Dr. Brent James Keynote Address

Last week the company I work for, Intermountain Healthcare, hosted the Healthcare Data Warehouse Association’s annual conference. The purpose of the conference is for different organizations to share their insight as to what works and what doesn’t work in terms of products, implementations, and integration.

The highlight of the conference, for me, was the key-note address given by Dr. Brent James. Dr. James is known world wide because of his work with analytics, and the impact he has had on the medical community. He has been the major force behind adapting “best practices” for physicians. When I explain to people what I do, I explain that my team pulls data from all of the hospitals so analysts can then compare outcomes for various clinical processes. For instance, which hospitals and doctors have the best recovery rate after open heart surgery? Then figure out what the best doctors are doing that those with the worst outcomes aren’t doing (or vise versa). Then try to have everyone adopt the best practice for the best outcomes. Dr. James has been the instrumental force behind that process.

Dr. James spoke to our group about how to change physician behavior based on the “truth” we find in the data warehouse. To me, his talk transcended medicine and data warehouses. To me it was a religious talk. Knowing truth, how do we help anyone change behavior – how do I help me change my own behavior.

Dr. James presented four methods that had been used to change physician behavior, and then had us rank which one we thought was most effective. The charts were referring to diabetes care. The first chart showed a doctor a list of all of his patients, and how all of them were doing over time. This allowed the Dr. to get more of a chronic picture of each patient, rather than just providing “episodal care.” So rather than treating the symptoms they see right now at this minute, they are able to see the current symptoms in light of the progress over time.

The second method was kind of a worksheet. It would prompt the doctor to look for other problems based on the current symptoms. So rather than just looking at blood sugar, the worksheet may prompt for some respiratory or other types of related problems. So this worksheet prompts the doctor to look at the body system as a whole instead of just one part of the body system.

The third method was to publish a list ranking each doctor by outcomes. The method here is that those doctors with worse outcomes will immediately know who to talk to for suggestions on how to do better. There is also a little bit of competition to be on the top of the list.

The last method was to give financial incentives for doctors obtaining an particular level.

So, as you read this, which method do you think would be most effective way to help doctors adopt a best practice? Personally I thought it was the comparison charts. It turns out that he presented them in their order of effectiveness.

He went on to say that in an integrated delivery system (HMO like Intermountain) there are various levels of service starting with the patient to the doctor’s office to the company to the nation to the global community. He mentioned that change has to be initiated between the patient and the doctor’s office level. Nothing can be pushed down effectively from the top down – real change comes from the bottom up. All that the upper levels can do is to identify “truth” (best practices). Any attempt to force the best practices on the physicians ultimately ends up hurting the providers.

Isn’t that fascinating!!

Now for the application – suppose that some “truth” has been determined by mom and dad, by coach, or some good book. How is the parent, the coach, or that good book, going to change the individuals to align themselves with the truth established? According to Dr. James, the least effective method would be to legislate the truth – in essence to force the change on the individuals. When truth is forced, the person will likely interpret their own meaning, or feign compliance. Other ineffective methods include bribing and comparing. “Why can’t you be more like so-and-so.” “Do it because I said so.” “Do it or else.”
More effective would be to look at the particular behavior in time rather than dealing with an individual moment. Is the trend as a whole becoming better? Then treat the trend, not the moment in time.

Also effective would be to treat the individual as a whole and not just the particular behavior. Could there be other factors in the person’s life that are contributing to the present bad behavior?

Then at a personal level – how do I change myself. By reading scriptures and attending the temple, I become aware of parts of my life that are out of alignment with divine truth. Most effective change come from measuring behavior over time rather than at one particular instant. So suppose I decided I want to be more honest. I will evaluate my progress over time then just at some future point. Also, I will examine every aspect of my life with regard to being honest. Am I honest on my taxes, in my tithing, in my fasts, in my relationships, with my employer, etc. Less effective agents of change would be to compare myself to others – “I’m not yet as honest as (Abe).” External rewards probably aren’t effective either. And we know that being honest cannot be enforced. No one can force us to be honest.
Others can’t cause me to change. They can only help me see the value and consequences of truth. Likewise, I can’t force anyone else to change. I can only, with patience and love unfeigned, work with individuals to help them see the benefits and consequences of following the truth.

I think Section 121 could illuminate each one of those points nicely.

Brian