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