The mountain cure

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GHIT Notebook

November 12, 2007

The mountain cure

Dr. Brent James — a gentleman by all accounts — has a murderous intent. He longs to snuff out a certain medical type: the arrogant, self-sufficient physician whose keen mind, honed by years of clinical experience, keeps him from making medical mistakes that vex mere mortals. Fortunately for James, the Hippocratic Oath doesn’t prevent him from killing a cliché.

The stereotype of the brilliant, infallible healer — not unlike TV’s splenetic Gregory House — isn’t accurate or even healthy, said James, who is vice president of medical research at Intermountain Healthcare in Utah and executive director of its Institute for Health Care Delivery Research. Worse, it’s not even scientific.

James has called U.S. hospitals “a major public health problem.” He co-authored the Institute of Medicine’s landmark 1999 report “To Err is Human: Building A Safer Health System,” which found that preventable medical errors result in as many as 100,000 deaths annually. Subsequent research indicates that the figure is probably much higher.

For more than two decades, James has treated the rehabilitation of health care the way he would treat a chronic illness — as a continuous process with a feedback loop of data, discovery and treatment. From cardiac care to cancer therapy to labor and delivery, Intermountain uses information technology to find and implement practices that yield better outcomes.

The results speak for themselves. Modern Healthcare magazine has named Intermountain the best or second best integrated health care system in the country for eight consecutive years. The mortality rates for key procedures at its Primary Children’s Medical Center were lower than those of any other children’s hospital in the United States.

“He is one of the leaders in health care and one of the pioneers in transforming health care,” said David Merritt, project director at the Center for Health Transformation, which promotes health care reform.

Moreover, his work is considered a model for how government leaders envision the health care system of the future.

“The president and I would like to see every American have access to the kind of care Dr. James has helped to make a reality in Utah,” Mike Leavitt, secretary of the Health and Human Services Department, told Government Health IT.

“His work is a prime example of how health IT can be used to improve the quality of health care and, at the same time, reduce costs,” Leavitt said. “His example demonstrates that higher quality care does not have to cost more.”

At a time when the country’s $1.7 trillion health care system is buckling under the weight of high costs and inefficiency, James is making the case that IT can help physicians make better decisions, improve clinical outcomes and save money. IT has already helped Intermountain save $100 million annually.

Last year, Dartmouth Medical School concluded its review of 4.7 million Medicare enrollees’ records over a four-year period and concluded that the program could have saved $40 billion on the care of the patients in question “if all U.S. hospitals practiced at the high-quality/low-cost standard set by the Salt Lake City region” served by Intermountain.

For James, the future of health care is in the numbers. “We measure our success in human lives,” he said.

The accidental reformer James didn’t set out to fix health care. He grew up on a cattle ranch on the Snake River Plain in Idaho and left home after high school to study physics at the University of Utah. A work-study job at the university’s high-energy physics lab exposed him to computer programming and the Advanced Research Projects Agency Network, the forerunner of the Internet.

“We played games trying to break into each other’s computers,” James said. The term “hacker” was a badge of honor.

One of his friends at the lab, a postdoctoral student from Columbia University, told James that teaching positions in physics were hard to come by. He suggested that medicine might be a better choice. James agreed, and he was accepted into the University of Utah’s School of Medicine, the only program to which he applied, with the intention of focusing on medical research.

To his surprise, James found himself fascinated with patient care. Hands-on medicine was technically and intellectually challenging, James said, but he was also intrigued by the possibility of “making a real difference to change peoples’ lives.”

As with most surgeons-in-training, challenges came in rapid succession. He recalls a 24-year-old patient whose descending aorta was ruptured in a car crash. The surgical team attempted to reconstruct the artery, but the man died with James holding his hand. Another time a child who had been hit by a truck bled to death on the operating table.

“What you remember most of all are your failures,” he said. “It makes you intensely search for how it could have been done differently and how it could work better next time.”

All the while, his interest in computers grew. In the 1970s, the University of Utah was one of the country’s top schools for computer science. James rubbed elbows with Tom Stockham, a creator of digital recording technology; Ivan Sutherland, a pioneer in computer graphics; and Nolan Bushnell, who invented the early video game “Pong” and founded the Atari game company.

“It was pretty heady days around here,” James said. “I was a geek.” He left Utah to accept a fellowship in cancer research at the Harvard School of Public Health only to find “that I couldn’t understand cancer without statistics,” he said. Ever the problem solver, he earned a master’s degree in the mathematical science of collecting, analyzing, interpreting and presenting data.

Following a divorce, he was drawn back to Utah and ultimately became an adjunct professor in the University of Utah’s Department of Biomedical Informatics.

“I was looking to come home,” he said.

The Intermountain way James returned to Utah determined “to have one foot firmly in academia and the other one in care delivery — feet firmly in the mud.” He pinned his hopes on working at Intermountain, whose flagship LDS Hospital had developed one of the first successful electronic medical record systems in the country.

“I believed that access to that tool would give me the data to do research that I couldn’t otherwise do,” said James, who had been frustrated at Harvard by the tendency to keep medical research separate from care delivery.

“I wanted to know what worked…to run experiments and apply the research and see if it made a difference in the lives of real patients,” James said. “The end goal was not a journal paper.”

At Intermountain, James’ examination of medical practices uncovered massive variations in clinical care — from the way doctors prescribe drugs to the way they set patients’ ventilators — and not only from one doctor to the next. James showed that in the course of a day, an individual physician’s decisions can vary greatly.

“There was not a single case where one physician was consistently bad or good,” James said. “If you looked at detailed data, you were forced to conclude that every physician had something to teach and something to learn. The best case was scattered.”

Quality, it turns out, is systemic. It is embedded deep in the workflow, a byproduct of good decisions made by many doctors. James came to believe that improving clinical outcomes hinges on reducing variation and better aligning doctors’ clinical behaviors with practices that are known to be effective. The underlying premise is that in 80 percent of cases, the best treatment is a standard practice.

Intermountain uses technology to compensate for physicians’ blind spots. Its 22 hospitals and scores of clinics rely on 40 programmers, analysts and other IT professionals to collect and crunch the numbers that become the basis for best-practice protocols. Those shared baselines help Intermountain retool workflows and eliminate guesswork. When confronted with evidence that their clinical outcomes are subpar, physicians are typically eager to modify their behavior.

“We have probably the most robust enterprise data warehouse in health care,” said Marc Probst, chief information officer and vice president of information systems at Intermountain. “We live and die by it.”

Inevitably, others will, too, James said. IT is fast becoming the health care tool that shapes clinical protocols, improves doctors’ decision-making and raises quality. Physicians in the IT age will be more likely to mine data than to mimic Dr. House, he added.

Two years ago, Intermountain and GE Healthcare formed a partnership to develop the health care system’s third-generation IT solution for capturing and managing data. The project is crucial to Intermountain’s continued success, James said.

“If you don’t develop an effective electronic medical record in the next 10 years, you will fail,” he said. “You won’t have good enough outcomes.”

Quality and cost James’ crusade to improve health care took a new turn when he met W. Edwards Deming, the renowned quality guru who is regarded as a major catalyst behind the transformation of Japanese manufacturing after World War II. A statistician, Deming promoted a methodology that included analyzing variances, using data to test hypotheses and eliminating costly errors.

“Deming had this crazy idea that as you improved outcome quality, the cost of operations would drop,” James said. “That was completely counterintuitive.”

James was eager to test Deming’s hypothesis. Intermountain was under intense pressure at the time to reduce costs, and most of the proposals under consideration involved limiting access to patient care. Instead, Intermountain developed a statistical method of parallel tracking that captured health care costs alongside clinical outcomes. “Within six months, we had proved that Deming was right,” James said. “As infections dropped, costs dropped.”

James and others have also proved an important corollary: Spending more money on health care doesn’t necessarily guarantee better outcomes for patients.

“From that point on,” James said, “things really started to move.”

Eliminating variation As word of Intermountain’s success spread, health care executives began flocking to James’ Advanced Training Program in Health Care Delivery Improvement. He has taught thousands of senior executives, including participants from Canada, Sweden and Argentina, and plans are under way to offer the course in France and Great Britain.

Dr. Elizabeth Hammond, former chairwoman of the Pathology Department at LDS Hospital, said James gave her a new perspective on the importance of rooting out variation in health care. To fulfill a project requirement of James’ course, she studied the effectiveness of breast cancer pathology reports, which at the time conformed to no standard and frequently lacked crucial information. One in three reports resulted in users calling the pathology department for clarification.

“Some were so bad that I, a pathologist, couldn’t understand them,” Hammond said.

Seeking to reduce variation, she documented the process of creating pathology reports and ended up developing a computer program that forces physicians to complete all fields in the reports, which eliminated the problem of missing information. A standard report format also ensured that users can glean crucial information without having “to read a bunch of garbage,” she said.

The College of American Pathologists adopted the strategy, and it has become a national standard.

The electronic reports also allowed Intermountain to track the frequency with which doctors were removing the lymph nodes of breast cancer patients, a procedure that is recommended in about 5 percent of cases. Intermountain found its physicians were performing the procedure at four times the standard rate, unnecessarily subjecting patients to infections and other complications. Within a year of uncovering the anomaly, the system had brought the rate of lymph node removal into the optimal range, to James’ great satisfaction.

“The thing that rings his bell,” Hammond said, “is to drive out variation.”

By John Pulley

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