
seeks to stimulate effective planning


28

for the use of all existing resources
and the sound further development
of health resources by the States,
metropolitan areas and local com-
munities. The two programs are in
concept complementary and mutually
supportive.

A pulicy statement has been issued
concerning these two programs which
outlines general areas of relationship
and support. (Exhibit XI) Practical
operating methods under these con-
cepts are now being refined. Dis-
cussions are taking place through-
out the country, at the levels where
the coordination must be put into
practice. These are the most critical
decisions of all, for, as Secretary
Gardner has pointed out: "We are
beginning to understand that much
of the problem of coordination must
be solved at the local level. If the
Federal Government tried to coordi-
nate all its programs at the Washing-
ton level, it would end up imposing a
pattern on State and local govern-
ment. More important, only State and
local leadership has the knowledge
of local needs and resources that will
enable them to put all the programs
together in a way that makes sense."

Arrangements are being made to
insure close coordination between
Regional Medical Programs and
other Federal activities. Continuing
liaison is maintained with the Na-
tional Heart Institute, the National

Cancer Institute, National Institute
of Neurological Diseases and Blind-
ness, National Institute of General
Medical Sciences, National Library
of Medicine, National Center for
Chronic Disease Control and the
National Center for Health Statistics.
Working relationships are being de-
veloped with the new Bureau of
Health Manpower and plans are be-
ing made for collaboration with the
proposed National Center for Health
Services Research and Development.
Similar cooperation is being devel-
oped with agencies outside the Pub-
lic Health Service, such as the Voca-
tional Rehabilitation Administration,
the Veterans Administration and the
Department of Housing and Urban
Development. This partial listing of
the programs whose missions relate
to that of the Regional Medical Pro-
grams is an indication of the magni-
tude of the coordinating task.

The need for and responsibilities
of Regional Medical Programs to
identify the most effective ways of
linking programs at the regional level
are emphasized in the Program Reg-
ulations and Guidelines. These indi-
cate, that in awarding grants, the
Surgeon General will take into con-
sideration "the extent to which the
applicant or the participants in the
program plan to coordinate or have
coordinated the regional medical

program with other activities sup-
ported pursuant to the authority con-
tained in the Public Health Service
Act and other Acts of Congress in-
cluding those relating to planning
and use of facilities, personnel, and
equipment, and training of man-
power."

                     __~---
__-- ~~-. -
Relationship Between Federal
and Nonfederal Financing

                            -
         --___..
Regional Medical Programs can
serve as an integrating force to bring
to bear all the resources required to
reduce the toll from heart disease,
cancer, stroke and related diseases.
Grant funds under Public Law 89-
239 will necessarily provide only a
very small fraction of the total funds
necessary to meet all the identified
needs. The costs of these diseases
constitute a large portion of the Na-
tion's $43 billion health care expendi-
tures. The full application of medical
scientific advances in the diagnosis
and treatment of heart disease, can-
cer, stroke and related diseases will
require additional support from many
public and private sources. Regional
Medical Programs will in fact provide
only a minor share of financing for
the full range of activities relevant
to accomplishing the purposes of the
Law, even though formal matching
requirements are limited to construc-
tion aspects of the programs.

Federal grant funds, while they
can provide only partial support,
must be adequate to stimulate the
continuing technological and social
innovations to translate the latest
scientific advances into the daily
practice of medicine at the commu-
nity level. The "venture capital" for
such ,innovative efforts must, in large
measure, be supplied initially from
public funds. The potential return is
high and will accrue to individuals
throughout the Nation. A relatively
small amount of new money, wisely
and flexibly applied and fully coordi-
nated with related efforts, can help
assure that benefits from the "cutting
edge of science" are realized both
now and in the future.
As noted previously the impact
of this program on medical care
costs has yet to be ascertained. If
the benefits of this program do result
in warrantable additions to health
services costs, the extent to which
such costs can be met by normal
financing methods versus direct Fed-
eral support through Regional Medi-
cal Programs will require careful
examination.

          ..___ ~~  ~___~. ---. --
The Role of
University Medical Centers

Public Law 89-239 does not specify
the role of the university medical cen-
ters in the development of Regional


29

Medical Programs. Yet the nature of
the functions to be carried out by the
Regional Medical Programs has
made the university medical centers a
vital resource in most areas for ac-
complishing the objectives of the
Law. In many Regions the university
medical centers have played leader-
ship roles in initiating the develop-
ment of the Regional Medical
Programs.

Some medical leaders have seri-
ously questioned whether the uni-
versity is an appropriate focus for
the leadership of these cooperative
efforts. These doubts are raised from
several points of view: ( 1) Some
medical school faculty members and
administrators have concerns that
Regional Medical Program respon-
sibilities might divert medical school
resources from carrying out their
teaching and research functions. (2)
Other health representatives have ex-
pressed concern that medical school
leadership will result in domination
or absorption of other health re-
sources by the medical schools to
serve their educational and research
interests. (3) Questions have been
raised from many sources about the
capacity of university medical centers
to  expand  their  administrative
frameworks to encompass the plan-
ning and administrative implementa-
tion of a major effort involving the

268-040 o-67-3

total health resources of the Region
with an ultimate focus on improving
the quality of patient care.

Since university medical centers
have played prominent leadership
roles in the initial development of
most of the Regional Medical Pro-
grams, these concerns about diver-
sion, dominance, and administrative
capacity deserve careful attention.
Solutions to these problems require
new forms of relationships between
the university medical centers and
the other health resources of the
Regions.

Coordination and Leadership

Various mechanisms are being
tested for administering and coordi-
nating regional efforts: (1) the de-
velopment of new administrative
frameworks within the university and
formalized administrative relation-
ships with the other primary health
resources; (2) the use of executive
coordinating committees representa-
tive of major health interests which
can serve as decision-making bodies
closely related to day-to-day operat-
ing problems, reserving for the large
Regional Advisory Groups a more
general advisory and policy-making
function; (3) the utilization of exist-
ing nonprofit corporations as frame-
works for administration of the

cooperative program; (4) the estab-
lishment of new nonprofit corpora-
tions with boards of directors rep-
resentative of the major health
interests and having as their major
responsibility the planning and ad-
ministration of the Regional Medical
Program.

The creation of new administm-
tive structures outside of the univer-
sity medical center framework, as de-
veloped in a number of Regions, seem
to offer a most attractive solution
to the problems noted. These. new en-
tities, however, create other problems
related to the provision of sufficient
status and stability to attract the high
caliber personnel .required for the
planning and administration of the
Region Medical Programs. If these
innovative approaches to the admin-
istration of cooperative health activi-
ties prove effective, they may be a
useful mechanism for broader health
purposes. They may, in fact, provide
a useful prototype for relating the re-
sources of the university to broader
social needs without undue diversion
of the university's attention from
functions of teaching and research.

Regional Medical Programs will
continue to contend with this array of
problems listed, as they continue
their development. The resolution of
most of these matters will derive

from the increasing sophistication and
experience gained in the course of
full program operations. Others will
require further evolution of national
health policies and attitudes. Certain
are dependent upon clear executive
or legislative action and form the
basis of the recommendations con-
tained in the following section.


Conclusions and
Recommendations









I       I


SECTION FIVE Conclusions and Recommendations

On the basis of the initial experience
in the implementation of Public Law
89-239 certain conclusions and rec-
ommendations are indicated.

CONCLUSIONS

0 An effective beginning has been
made in the creation of cooperative
arrangements among the health re-
sources on a regional basis for im-
plementing the purposes of the Law.

0 The regional cooperative arrange-
ments being established and the plans
being developed and implemented
show great promise for providing the
benefits of the advances of medical
science to persons threatened or af-
flicted with heart disease, cancer,
stroke, and related diseases.

0 The Regional Medical Programs
will be seeking to accomplish their
mission during a time when many
major problems beset our health pro-
fessions and institutions. The Re-
gional Medical Programs seem to
provide a relevant and useful tool in
the search for better solutions to
these health problems.

O The extension of this program
and the indication of substantial
further national support are needed,
to sustain and nurture the individual
and institutional commitments as well
as the enthusiasm which give vigor
and substance to the regional co-

operative arrangements. These initial
efforts require an environment of
stability and status in which per-
manent effective cooperation can
flourish.

0 The initial progress provides solid
evidence for continuing the program
without modification of its essential
nature and purposes.

0 A more effective means for meet-
ing the special space needs generated
by this program is requisite to the full
achievement of the purposes of the
legislation.

RECOMMENDATIONS

Extension of the Act

As discussed in the earlier sections of
the Report, the sum of experiences in
the development of Regional Medi-
cal Programs throughout the country
demonstrates the validity and poten-
tial of these new cooperative ar-
rangements in both planning and
action. The needs are pressing and
the opportunities promising for mak-
ing available the benefits of medical
research advances. The establishment
of the Regional Medical Programs as
continuing instruments in the health
field will contribute significantly to
the fulfillment of these opportunities.

Many groups and individuals initi-
ally expressed uncertainty and doubt

about the Regional Medical Program
concept. Most have been reassured on
the value of this approach as major
regional interests have come together
to determine locally the most appro-
priate and effective ways of moving
the program forward in their Regions.
Groups throughout the Nation are
coming to recognize that through Re-
gional Medical Programs, local plan-
ning, decision-making, initiative, and
capabilities to meet the needs of
patients with heart disease, cancer,
stroke and related diseases can be
enhanced significantly.

Individuals undertaking regional
planning have reported that uncer-
tainty about the program's future is a
serious obstacle in recruiting well
qualified persons for leadership and
key staff positions. Some institutions
and agencies have been reluctant to
embark upon a course of action, what-
ever its promise and potential, with-
out reasonable assurance that the
program will be continued. There-
fore, extension of the program will
prevent a loss of momentum and
enthusiasm already achieved and will
provide a firm basis for strengthening
and building upon the beginning
efforts.  The importance of this
momentum and enthusiasm for the
success of a voluntary cooperative
endeavor should not be underesti-
mated.

A 5-year extension should attract
the long-term commitment of the
kind and quality of people, and
the full participation of all affected
institutions which are essential to the
program's success. This requirement
calls for an authorization that, in both
its duration and its level of funding,
will indicate a national intent to
maintain this effort until the job is
done.

Funds for Regional Medical Pro-
grams can be a critical factor, even
though they are only a small fraction
of the total national expenditures for
heart disease, cancer, stroke, and re-
lated diseases. For these funds, effec-
tively used, can be a fulcrum in rais-
ing the quality of care generally
throughout the country as well as in
significantly enhancing the diagnosis
and treatment of these diseases.

Experience gained thus far indi-
cates that the annual cost of operation
for each Regional Medical Program
may be as much as $10 million or
more. There are several bases for this
estimate.  The initial operational
grants and the plans being developed
around the Nation indicate that there
are myriad opportunities for improv-
ing the diagnosis and treatment of
heart disease, cancer, stroke, and re-
lated diseases by bringing the latest
advances into the daily practice of
medicine in all parts of the Nation.


33

The number of potential partici-
pants-institutions, groups, agencies,
and health personnel-is very great.
All must contribute if the benefits of
the programs are to be widely avail-
able to the population of the Nation.
Frequently, sophisticated and ex-
pensive equipment is required be-
cause of the high order of technologi-
cal innovation entailed by many
recent medical and related advances.
This equipment will advance clinical,
communication and computing serv-
ices. Many technological innovations
should be rapidly introduced to bring
to patients the benefits of the ad-
vances. This will require effective re-
gional planning with the cooperative
involvement of full-range medical
resources. It will also require sources
of funding to be spent on the basis of
regional priorities which do not have
to compete with pressing needs of the
individual institutions.

It is recommended that the pro-
gram be established on a continuing
basis.

New Construction of
Essential Facilities

The originA Administration proposal
to the Congress in 1965 requesting
legislative authority for Regional
Medical Programs included grant as-
sistance for construction of new as
well as the renovation of existing

facilities. It thus identified the need
for facilitating construction in the
successful development of Regional
Medical Programs.

In enacting Public Law 89-239,
however, Congress amended that pro-
vision to limit construction authority
to "alteration, major repair, rcmodd-
ing and renovation of existing build-
ings" during the initial period of
authorization. In so doing, the Report
of the House Committee on Inter-
state and Foreign Commerce stated:
"The lack of this authority for new
construction should create no serious
problems during the three years au-
thorized in this legislation and when
a request is made for extension of
this legislation in the future, the com-
mittee will review this question
again."

The lack of authority to assist new
construction has not presented serious
obstacles to the initial planning and
development of Regional Medical
Programs. Thus, the early judgments
of the Congress have been confirmed.
Experience, however, has identified
several areas in which authority to
assist new construction will be essen-
tial to the full development of Re-
gional Medical Programs.

Specific construction needs essen-
tial to the work of Regional Medical
Programs have been more clearly de-
fined and documented during the
initial planning phase. Information

obtained from Regional Medical Pro-
gram Coordinators and key staff, Re-
gional Advisory Group Members, and
others involved with these programs
at the regional level indicates that
there are major needs in a number of
areas. These inadequacies will ham-
per activities within the next several
years as Regional Medical Programs
move into the operational phase and
their range of activities increases.
The likelihood of significant limita-
tions on Regional Medical Program
activities from space shortages is
increased by the overwhelming de-
mand for new health facilities gen-
erally in the years immediately
ahead. The demands of an expanded
population and its desires for high
quality medical care, the expansion
of medical education facilities, and
the backlog of demand for health
research facilities all indicate very
great competition for funds to finance
the necessary facility expansion.

The types of construction needs
described below, defined according to
regional priorities, will have great dif-
ficulty in competing successfully with
the immediate and overwhelming
construction needs to house ade-
quately the basic functions of the par-
ticipating institutions. Construction
of facilities needed for the purposes
of the Regional Medical Program is
likely to be delayed until these urgent
institutional needs are met. Since the

lag between identifying a need for
construction and the availability of
the facility is so great, this competi-
tive position might seriously delay the
implementation of the Regional Med-
ical Program.

It is also important that the types of
needs cited below be given adequate
consideration during the general ex-
pansion of health facilities of the
Nation. Only then will the activities
represented by them become an
integral part of the functions of the
medical institutions of the Retions:

0 Space for continuing education
programs and training purposes is
urgently needed, including class-
rooms and conference room space,
learning center facilities, and medical
reference and audiovisual facilities.
This is the need most frequently
cited by Regional Programs and
other groups, such as the Association
of Hospital Directors of Medical Edu-
ration. It is particularly acute in
community hospitals.

In the past there has been a paucity
of operational support in both com-
munity hospitals and medical centers
for continuing education activities.
The same situation has been true
with respect to capital expenditures.
Most of the Nation's 7,000 hospitals,
especially the smaller ones, simply do
not have existing space that can be
converted or renovated for educa-


34

tional purposes. The same holds true
for most medical schools, most of
which cannot significantly expand
their present postgraduate educa-
tion programs without additional
space and facilities. In the past, as
documented by the 1962 survey of
the American Medical Association
Council of Medical Education, con-
tinuing education programs have not
been a major responsibility and in-
terest of most medical schools; ac-
cordingly, the development of appro-
priate resources (including related
facilities and space) was usually
neglected.

In both community hospitals and
medical schools, the pressures of ris-
ing expenditures for direct patient
care have made it impossible to
allocate sufficient funds to the con-
tinuing education activities that are
essential to high quality cam. Thus,
the potential impact of continuing
education and training programs in
heart disease, cancer, stroke, and re-
lated diseases will be seriously ham-
pered unless essential facilities are
constructed.

0 There is a critical need for addi-
tional space and facilities for patient
care demonstration and training pur-
poses. Intensive care units, radium
therapy facilities, and specialized sur-
gical suites are, for example, often
necessary in order to provide facilities

to demonstrate to practicing physi-
cians, nurses, and allied personnel the
use of these and similar advanced
tools and techniques for diagnosis and
treatment.

Only if physicians and the other mem-
bers of the health care team learn how
to utilize these advances "by doing,"
and have the required facilities avail-
able to them at the community level,
will they be able to fully exploit the
continuing education and training
afforded them, and bring to their
patients the full benefit of their
learning.

Most community hospitals do not
now have such facilities. In the case
of older hospitals, adequate provision
was not made for the inclusion of
such specialized facilities because the
underlying advances which make
continuing education a necessity
today had not yet been made; newer
hospitals often were unable to in-
clude sufficient space for these pur-
poses because of limited funds (pub-
lic and private) available for initial
construction. Developing these facili-
ties on the basis of regional planning
will permit great educational impact
at minimal cost.

0 Some community hospitals have
need for additional space for new or
expanded diagnostic laboratory facili-
ties. Both the introduction of new

diagnostic tests and procedures, and
the fuller use by practitioners of exist-
ing tests, depend upon adequate hos-
pital laboratory facilities. Such facili-
ties will serve as teaching laboratories
for medical technologists and other
supporting personnel.

0 The establishment of integrated
data banks and communications sys-
terns for the storage and rapid trans-
mission of diagnostic information,
patient records, etc., requires space
to house the computer and communi-
cations facilities. Similarly, television
and radio transmission of continuing
education programs will require new
space and facilities.

Most Regional Medical Programs
are undertaking inventories of exist-
ing facilities for both educational and
specialized clinical care activities re-
lating to heart disease, cancer, stroke
and related activities. These planning
efforts are being closely coordinated
with State and area-wide hospital
planning agencies. Experience in ad-
ministration by the Public Health
Service of other recent programs,
such as the construction of commu-
nity mental health centers and mental
retardation facilities, has developed
patterns and procedures that can help
assure  necessary  coordination of
effort.

The construction of new facilities
for Regional Medical Programs must

be limited to facilities that are essen-
tial, carefully selected, and designed
to meet regional needs. Each such
request will need to be approved by
the Regional Advisory Group which
represents the major health interests
of the Region. This review and ap-
proval process will ensure that an
excessive amount of attention and
funds are not devoted to construc-
tion, and that no construction is
undertaken exclusively or primarily
for the benefit of any single institu-
tion or group in the Region.

Most community hospitals, medi-
cal schools, and other institutions
would have serious or insurmountable
difficulties in raising matching funds
for construction of facilities needed
for continuing education and demon-
stration essential to meet regional
needs. The regional nature of the
program may make it especially dill%
cult for any individual agency to ob-
tain substantial funds for this pur-
pose. The current matching require-
ment of 10 percent applicable to ren-
ovation and alteration of facilities, re-
quires a local commitment without
impeding progress. A larger matching
requirement at this time in the devel-
opment of this pioneering new pro-
gram could be self-defeating.

It is recommended, therefore, that
adequate means be found to meet the


35

needs for construction of such jacili-
ties as are essential to carry out the
purposes of Regional Medical Pro-
grams. Priority should be given to
facilities required for continuing edu-
cation, training, and related demon-
strations of patient care, particularly
in community hospitals.
In meeting these needs, the follow-
ing considerations should be taken
into account:

1. Construction undertaken for
Regional Medical Programs
should be directly supportive of
the operational programs and
should be broadly distributed
for maximum impact. This
might be done by (1) limiting
the amount available for con-
struction to no more than 15
percent of the total appropria-
tion for operational activities;
and (2) restricting grants for
such construction to no more
than $500,000 for any single
project.

2. The special space needs of the
program can be met either
through additional authority to
aid new construction as part of
grants for Regional Medical
Programs under Title IX of the
Public Health Service Act or
through other mechanisms, such
as amendments to Title VI and
Title VII of the Public Health

Service Act (Hospital and Med-
ical Facilities and Health Pro-
fessions Educational Facilities
Construction Programs).

Support of Interregional and Other
Supporting Activities

The present Act authorize grants for
the planning and operation of indi-
vidual Regional Medical Programs.
No consideration was given during
the development of the legislation to
support for other activities which
might contribute to the implementa-
tion of the Regional' Medical Pro-
grams. These activities include both
cooperative efforts among several Re-
gions and other activities supported
centrally which make available to all
or several Regions specialized skills
and resources which are not generally
distributed throughout the Regions.

The desirability for extensive co-
operation among Regional Programs
was foreseen. However, the extent of
and rapidity with which cooperative
arrangements among Regions would
develop was not fully anticipated.
Nor, in turn, was the corollary need
for additional funding for this pur-
pose apparent.

During the first year of the pro-
gram, individual Regional Medical
Programs devoted considerable at-
tention to coordinating their efforts

with other Regions. Interregional car
operative efforts involving several
Regions have already evolved in a
number of areas throughout the
country. In some instances, these
arrangements are still informal; in
others, interregional agencies are be-
ing established.

These interregional activities have
arisen in response to real needs. Re-
gions have identified a number of
objectives that can be best served
and activities carried out in this way.
Among the principal potential bene-
fits are the following:
El `1-0  facilitate communications

among Regions, including exchange
of information on approaches to and
problems in planning and program
development.

0 To help in defining responsibili-
ties and coordinating efforts in "in-
terface" areas between Regions.
l-J To foster consistency in ap-
proaches to the conduct of planning
studies.

0 To achieve comparability in data
collection and program evaluation.
l-`J To develop and apply better and
more comprehensive methods of pro-
gram evaluation.

O To utilize more effectively skilled
manpower, specialized facilities and
resources.

O To help achieve compatibility in
communication networks and com-
puter systems.

0 To plan and conduct joint epi-
demiological and research studies.
[7 To develop jointly common edu-
cational programs and materials.
iJ To orient and train staff person-
nel.

A somewhat similar situation has
been identified with respect to cer-
tain specialized needs common to all
or a number of Regions. The support
of a limited number of facilities and
programs is needed to develop tech-
niques and prepare personnel to
facilitate the work of individual Re-
gional Medical Programs. The sup-
port of such activities in agencies
that can serve a number or all of the
Regions will avoid unnecessary delay
and duplication of effort and make
the best use of specialized facilities.
Central support for these activities
will enable the Division of Regional
Medical Programs to make avail-
able to some regions skills and re-
sources which are not available with-
in the Region. This assistance at a
crucial time in the development of a
regional program could improve the
quality and accelerate the pace of the
region's activities.

For example, continuing education
and training programs will require


significant numbers of specialixed
professional personnel (e.g., educa-
tion specialists, communication and
information specialists). Many of
these categories of personnel are in
scarce supply and the facilities in
which they can be trained are
limited.

There are also numerous studies
and demonstrations that need to be
carried out in such areas as motiva-
tion, learning theory and evaluation
affecting both continuing education
and other aspects of Regional Med-
ical Programs. In many instances,
these studies will call for resources in
one Region to study these issues in a
number of Regions. These interre-
gional efforts, too, will substantially
assist and expedite work of the indi-
vidual Regional Medical Programs.

It is recommended that un efiective
mechanism be found for the support
of interregional activities necessary
to the development of Regional Med-
ical Programs. This assistance will
facilitate the work and implementa-
tion of individual Regional Medical
Programs.

Referrals by
Practicing Dentists

Section 901 (c) of the Act provides
that "no patient shall be furnished
hospital, medical, or other care at any
facility incident to research, training,

or demonstration activities carried out
with funds appropriated pursuant to
this title, unless he has been referred
to such facility by a practicing phy-
sician."

In certain instances, in carrying out
the programs authorized by the legis-
lation, a dental practitioner may as-
sume responsibility for the-referral of
a patient. For example, a patient with
oral cancer may be diagnosed by a
dentist and referred by him for treat-
ment and rehabilitation. It is desir-
able to clarify the Lay to cover this
type of situation.

It is recommended that patients
referred by practicing dentists be in-
cluded in research, training and
demonstration activities carried out
as necessary parts of Regional Medi-
cal Programs. This modification is in
line with the original intent of the
legislation in this regard and would
correct the original oversight.

Funding of Activities
In Federal Hospitals

-

Veterans Administration and Public
Health Service Hospitals in many
areas have been involved in the plan-
ning of Regional' Medical Programs.
The participation of these institu-
tions has been particularly helpful and
desirable in light of their significant
role in providing diagnosis and treat-
ment services to many residents of the

Region. The effectiveness of the pro-
grams operated by Federal ho&ah
can be enhanced by close cooperation
and sharing of effort and resources
with other health facilities in neigh-
boring communities.

The Congress recognized and en-
dorsed this principle in enacting the
Veterans Hospitalization and Medi-
cal Services Amendments of 1966,
Public Law 89-7.85, enacted Novem-
ber 7, 1966. Among other provisions,
this slegislation authorized the Vet-
erans Administration to enter into
cooperative agreements for the shar-
ing, of medical facilities, equipment
and information with medical schools,
hospitals, research centers and others.
The Law required that, to the maxi-
mum extent practicable, such pro-
grams should be coordinated with
Regional Medical Programs. A some-
what similar provision is included for
Public Health Service Hospitals in
legislation now pending before the
copgress.

While the staffs of Federal hospitals
may now participate directly in plan-
ning Regional Medical Programs,
those institutions are not eligible to
receive funds from the grants author-
ized by Public Law 89-239. Thus, a
technical modification is necessary to
authorize Federal hospitals to receive
such funds on the same basis as other
hospitals. In this way, programs can
be developed in these facilities when

such an approach is identified as the
most desirable way to strengthen the
total Regional Medical Program. As
in the case of all other projects pro-
posed for support as part of Regional
Medical Programs, such requests
must be part of the overall regional
program and will need to be approved
by the Regional Advisory Group and
the National Advisory Council on Re-
gional Medical Programs.

It is recommended the Federal hos-
pita& be considered and assisted in
the same ways as community hospi-
tals in planning and carrying out Re-
gional Medical Programs. This modi-
fication will, in effect, increase the
flexibility, discretion and capabilities
of Regional Programs.


Regional Medical
Programs in Action

"One of the strengths of the bill is
that it provides the flexibility neces-
sary to accommodate the many differ-
ent patterns of medical institutions,
population characteristics, and or-
ganizations of medical services found
in this Nation."

Excerpt from the. Report of the
House Committee on Interstate and
Foreign Commerce on H.R. 3140
(PA 89-239)


SUPPLEMENT R egional Medical Programs in Action

Regional Medical Programs are best
defined by the particular actions and
activities being undertaken across the
country. In this Chapter, outlines of
a number of individual Programs are
presented.

O Faur reports summarize what has
happened in the planning of the
Iowa, North Carolina, Washington-
Alaska, and Western New York Re-
gional Medical Programs. They sum-
marize salient developments in the
preliminary and initial planning
phases and the interaction among
various institutions and groups that
has occurred.

O Two reports indicate the nature
of the initial operational activities of
the Intermountain and Missouri Re-
gional Medical Programs. They high-
light how these activities will benefit
the practicing physician and his
patients.

O In addition, excerpts are pre-
sented from the annual progress re-
ports of the 10 Regional Medical Pro-
grams for which the first grants were
effective July 1, 1966Albany (New
York), Connecticut, Hawaii, Inter-
mountain, Kansas, Missouri, North
Carolina, Northern New England,
Tennessee Mid-South, and Texas.
These excerpts provide further in-
sights into specific aspects of the Re-
gional Programs.

Collectively these reports reveal, in
some detail, the accomplishments and
problems of individual Regional
Medical Programs. It is through
these individual efforts and actions
that Regional Medical Programs will
be more precisely defined and ulti-
mately will serve the needs of the Na-
tion's medical professions, institutions
and patients.

PLANNING GRANTS

Iowa Regional
Medical Program

The Iowa Regional Medical Pro-
gram, like a number of others, is
built on a significant base of past re-
gional activities. Extensive interrela-
tionships between hospitals and prac-
titioners have developed over the last
50 years. By an interchange of pa-
tients,  physicians throughout the
State have become, in effect, inte-
grated with the activities of the staff
of the University of Iowa Medical
Center. Continuing education pro-
grams have been developed over the
last 30 years and include courses at
the Medical Center, programs at
community hospitals, and closed cir-
cuit television educational programs
between the Center and a number of
these hospitals. As a result, it has been
possible to move forward in a num-

ber of directions since the receipt of a
planning grant in December 1966.

Even with this previous experience
of cooperative arrangements, how-
ever, there was need to plan for an
Iowa Regional Medical Program.
This preliminary planning involved
cooperation between the Medical
Center and three other major health
planning groups-the Health Plan-
ning Council of Iowa, a voluntary
agency organized to coordinate state-
wide health care planning; the Coun-
cil on Social Agencies of Des Moines;
and the Des Moines Health Planning
Council. Other localities are also or-
ganizing planning groups that will
be related to the Regional Medical
Program.

The Regional Advisory Group,
designated to guide the expanded ef-
fort now being embarked upon, is
broadly representative of all of the
Region's health professions and
agencies. It includes the Dean of the
College of Medicine, the Commis-
sioner of Health, Past Presidents of
the Iowa State Medical Society,
Heart Association, Cancer Society
and League for Nursing; also in-
cluded are representatives of the Iowa
Hospital Association, Society of
Osteopathic Physicians and Surgeons,
Dental Associations, Nursing Home
Association, Nurses Association, State
Department of Social Welfare, re-

habilitative groups, and members of
the public. This Group has met seven
times through March-or almost
monthly since its creation in mid-
1966.

The goals which the Iowa Re-
gional Medical Program has set for
itself, with the advice of the Regional
Advisory Group, are to: ( 1) aug-
ment present education and training
capabilities; (2) improve continuing
education programs; (3) expand re-
search programs; (4) broaden re-
gional communication to promote
dissemination and interchanges of
knowledge and techniques; (5) de-
velop programs for public education;
and (6) develop demonstration units
and systems.

To accomplish these goals, the Pro-
gram has been organized into four
sub-areas: an Education Program, a
Research Program, a Comprehensive
Patient Care Program, and a Com-
munications Program.

Within the Education Program, for
example, studies have been initiated
to develop basic 2-year curricula for
post-graduate education on heart
disease, cancer and stroke. These
curricula, once developed and tested,
will be taught through a coordinated
program of the College of Medicine
and regional hospitals, utilizing live
conferences and video-taped mate-
rials. Extension of this endeavor to


39

the community level for individuals
or small groups of physicians using
kinescope presentations is also
contemplated.

Other planning activities or proj-
ects in the other program sub-areas
have also been initiated. These in-
volve a number of different agencies
or groups. For example:

O The Iowa State Department of
Health is planning program elements
which concern public health gener-
ally, professional and public com-
munications, disease entity report-
ing and health manpower.

c] The University of Iowa Depart-
ment of Economics is involved in re-
search on the economic structure and
performance of the medical care in-
dustry in Iowa. One of its first proj-
ects is the delineation of the Iowa
Medical Care Region, considering
economic and demographic factors,
traditional service areas, and political
boundaries.

O The Iowa Central Tumor Regis-
try is providing planning information
and analysis guidance concerning
disease registries.

At the same time, the participation
of the Colleges of Dentistry, Nursing
and Pharmacy of the University and
other health care and educational in-
stitutions is being developed.

North Carolina
Regional Medical Program

In North Carolina, as in many other
states and regions in the country,
planning for regionalizcd medical
and health programs has been
underway for over twenty years.
However, limited resources and other
local factors have resulted in incom-
plete implementation of these plans.
Passage of the Regional Medi-
cal Program legislation provided an
opportunity for North Carolina to
move ahead quickly and build upon
its past experiences in developing a
Regional Medical Program.

The Program was established with
the award of one of the first plan-
ning grants effective on July 1, 1966.
Even before the legislation was
signed into Law, the deans of the
three medical schools in the State
met with the President of the Medi-
cal Society to form an Executive
Committee to make preliminary
plans. The Executive Council of the
Medical Society approved the plans
for cooperation from which emerged
a new, non-profit organization to
carry out the purposes of the Pro-
gram. The Association for the North
Carolina Regional Medical Program
was officially established in August
1966, and is made up of the three
public and private medical schools in

the State, the University of North
Carolina School of Public Health
and the Medical Society of North
Carolina. It has adopted Articles of
Association, and established a Board
of Directors which has been actively
working with the Program Coordi-
nator and Advisory Council.

To provide leadership and overall
direction to its Program, North Caro-
lina selected as Program Coordinator,
Dr. Marc J. Musser, a physician with
extensive experience in medical edu-
cation, medical research and adminis-
tration. His prior position as Deputy
Chief Medical Director of the Vet-
erans Administration and his previ-
ous 25 years as Professor of Medicine
at the University of Wisconsin School
of Medicine provided background
and   stature  invaluable  to the
Program.

A 25 member Advisory Council,
representing  the major  relevant
health interests in the State, was
organized to provide averall advice
and guidance to the Program. Its
Chairman is past president of the
State Medical Society and its mem-
bership includes the Director of the
State Board of Health, the Directors
of the North Carolina Public Health
Association, Heart Association, and
Cancer Society, other voluntary as-
sociations, the current President of
the State Medical Society, the State

dental, nursing, pharmaceutical, and
other allied health professional as-
sociations, practicing physicians, the
North Carolina Health Council, the
deans of the three medical schools, a
leading hospital administrator, and
members of the public. They have
met monthly since August 1966, and
have conducted intensive reviews of
project applications.

Subcommittees of the Council have
also been organized to focus on and
provide expertise in specific problem
areas, such as heart disease, cancer,
stroke and dentistry. Represented on
these subcommittees are all the lead-
ing organizations and experts in the
respective fields in North Carolina.
For example, the Subcommittee on
Cancer is composed of representatives
from the Cancer Society, all the offi-
cial relevant State agencies, practic-
ing physicians, the experts from the
North Carolina Division of the
American College of Surgeons, the
medical schools, and the State Medi-
cal Society. Their discussions im-
mediately revealed the need for a
state cancer registry which would
augment, coordinate, and make more
effective use of the several on-going
independent cancer registries in the
State. This led to recommendations
of a project proposal which was sub-
mitted to the Advisory Council, COU-
pling the resources of the Regional


40

Medical Program with the on-going
cancer registry activities of the other
health agencies. Financial contribu-
tions from many of the participating
agencies were also anticipated as part
of the Program.

In the field of heart disease a sim-
ilar process took place which resulted
in a feasibility study now underway
to develop a regional plan for pro-
viding on-going educational services
to coronary care units. Other pro-
grams underway in North Carolina
include planning for a statewide dia-
betic consultation service; planning
for education and research in com-
munity medical care; studies and sur-
veys of education program needs and
resources; surveys of relevant health
professions needs and resources; and
studies of patterns of illness and care.
The impact of the Regional Med-
ical Program is already being felt in
the health affairs of the State. With
the State Medical Society taking an
early leadership role in developing
the program  with the medical
schools, practicing physicians  are
actively involved in the planning
phase. The channels of communica-
tions which have opened up at all
levels and among all health groups
are quickly leading to fruitful discus-
sions on a multitude of problems.

The Dean of Duke University School
of Medicine described the phenome-
non when he said: "Channels for co-
operation for many endeavors have
now been opened. Although we have
talked together a great deal before,
we now have available more effec-
tive channels of communications and
financial resources to implement such
programs, not only with other medi-
cal schools but alsa with all other
health agencies." As the North Caro-
lina program moves ahead, it will be
a program conceived, designed and
implemented by and for the people
of the State. As one leading official of
a voluntary health agency put it:
"We hope to weave it so that it won't
be your program, or my program,
but our program."

Washington-Alaska
Regional Medical Program

Although the Washington-Alaska
Region previously had little regional
health activity, Alaska, which has
no large medical center, is naturally
related to Washington by transpor-
tation,  communication,  economic
and social ties and traditional pat-
terns of medical referral and consulta-
tion. The joint Washington-Alaska
Regional Medical Program is being
developed on this basis.

Here, as in many other regions,
there was widespread participation
in the preliminary planning and
preparation of an application. An
initial conference, held only one
month after Public Law 89-239 had
been enacted,  included some 35
members of the University of Wash-
ington Medical School faculty, ap-
proximately 50 practicing physicians,
and representatives of the Washing-
ton Hospital Association, State De-
partment of Health, and the Seattle-
King County Department of Health.
Though the planning proposal that
eventually resulted was formally sub-
mitted by the University of Washing-
ton Medical School, it had the ap-
proval of the Governors of both
Washington and Alaska, the Presi-
dent of the University of Washing-
ton; the Washington and Alaska State
Medical Associations, Dental Asso-
ciations, Nurses Associations, and
Heart Associations; the Washington
and Alaska Divisions of the American
Cancer Society;  the Washington
Health Department, Alaska Depart-
ment of Health and Welfare and the
Divisions of Vocational Rehabilita-
tion in both States.

Many of the health institutions in
the region are being involved in the
Regional Medical Program. Repre-
sentatives from virtually all of the 130
hospitals in the region have been con-

tacted. Interest has been expressed
by the Heart Associations and the
Cancer Societies of both Washington
and Alaska; their programs of re-
search, professional and public edu-
cation, community service, trainee-
ships and direct patient services will
be coordinated in a joint effort.

The Program Coordinator for the
Washington-Alaska Regional Medi-
cal Program, Dr. Donal Sparkman,
assumed his position on March 1,
1966, six months prior to the begin-
ning of the planning grant. Thus, the
Program has had the benefit of over-
all administrative direction since its
preliminary planning phase. Dr.
Sparkman has had extensive expe-
rience in the practice of internal
medicine, in teaching at the Uni-
versity's School of Medicine and with
the State Department of Vocational
Rehabilitation.

Other key staff, including a co-
ordinator for Alaska, an associate
director, a cardiologist, a hospital ad-
ministrator, and a systems analyst,
have been recruited since the Rc-
gion's planning grant was awarded,
effective September 1, 1966. In
addition, a wide variety of consul-
tants,  including  epidemiologists,
statisticians,  economists and com-
munications specialists, are being
utilized.


41

The Program strategy of the Wash-
ington-Alaska Region is to concen-
trate first on the following:

0 Assess the existing disease problem
in the region.
0 Delineate resources and needs in
patient care, education, training and
research.

0 Investigate the effectiveness of
current programs and how they can
be improved by regional planning and
cooperative efforts.

Initial planning studies now un-
derway are focused on identifying
needs of physicians, particularly
needs for continuing education and
the best use of medical consultants
visiting smaller communities. Partic-
ular attention is being given to phy-
sician manpower needs in Alaska as
well as transportation and communi-
cation patterns in that part of the
region.

Planning studies relating to the
coordination of coronary care facili-
ties and services, a post-graduate pre-
ceptorship program, and the estab-
lishment of a regional medical library
system have also been inaugurated.
Other planning studies soon to be
initiated will concern methods of
pooling data from cancer registries, a
feasibility study of open channel tele-
vision, a survey of physician and nurse
participation and interests in con-

tinuing education, and the early de-
tection and care of coronary disease.

Western New York
Regional Medical Program

Western New York is a comparatively
small and compact but heavily popu-
lated Region. It is essentially urban
and dominated by metropolitan
Buffalo. There had been relatively
little regional and cooperative ac-
tivity among the health resources and
interests in this area in the past. Sub-
stantial and rapid progress has been
made in creating a regional health
organization and framework for de-
cision-making since the enactment of
Public Law 89-239.

The development and creation of
a Western New York Regional Medi-
cal Program has been characterized
from the very beginning by the wide-
spread participation by nearly all of
the major health institutions, groups,
and agencies in the eight-county re-
gion covered by it (Allegheny, Cat-
taraugus, Chautauqua, Erie, Genesee,
Niagara, and Wyoming Counties in
New York, and Erie County in Penn-
Sylvania). The Regional Medical
Program has been received by the
practitioners. with unexpected en-
thusiasm following the well-publi-
cized interest of the State University
of New York at Buffalo (SUNYAB) ,
Roswell Park Memorial Institute and

other major hospitals in the area to
build on and strengthen the existing
good relationships.

In November 1965, following pas-
sage of Public Law 89-239, an
Interim Coordinating Committee
composed of key people concerned
with health and health care was
formed to study the bill and "to
promote as rapidly as possible re-
gional interest in the establishment of
a regional program" for heart dis-
ease, cancer, and stroke. The com-
mittee, as initially constituted, in
eluded the Dean of the Medical
School, Director of Roswell Park, the
Executive Director of the Western
New York Hospital Review and
Planning Council, the Past President
of the Erie County (N.Y.) Medical
Society, Erie County Health Com-
missioner, and the Regional Officer
for Western New York of the State
Health Department.

In January 1966 this committee
called together representatives from
the medical, hospital, and other
health-related professions, practicing
physicians and voluntary health agen-
cies. From each of the eight counties
came the health and hospital commis-
sioners, the medical society repre-
sentatives, chairmen of the Boards of
Supervisors, the hospital administra-
tors,  and the American Cancer
Society and Heart Association Chair-
men. Individuals from social welfare

agencies, public health and nursing
representatives, as well as education
personnel were also present. A total
of 78 persons representing 70 organi-
zations, institutions, and groups at-
tended.

This group, originally invited to
participate in the formation of the
program, evolved into the Regional
Advisory Group. This `was no simple
task. For the first time in the history
of Western New York, an assemblage
from the above groups met with a
common objective. In an atmosphere
paralleling that of a town meeting,
each force presented its particular
point of view. As the day wore on,
a unique spirit of understanding and
cooperation evolved. It was unani-
mously agreed that it is the patient
who rnust benefit from the Law.
Wholehearted support was expressed
for a Western New York Regional
Medical Program.

Several meetings were held by the
group during the spring of 1966. The
outcome of these meetings was the
formation of a new nonprofit organi-
zation called Health Organization of
Western New York, Inc. (HOWNY)
and the designation of its 1 I1 mem-
ber representatives as the advisory
body.

Their initial grant application,
looking toward the development of
a sound and workable proposal, in-


42

corporated  a six-point planning
program.

0 A coronary care unit feasibility
study

0 The feasibility of multiphasic
screening in Western New York
O Health care team planning

O A medical communications study
0 A planning survey for a local con-
sultation program

O A health care manpower survey
By the time a planning grant was
awarded in December 1966, some
other important and parallel devel-
opments had also taken place.

0 New channels of communication
had been opened among the many
diverse health institutions and groups
in the region.

O A parallel organizational frame-
work was established at the com-
munity level. Through these local ad-
visory committees, broadly represent-
ative of the health interests in the
communities and including public
members, the intent and aims of Re-
gional Medical Programs were more
fully and accurately conveyed to the
practicing physicians and others at
the community level. In addition,
communities had been prompted to
examine their own needs.

O Perhaps most significant was the
decided change in the attitude of

the practicing physicians in the m-
gion. Initially they had been quite
wary and somewhat suspicious of the
medical centers and the "cooperative
arrangements" approach embodied
by Regional Medical Programs. This
view has altered with their increasing
involvement in and better under-
standing of the program, so that now,
in the judgment of many, including
the Regional Advisory Group Chair-
man, who is himself a private prac-
titioner, a majority of them support
it.

Since the award of its planning
grant, the Western New York Re-
gional Medical Program has obtained
a full-time Program Director, Dr.
John R. F. Ingall, formerly an associ-
ate cancer research surgeon at Ros-
well Park. The Director has begun
visits to all the medical communities,
large and small, to explain the re-
gional concept of the program and to
stress the need for coordination. He
aims personally to discuss with physi-
cians and the health service agencies
the aim of the Regional Medical
Program to support all involved in
giving medical care; the patient is
most important and his needs can
only be met by action in concert. The
patient in turn, as consumer, is being
informed by radio and television of
the objectives of the Program. The
health care manpower and coronary

care unit feasibility studies had al-
ready been launched prior to his ap-
pointment; the remainder of their
proposed planning activities have got-
ten underway since then.

The HOWNY Board of Directors,
with members from each of the par-
ticipating counties--one representing
the county medical society, the other
usually from a health related field-
as well as SUNYAB, Roswell Park,
the Western New York Hospital Asso-
ciation, the area-wide hospital plan-
ning group, and official public health
agencies, has already set up proce-
dures for reviewing proposed pilot
projects. These include, in addition
to a number of tentative proposalls
generated by local communities, pro-
posals for the establishment of a
regional hematology reference labora-
tory and a regional blood bank com-
fmmication system.

Intermountain
Regional Medical Program

The initial operational activities of
the Intermountain Regional Medical
Program will provide the following
opportunities to a medical practi-
tioner in this Region (which encom-
passes Utah and parts of Calorado,
Idaho, Montana, Nevada and Wyom-

ing) to improve the care of his
patients:

0 He will have available at his com-
munity hospital a communication
network, including radio and tele.
vision facilities, which will provide
education programs and opportu-
nities for interchange and discussion
with consultants at the medical

center.

O He will have available at his com-
munity hospital for himself, nurses
and other personnel, a training pro-
gram in the resuscitation of patients
with heart disease, and the necessary
equipment to make it possible to carry
out these techniques. He will also
have on call a medical consultant who
has been specially trained to head
hospital cardiopulmonary arrest alert
programs.

17 He may have tested at his hospital
the feasibility of a system that trans-
mits, in a 24-hour day operation.
physiological information on heart
disease patients to a computer facility
in Salt Lake City and transmits
promptly back to stations within his
hospital information for diagnosis
and treatment.

n He will bc able to attend traininp
courses in the intensive care of heart
patients and will have available for
consultation medical and nursing spe-


43

cialists who have completed such
training.

0 He may participate in seminars
led by local, regional and national ex-
perts in order to better understand
trends which are influencing medical
care practices as well as new methods
of maintaining and extending his
medical skills.

0 He will have available at his hos-
pital both continuous 24hour con-
sultation by telephone and visits by
special consultants knowledgeable in
the latest information in the diag-
nosis and treatment of cancer.

17 Through the use of a computer-
ized tumor registry, he will be able to
analyze and compare his own cancer
patients with local, regional and na-
tional standards.

17 Consultants will visit his hospital
(if it is in a community with less than
10,000 persons) periodically, to as-
sist him in the diagnosis and care of
heart disease patients by working at
the bedside of his patients.

0 He may apply for a special clini-
cal traineeship in cardiology that will
involve specialized training at 5 co-
operating medical institutions in pro-
grams designed to meet the individual
interests and problems of the par-
ticipating physicians.
[7 He will have available a com-
munication  and information ex-

change service that will provide in-
formation on the prevention and con-
trol of these diseases to public groups
as well as to professional and allied
health workers.

0 He, along with other health work-
ers and members of the public, will
have opportunities through a formal
feedback system to communicate with
the planners and leaders of the Re-
gional Program to indicate his reac-
tions, needs and recommendations for
developing new program activities.

Missouri
Regional Medical Program

The initial operational endeavors of
this Program are "oriented toward
maximizing the amount of diagnosis
and care which can be delivered in
the . . . community by the physician
and the local medical resources while
maintaining and improving the qual-
ity of medical effort. . . ." As the
program is implemented in the fu-
ture, a medical practitioner in the
Missouri Region may have the fol-
lowing opportunities available to as-
sist in the care of his patients:

0 He will benefit from the develop-
ment and demonstration of a compre-
hensive health care system that is
being tested in Smithville, a subur-
ban-rural community north of Kansas
City, with a view to eventual replica-

tion throughout the Region. This
project is exploring the benefits to
practicing physicians of having avail-
able automated clinical laboratory
testing for multiphasic screening and
a computer fact bank displaying the
results to him audio-visually; an au-
tomated patient history system pro-
viding him with a patient's complete
medical history before seeing the pa-
tient; an automated EKG service
connected with the University Medi-
cal Center for rapid, accurate trans-
mission, receipt and interpretation of
electrocardiograms; specialists con-
sultation from the medical center by
telephone; and an integrated con-
tinuing education program at his hos-
pital for himself and the allied health
personnel supporting him.

He may, through the connection
of his community hospital with the
Medical Center's Department of
Radiology and computer facility, ob-
tain computer aided radiologic diag-
nosis that will help improve the ac-
curacy and reliability of his diagnosis
of bone tumors, gastric ulcers, and
congenital heart disease.

0 He may, after a period of pilot
testing and validation, have at his
disposal an automated patient history
acquisition system through which he
can obtain a complete medical his-
tory of a patient before seeing him.
Presently this requires an amount of

time not normally available to the
busy practitioner.

0 He will, if the result of experi-
ments being initiated are successful,
have direct access by means of com-
puter terminals in his office to a Com-
puter Fact Bank providing the best
and latest information concerning the
diagnosis and care of stroke patients.
This information will not only be
available for application to individual
patients while in the physician's office
but will make possible discourse with
the computer so that the experience
constitutes an integral part of his con-
tinuing education.

0 He will have the use of a multi-
phasic screening center to be estab-
lished to provide him and his patients
with 11 blood chemistry tests, com-
plete blood count, urinalysis, stool
guaias, and Pap smear.
[7 He and his colleagues in the
Ozark area will have available at St.
John's Hospital in Springfield, and
later at other small hospitals, a re-
fined and more comprehensive car-
diovascular care unit that will demon-
strate the feasibility of an intensive
care program without house staff.
0 He and others will have available
to them as a result of the establish-
ment and sampling of population
study groups, more current and ac-
curate information about the true


rates of disease incidence and preva-
lence in the Region.

0 He and his patients will benefit
from an operations research and sys-
tems design project aimed at (1)
improving early detection of heart
disease, cancer and stroke and (2)
optimizing the utilization of the re-
sources committed to these diseases
in terms of the effectiveness of the
medical services provided.

0 He and his patients will benefit
from improvements in bioengineering
techniques  utilizing   sensor-trans-
ducers for early detection of heart
disease, cancer and stroke.

0 He and his patients similarly will
stand to benefit from studies of the
Program Evaluation Center, a mul-
tidisciplinary research unit of the
Missouri Medical School, dealing
with the problems of the distribution
of health services and medical facili-
ties. Priority will be given to develop-
ing instruments for evaluating the
quality of care and level of health,
both individual and community-wide.

0 His patients will be the ultimate
beneficiaries of a communications re-
search project aimed at better under-
standing public attitudes, opinions,
and knowledge about heart disease,
cancer, and stroke, in order to en-

hance prevention and early detec-
tion.

c] He and the community service
agencies and others will be provided
with a directory of the names,
services and addresses of all medical
and paramedical services in the State
to facilitate the referral of patients
between agencies and the full use of
available resources.

EXCERPTS FROM
ANNUAL PROGRESS REPORTS

Albany
Regional Medical Program

"In our Operational Grant Appli-
cation it was mentioned that `there
is no question but what the develop-
ment of the Albany Regional Medi-
cal' Program has produced very im-
portant effects, both in the surround-
ing medical communities and at the
Medical Center. The predominant
attitude is one of interest, enthusiasm
and cooperation. Relative to need
the program is ideally timed. An
early addition of operational support
should allow us to take full advan-
tage of the momentum of our rapid
initial progress. . . .'

"To this statement should be add-
ed the fact that the April 1, 1967,
approval of our operational grant

request allows us to intensify the
continuous planning activity as the
conduct of our Pilot Projects reveals
additional planning opportunities.
We believe the most effective plan-
ning will result as we relate the plan-
ning to the conduct of our operational
program. . . .

"However, since the initial proj-
ects of our operational program are
not intended to result in a complete
program, it will obviously be neces-
sary to continue planning supple-
mental projects which will further
increase the capability for diagnosis
and treatment of heart disease, can-
cer and stroke. In particular, we con-
template extensive planning of con-
tinuing education and training for
medical and allied health professions.

"The purpose of the Albany Re-
gional Medical Program is to utilize
research,  education,  training and
demonstration care in an organized
cooperative and effective approach
to the prevention, detection and
management of heart disease, cancer
and stroke. Although leadership and
the dissemination of scientific infor-
mation are among the important rc-
sponsibilities of the Medical College,
the intent is to promote interrelation-
ships among all relevant institutions,
agencies and individuals in a man-
ner which will produce a sustained

effort by the citizens of each local
community. The i n ten t is to
strengthen community medicine and
thus improve patient care. . . .

"The Albany Medical College was
involved in a great deal of advanced
planning in anticipation of its in-
volvement in Regional Medical Pro-
grams. This resulted in extensive ac-
tivities prior to the planning grant
award. . . .

"Five mature experienced physi-
cians were contacted relative to their
interest in becoming full-time mem-
bers of the Department of Post-
graduate Medicine, which has the
primary responsibility for the
administrative direction of the
Program. . . .

"The needed nonprofessional ad-
ministrative personnel were sought
and excellent individuals were ac-
quired. One of these is now our Di-
rector of Community Information
Coordinators. He has three coordina-
tors working with him. These men are
experienced former pharmaceutical
house  representatives  who  have
proven their ability to relate well to
physicians and be successful in their
contacts with physicians. . . .

"Regional Medical Program staff
have met with the administrators and
staff of many of the hospitals in the
Region. To date, 58 hospitals have


45

been contacted; and formal presenta-
tions on the Albany Regional Medical
Program have been made to the
medical staffs and/or boards of trust-
ees of 25 of these. All of the latter
have indicated, by vote, their desire
to participate in the Program. . . .

"In general all of rhe hospital ad-
ministrators, staff physicians, and
board members have indicated their
sympathetic agreement with the con-
cepts of Regional Medical Programs.
In some instances there were mis-
conceptions about the Program based
upon the Report of the President's
Commission on Heart Disease, Can-
cer and Stroke; these were quickly
and easily dispelled. The administra-
tors and staff of many of the hospitals
expressed the desire, long felt, for a
closer working relationship with the
Albany Medical College and Center,
especially with respect to patient con-
sultations with specialists; increased
opportunities for continuing educa-
tion in the physician's home com-
munity; assistance in updating their
knowledge and ability to diagnose
heart disease, cancer, stroke and
related diseases; guidance and aid
in the training of more nurses and
other allied health personnel; and
advice as to whether or not to engage
in research activities as well as the
nature thereof. . . .

PROGRESS REPORT ON
SELECTED PLANNING PRO J ECTS

Project to Improve
and Expand Cancer
Detection and Therapy

"A major project preparation has
been prepared, involving the efforts
of physicians and administration at
Vassar Brothers Hospital at Pough-
keepsie, New York. The study is di-
rected towards the objective of en-
abling more effective early diagnosis
and treatment of cancer in the
Poughkeepsie area. . . .

Vaginal Cytology
Screening Program

"This project proposes to develop
a model for cytological screening of
all female patients in a given com-
munity for cervical cancer. Continu-
ing study is underway to establish the
most effective coordinated approach
to the objective, combining the ca-
pabilities of the Regional Medical
Programs with the opportunities
which other State and Federal efforts
provide. . . .

Multiple Hospital Prospective
Cancer Investigation Program

"This project proposes to establish
a sub-regional and eventually a re-
gional approach to a prospective

cancer investigative program which
would result in major dividends with
regard to research, with regard to
diagnostic and therapeutic proce-
dures and with regard to general
cancer education. . . .

Cardiopulmonary Laboratory
Development

-

"It is proposed to establish a car-
diopulmonary physiology and diag-
nostic laboratory at the Pittsfield Af-
filiated Hospitah, Pittsfield, Massa-
chusetts. Such a laboratory would
provide accurate diagnostic facilities
in heart disease, diseases of the blood
vessels and pulmonary disease. In ad-
dition, its establishment will lead to
improved local physician continuing
education in this field.

Cardiac Care Unit at
Herkimer Memorial Hospital

"This project proposes the estab-
lishment of a firmly based Cardiac
Care Unit building upon the hospi-
tals existing embryonic `homemade'
one. Such a unit will permit nurse
training in intensive coronary care in
this locality."

Connecticut

Regional Medical Program

"During the `tooling up' phase,
when the program objectives were

being set and the action program was
being formulated, the primary work
involved the RMP staff, the Plan-
ning Committee and the Regional
Advisory Board. Good communica-
tions were maintained by frequent
meetings, which were well attended,
and by circulating full follow-up
minutes. . . .

"The Planning Design, as finally
adopted,  is concerned with such
fundamental elements as health per-
sonnel, facilities, and finances-and
their effective blend into a coordi-
nated regional medical program serv-
ing all the people of Connecticut. . . .

"It involved the creation of nine
Task Forces to study specific compo-
nents of the Connecticut health care
system, to determine deficiencies, to
chart action programs and ulti-
mately to work for their implementa-
tion. A serious effort was made to
have various segments of the health
community represented on each Task
Force, as well as to obtain a reason-
able geographic distribution. Each
includes representatives of various
points of view appropriate to the
topic under consideration, drawn
from private practice, education, vol-
untary agencies, governmental service
and the public at large. . . .

"These Task Forces are concerned
with the (1) supply and distribution
of physicians and dentists; (2) re-
cruitment, training, distribution and


46

continuing education of nurses and
other allied health professionals;
(3) continuing education of physi-
cians and dentists; (4) extended care
facilities and programs; (5) univer-
sity-hospital relationships; (6) the or-
ganization of special services within
hospitals; (7) implementation of a
state-wide library system; (8) financ-
ing of medical care; and (9) defini-
tion of the Connecticut region and
its subregions. . . .

"The RMP staff is responsible for
assembling the complete information
on the health resources in Connecti-
cut needed by each Task Force in its
subject field in order to go about its
work. To date, preliminary steps have
been taken to ascertain what data is
available through a number of estab-
lished health organizations. Fortu-
nately, the assembly of health infor-
mation by such organizations as the
State Health Department, the Con-
necticut Hospital Association, the
Connecticut Hospital Planning Com-
mission and others will provide much
of the information needed. It re-
mains, however, for the RMP staff to
carry out some special studies and,
ultimately, to compile much of the
health resources data in a central
profile.

"There have been many opportuni-
ties to discuss the Planning Design
with boards of directors of health or-

ganizations, with hospital staffs and
with many interested individuals,
both from the medical and lay ranks.
Thus, the potential of Regional Med-
ical Programs is becoming known in
a widening circle; and communica-
tions among various segments of the
Connecticut health community are
improving. . . .

"The Regional Advisory Board
has assumed responsibility for the
pivotal decisions relating to the de-
velopment of the Program, e.g. the
approval of the planning grant re-
quest, the appointment of the Plan-
ning Director, the adoption of the
Planning Design and the appoint-
ment of the Task Force member-
ship. . . .

"It is noteworthy that Regional Ad-
visory Roard mcmbcrs are now serv-
ing as Chairmen of eight of the nine
Task Forces and that every Board
member has a position on one of
them. This means that Board mem-
bers will be deeply involved in plan-
ning activities, that they will be in
good positions to weigh proposals for
the operating program one and two
years hence, and that they will have
the background knowledge needed to
push their implementation. . . .

"The most difficult problems m-
countered to date are the following:
(a) the complexity of the subjcrt
fields under study; (b) the weakness

of communication links between seg-
ments of the health system; (c) the
shortage of experienced health plan-
ners and researchers in the delivery
of health care; (d) the overlapping
and uncertain jurisdiction of related
health planning organizations; and
(e) the shortness of time available
to achieve measurable results

"With regard to the complexity
of the subject fields under study, it is
pertinent that the Connecticut Re-
gional Medical Program is probing
questions which have perplexed lead-
ers from the fields of medical edu-
cation and medical care alike in re-
cent and past years. There are no
ready answers, for example, on how
to provide family medical care to all
citizens in the years ahead, or how
to recruit and educate the necessary
nurses and other supporting health
personnel and make them a part of
a true health team, or how to imple-
ment effective programs of continu-
ing education for all health practi-
tioners, etc. It is even difficult to
structure planning studies to lead to
the best solutions to these important
issues. Yet, the Program has chosen
to ronccrn itself with those very is-
sues in the health field which are of
greatest conrrrn to the people of
Connecticut. . . .

"It is pertinent that in Connccti-
cut, as elsewhere, there has been rela-

tively little contact in the past
between the medical and* social sci-
ences in the universities. These need
to work together to chart overall
social progress in the health field.
There has been a considerable `town
and gown' rivalry between clinicians
in the university and community sct-
tings. There has been too little con-
tinuing contact in the past between
health spokesmen from the educa-
tional and voluntary segments, on the
one hand, and from local and state
government, on the other. The plan-
ning efforts of the Connecticut Re-
gional Medical Program depend in
great measure on full collaboration
between representatives of the health
establishment drawn from education,
from the voluntary community and
fram govcrnmcnt. Some of the nccd-
ed communications links are having
to be forged as a part of the Con-
necticut Regional Medical Program
planning process itself. . . .

"Despite the major problems en-
countered and the enormity of the
task . . . a sound organizational framc-
work for planning has been estab-
lished ; broad consensus has been
reached on the program's planning
design ; and a large number of key
leaders from the Connecticut health
scene have become involved in tllc
planning process.


47

Hawaii
Regional Medical Program

"The assessment ot the overall situ-
ation, and the establishment of com-
munication with the participating
agencies have been the major items
of activity since November 1966,
when a full-time Deputy Program
Director (General W. D. Graham,
M.D.) arrived in Hawaii. Informal
conferences with members of the Re-
gional Advisory Group and their rep-
resented agencies and with other
participants have been held, and the
status of the public, private, and
voluntary programs in the health field
have been studied.

"Local assessment, and the detailed
consideration of the content and
concepts of programs under way in
other regions, lead to the conclusion
that tangible progress in the program
here is contingent upon projects in
continuing education. There is at
present no fully-staffed, on-going
academic clinical teaching center in
Hawaii. Those highly qualified per-
sonnel currently engaged in the train-
ing programs of the teaching hospital
are engaged to full capacity, and are
augmented by `visiting professors'. By
locating full-time teaching specialists
in teaching hospitals, significant ad-
ditional support for postgraduate
training programs will result and will

bring these specialists in close touch
with private practitioners. . . .

"Additional programs of particular
interest are the Stroke Registry and
the Facilities Studies. On March 1,
1967, exploration of the feasibility
of the establishment of a Stroke Reg-
istry was begun. Consultations with
physicians and with medical record
librarians have progressed most satis-
factorily. Field testing of method-
ology will commence about May 1,
1967, in selected hospitals. . . .

"The project for stroke rehabilita-
tion education involves a plan to set
up a training program for various
categories of rehabilitation personnel
at the Rehabilitation Center of
Hawaii in Honolulu, at outlying hos-
pitals on Oahu and on the neighbor
islands, in order to augment stroke
rehabilitation capabilities, which are
at present at the full capacity of the
Center staff.

"The goal of a facilities study by
the Hawaii Heart Association is to
determine equipment status in facili-
ties which provide diagnosis and
treatment to patients with heart
disease. A questionnaire has been
directed to hospitals and clinics and
the returns will be preliminarily
evaluated, using volunteer services.
Collation, analysis, and subsequent
development of the information will
require RMP support, and will begin
about June 1, 1967. . . .

"Planning is under way for a pro-
gram directed toward the hematolog-
ic aspects of the care of heart, cancer
and stroke patients. This will also
have components of continuing edu-
cation, consultative service and lab-
oratory and investigational activity
directed toward assisting physicians
in diagnosis and patient care.

Intermountain
Regional Medical Program

"Organized efforts to develop a Re-
gional Medical Program for this
Region began in the fall of 1965.
Efforts were made early to enlist the
interest and support of organized
medicine. . .

"In October 1965, Dean Castleton
and Dr. Castle of the University of
Utah School of Medicine met with
the Utah State Medical Association
Executive Committee to gain their
interest and support for a regional
program. Subsequent meetings were
held with representatives of the Utah,
Idaho and Nevada State Medical As-
sociations, and county medical soci-
eties in Reno and Las Vegas, Nevada;
Grand Junction, Colorado; Idaho
Falls, Pocatello, Twin Falls and
Boise, Idaho; and Butte, Great Falls
and Billings, Montana. Meetings also
were held with members of the hos-
pital staff in all the major hospitals
in the region. . . .

"On February 26, 1966, a regional
workshop was held at the University
of Utah Medical Center in Salt Lake
City, which was attended by repre-
sentatives from all six states involved
in the proposed region and all profes-
sions, organizations and institutions
concerned about heart disease, cancer
and stroke. The purpose of the meet-
ing was to begin to define a Region
which could work together as a unit
and to obtain ideas as to regional
resources and needs, and how a pro-
gram should develop. Ideas expressed
at this meeting served as a foundation
for the planning grant application
submitted in May 1966 and awarded
effective July 1, 1966. . . .
"Since July 1966, the major efforts
in planning have been in recruiting a
planning staff, establishing lines of
communication with all elements
within the region and with other re-
gional programs in the country and
developing systems for sustaining
active  interaction  among  these
groups, explaining the purpose of the
program to professional and lay com-
munities, developing methods for
collecting data relative to heart dis-
ease, cancer and stroke, identifying
needs which can be met by Regional
Medical Program legislation, and
formulation of proper procedures for
construction of pilot projects and
methods for their review and ap-


48

proval by reacting panels and the
Regional Advisory Group. . . .

"Progress has been made toward
meeting all objectives outlined in the
planning grant application, but none
have been completed and will require
an intensity of planning similar to
what has been established within the
last few months for at least another
year. One major obstacle to more
rapid progress within the region has
been the slow process inherent in ob-
taining outstanding people to serve in
key positions on the planning staff.
Although the Intermountain Re-
gional Medical Program has been
particularly fortunate in obtaining an
outstanding, dedicated, hardworking
staff, the process of bringing them
into a new program, allowing them
time to understand the program and
to define their role, has taken much
longer than anticipated at the outset.
In lieu of people with background
and experience in developing the
type of program outlined under Pub-
lic Law 89-239, it has been necessary
to recruit personnel with a variety of
career commitments and ask them to
make major changes in their careers
in pursuing this new national pro-
gram. . . .

"To meet some of the most pressing
needs in initiating a Regional Medical
Program, specific projects to provide
training for personnel and to involve

certain institutions, organizations and
individuals in an active way were
identified early in planning. . . .

"The community profiles devel-
oped by the Intermountain Regional
Medical Program are being used by
the Mountain States Regional Medi-
cal Program and the community com-
mittees to be formed in Nevada, Wy-
oming, Idaho, and Montana, will
serve as liaison to both programs over-
lapping these areas."

Kansas
Regional Medical Program

"By the first of the year the posi-
tion of Regional Medical Programs
with relation to Public Law 89-749
and other efforts of the medical
school had become somewhat clari-
fied. Dr. Charles Lewis, professor
and chairman of the Department of
Preventive Medicine and Commu-
nity Health, who had been active in
both the planning grant body and in
preparing the operational grant ap-
plication, agreed to take full-time
responsibility as director of the Kan-
sas Regional Medical Program. He
assumed this role on March 15, 1967.
Since this time considerable progress
has been made with regard to a prin-
cipal staff and development of a for-
mal organizational structure. . . .

"In addition, a Regional Medical
Program office has been established

in the Wichita area. This was done
since this metropolitan area contains
15.75 percent of the population of
the state of Kansas as well as 357
physicans and 1,825 nurses. Mr.
Dallas Whaley, the previous execu-
tive-secretary of the medical society
in Sedgwick County (Wichita) was
approached and hired. . . .

"In addition to the Regional Ad-
visory Council, two additional groups
have been appointed to serve as staff
advisory committees. One of these
is the Professional and Scientific Re-
view Committee. This is made up of
individuals nominated from various
organizations and groups, such as the
Heart Association, the Cancer So-
ciety, the state Medical Society,
those from certain sections of the
School of Medicine, etc. . . .

"The second group appointed is a
physicians' panel. This is composed
of a group of physicians selected by
stratified random sampling with re-
gard to geographic area, type of
practice, and age. This panel of
names will be submitted to the presi-
dent of the Kansas Medical So-
ciety. . . .

"The Regional Advisory Council
was recently enlarged with the addi-
tion of eight new members. This en-
largement was accomplished in or-
der to gain further representation of
o t h e r non-health-related groups

within the state and also to increase
representation from the Wichita
area. . . .

"Considerable discussion has taken
place with the Missouri Regional
Medical Program regarding coopera-
tive planning efforts, particularly with
regard to data pooling and evalua-
tion. Special attention and coopera-
tive planning have been directed to
the complex Kansas City metropoli-
tan area which crosses the Missouri-
Kansas State boundary and six
county boundaries. . . .

"A special Metropolitan Kansas
City Coordinating Committee has
been established to advise and assist
with the planning for this area. This
committee, which is made up of rep-
resentatives of both the Missouri and
Kansas Regional Medical Programs,
will consider all proposals of either
Region which would have an impact
in the greater Kansas City area. . . .

"An interregional conference on
health manpower data recording and
evaluation was held May 22-23,
1967, at the University of Kansas
Medical Center. Representatives of
the Oklahoma, Missouri, and Kansas
Regional Medical Programs partici-
pated with outside experts. The pur-
poses of this conference were ( 1) to
define basic core information which
must be recorded on all professionals
(having decided what disciplines will


49

be covered) and to develop a com-
mon data base for the three Regions
for the transmission and comparison
of manpower data, and (2) to em-
phasize the importance of proper
evaluation rather than developing ar-
tificial indices which mean nothing in
terms of health delivery systems. . . .

"It should be noted that feasibility
studies will soon be under way in the
Wichita regional area. A group
representing the hospitals and physi-
cians of that area is now making
plans to develop a non-profit corpora-
tion in order to seek non-federal fi-
nancing from private industry to sup-
plement funds from Regional Medi-
cal Program resources. . . .

"It is hoped by the first of Septem-
ber that manpower data recording
for the state of Kansas will be al-
most complete. It is also projected
that during the summer of 1967-
several field investigations will be
carried out on consumer and health
professionals' attitudes toward cur-
rent systems of health care. A proba-
bility sample of consumers will be
interviewed, comparing their atti-
tudes'toward medical care. In addi-
tion, physicians, nurses, hospital ad-
ministrators, etc., will be similarly
consulted. The purpose of this is to
describe the system in as many ways
as possible and to correlate this with
other information regarding param-
eters of health care, i.e., morbidity

and mortality data, utilization of
beds, number of office visits, costs, etc.
By comparing two or three different
types of medical care systems in
different parts of the state, we will
have a better idea of the means by
which we can evaluate changes and
variations on the original theme of
delivering health care to patients and
improving the quality of care for
those with heart disease, cancer, and
stroke. . . .

"Another development which will
be completed before the end of this
planning year is the attempt to de-
velop a health data bank. To this
end the University of Kansas Medical
Center, the Kansas Regional Medi-
cal Program, the Kansas State Board
of Health, Kansas Blue Cross-Blue
Shield, and Kansas Health Facilities
Information Service, Inc., have all
agreed to pool data on manpower,
postgraduate training, resources for
health care, facilities, utilization,
morbidity, mortality, vital statistics,
economic development, outpatient
utilization of office visits, etc."

Missouri
Regional Medical Program

"Under the leadership, guidance
and direction of the Regional Ad-
visory Council, planning for the
Missouri Regional Medical Program
and development of pilot projects for

implementation   have  proceeded
simultaneously during the year. The
Advisory Council, with advice from
its Scientific Review and Liaison
Subcommittees and the Metropolitan
Kansas City Coordinating Commit-
tee, serves as the governing body, de-
termines policies, and approves (or
disapproves)  and  sets priorities
among proposals for pilot projects.
The Scientific Review Subcommittee
advises the Council relative to sci-
entitic problems, including the merit
of pilot project proposals. The
Liaison Subcommittee serves as a two-
way medium of communication be-
tween the member organizations and
the Missouri Regional Medical Pro-
gram. The Kansas City Metropolitan
Coordinating Committee reports to
the Advisory Councils of the Kansas
Regional Medical Program and the
Missouri Regional Medical Program
and works to encourage cooperation
and avoid duplication of pilot project
proposals among institutions, hospi-
tals and other agencies of Metropoli-
tan Kansas City. All the organiza-
tions and institutions represented on
these Committees have an active role
in planning, and two have submitted
pilot projects now under considera-
tion and three are preparing pilot
project proposals. . . .

"The Advisory Council made an
early and crucial decision to place
primary emphasis on maximum use

and refinement of present resources.
This means learning more about the
needs of practicing physicians and
other health professions, the con-
sumer, and State and local health
resources. Missouri Regional Medi-
cal Program aims to assist the prac-
ticing physician in providing optimum
patient care as close to the patient
as possible, with equal access to any
needed national resource. According-
ly, Missouri Regional Medical Pro-
gram stresses prevention and early
detection, continuing education, pub-
lic education and information, and
appropriate demonstrations of patient
care. . . .

"The Missouri Regional Medical
Program staff is confident that the
splendid interest, concern and con-
tributions of the Advisory Council
are, in important part, related to its
decision-making authority. (There
appears to be evidence that the con-
tributions of  Regional Advisory
Groups to a certain extent parallel
their responsibility for decisions.) . . .

"Since July 1, 1966, the staff have
taken steps to strengthen inter-agency
cooperation and communications.
The Program Coordinator and staff
have made speeches at society meet-
ings, meetings of other health profes-
sion organizations and lay groups.
The staff has also conducted seven site
visits with reference to pilot projects


proposed by various communities;
has been in communication with six
other communities relative to possible
pilot projects; has consulted with nu-
merous official health agencies and
other organizations and individuals;
has discussed plans, projects and ac-
tivities with numerous visitors. . . .
"Thus far all agencies, institutions,
organizations, and individuals asked
to cooperate have responded favor-
ably. . . .

"However, some practicing physi-
cians need to be informed that Mis-
souri Regional Medical Program is
primarily patient oriented and not
Medical Center oriented, and that
Public Law 89-239 emphasizes co-
operative arrangements, continuing
education, and demonstrations of pa-
tient care within the present system
of medical practice. . . .
"Missouri Regional Medical Pro-
gram may face problems when agen-
cies present pilot projects for fund-
ing and a choice must be made. How-
ever, we are develaping Guidelines
on which funding decisions will be
based and explained to interested
agencies. . . .

"The Missouri Regional Medical
Program emphasizes the importance
of evaluation of results. The Program
Evaluation Center for the University
of Missouri School of Medicine is be-
ing used to develop whatever meas-
urement devices are required and to

apply them to the results achieved by
various funded programs. The staff's
activities have been spent in attempt-
ing to conceptualize comprehensive
coordinated community health serv-
ices in terms of `schemes of action'
rather than `schemes of arrange-
ment.' Thus, the model will be de-
fined in such terms as access, com-
munications, and end points. . . .
"Pilot projects proposed by Mis-
souri Regional Medical Program in-
clude built-in evaluative mecha-
nisms. . . .

"A study is being conducted in a
rural Missouri community, Glasgow,
approximately 40 miles from Colum-
bia, to examine some of the decisions
made and the systems used by mem-
bers of this community in seeking
medical care. . . .

"In keeping with the `scheme of
action' concept, this one has looked at
( 1) routes of access to care which
have been used; (2) critical coordi-
nation and comunication points in
the systems used; and (3) endpoints
or reference points in the health
service system.

"Missouri Regional Medical Pro-
gram will continue to coordinate its
planning and pilot projects with other
health and related programs. This
applies especially to Public Law
89-749 and a new State law relating
to State and regional comprehensive
planning and community develop-

ment (including health). A new Of-
fice of State and Regional Planning
and Community Development has
been designated by Governor Hearnes
for administration of these two laws
in Missouri. In order to effect proper
coordination between Missouri Re-
gional Medical Program and the Of-
fice of State and Regional Planning
and Community Development, a new
senior staff position (Liaison Officer)
has been established. . . .
"Up to this writing, Missouri Re-
gional Medical Program has consid-
ered approximately 40 pilot project
proposals. Of these, 27 were for-
warded to the Division of Regional
Medical Programs in the form of
three operational grant applications.
If current negotiations are confirmed,
15 of these will be initiated during
April 1967, as follows:
Smithville Project
Communication Research Unit
Multiphasic Testing
Mass Screening-Radiology
Automated Patient History
Data Evaluation and Computer Sim-
ulation
Computer Fact Bank
Operations Research and Systems
Design
Population Study Group Survey
Automated Hospital Patient Survey
Program Evaluation Center
Bioengineering Project

Central Administration
Comprehensive Cardiovascular Care
Unit (Springfield)
Manual of Services

"Staffing arrangements for these
projects are underway and are ex-
pected to be completed in major part
within the month."

North Carolina
Regional Medical Program

"Very early in the consideration of
the North Carolina Regional Pro-
gram it became clear that in order to
fully implement the provisions of
Public Law 89-239, it was necessary
to develop a core concept which
would make possible the coordination
and augmentation of an already large
number of existing health activities,
interests, and institutions and in the
process enhance the ultimate effec-
tiveness of each component element.
This unifying conceptual strateg)
called for the mobilization, through
comprehensive planning and cooper-
ative enterprise, of all health care
knowledge and resources for a con-
certed attack upon the problems of
heart disease, cancer, stroke and
related diseases. . . .

"The program has the unique op-
portunity of being in a position to
bring together the talents of this
hitherto widely diffused leadership