Melinkovich, director of community health services at Denver Health, represented the multifacility public healthcare delivery system in picking up a Codman award for outpatient organizations.
Denver Health, which operates a string of nine publicly owned health clinics and 12 school-based clinics in addition to a public hospital in the metro Denver area, was named the winner in the category for ambulatory care.
Melinkovich is, in effect, the head of the outpatient clinics for the organization. IT played a key role in the program of childhood-immunization tracking that led to the award at Denver Health, according to Melinkovich.
Denver Health uses a combination system of paper-based and electronic medical records. Paper records are scanned into an electronic database that tags the records for re-identification and makes them accessible across the system. But the immunization effort used a separate electronic immunization registry based on an off-the-shelf software program from a company that went out of business about three years ago, Melinkovich said. Undeterred, "Our IT department built it into a Web-based application," he said. The VaxTrax software is now available by Interlink Group, a software company that worked with Denver Health on the development effort, Melinkovich said.
"We developed a computerized registry of all the childhood vaccines that we deliver," Melinkovich said. "For every child we started on vaccines, we were able to track when they received a vaccine and when they needed a vaccine. Nurses were able to track what vaccine they (patients) were eligible for without a physician order."
"We were able to demonstrate sustained improvement over a five-year period in increased immunization rates," he said. "Basically, we were looking at immunizations for children from ages 0 to age 2.
"We increased our 2-year-old immunization rates by 46% to about 87%" for children who are fully immunized for diphtheria, whooping cough, tetanus, measles, mumps, rubella, hepatitis B and haemophilus influenzae, he said.
Both the tracking program and the higher immunization rates will be sustainable going forward, Melinkovich said.
"We're expanding its use in adolescent and adult vaccine delivery," he said. "I don't think it will be hard to sustain. It's become a standard part of practice."
James said his Codman award was given more for lifetime achievement at Intermountain than a specific recent program. In April, HITS' sister publication Modern Physician placed James at 30th on its 2006 list of the 50 Most Powerful Physician Executives in Healthcare.
"Brent James has created and progressively expanded a remarkable laboratory for continuous improvement and learning in real-world clinical settings at Intermountain," said JCAHO President Dennis O'Leary, in a news statement. "His pioneering efforts, now recognized around the world, demonstrate the potential benefits to patients that can be achieved through creative systems design and sound HIT applications."
"I'm the public face of a very good team of nurses, physicians and administrators," James said. "It's really Intermountain that gets this award, in the honest truth. I'm blessed to be with them."
James credits a series of happenstances rather than a focused career path that brought him first to medicine, then to medical informatics, and then back home to Utah from the Harvard School of Public Health in 1986.
James said his desire to be close to home and family drew him back to the University of Utah to work under internist Homer Warner, then head of the department of medical informatics, the first of its kind in the country.
Enrolled at the University of Utah, "I was on a straight-through physics Ph.D. program" working in the physics lab helping write a computer language for calculus under Professor Anthony Hearn, a pioneer in the development of computer languages for mathematics.
There in the lab James struck up a conversation with a post-doctoral fellow "who told me I was crazy going into physics, there was no work," James said. "He said some of the finest research work out there was medicine (so) I applied to one medical school and they accepted me."
After earning undergraduate degrees at Utah in computer science in 1974 and medical biology in 1975, James completed his medical training in 1978 and a surgical residency at University of Utah School of Medicine in Salt Lake City. He earned a master's degree in statistics from Utah in 1983.
He did stints in cancer research with the College of Surgeons in Chicago and, in 1983, began a fellowship in the department of biostatistics at Harvard School of Public Health, where he also taught, but did not stay.
As a med student in the mid-'70s, James first used computers in clinical practice, since LDS Hospital, one of the earliest adopters of healthcare IT, was already posting lab values on computer screens. On his return in 1986, James began his work applying to healthcare the ideas of quality-improvement guru W. Edwards Deming, whom he had met at a conference.
James' groundbreaking work has been in exploring the links between clinical quality improvement and cost reduction.
"Talking to Deming, he had this crazy idea that as you improved your quality, your costs would drop, which was highly antithetical in medicine," James said. His first project was to measure the financial impact of a clinical trial on post-operative deep-wound infections. "The question was, How do you measure costs?'"
To do it, James said, he quickly teamed up with two men working on the financial side of the house at Intermountain, Steven Busboom, vice president for finance, and Greg Poulsen, now senior vice president for planning, but then "a young MBA fresh out of school."
"We started to lay out our clinical outcomes data with our cost data and proved Deming was right, that improving your clinical quality could drive your costs down," he said. "Having that rigorous cost data available turned out to be a godsend."
By lowering the infection rate from 1.8% to 0.4%, the hospital documented an annual savings that today amounts to about $750,000 per year, James said.
In 1994, physician-researcher Kim Bateman studied variations in care of patients with community-acquired pneumonia, noting more than 60 different combinations of antibiotics were being used by Intermountain physicians.
Analysis of the data led to the adoption of a clinical protocol calling for the appropriate timing and use of a limited selection of drugs. According to published Intermountain data, in 1995, the first year with the new protocol, Intermountain had cut time-to-antibiotic to 1.5 hours compared with 2.1 hours in 1994; average length of stay to 1.5 days from 2.1 days; and complication rates based on "outlier" DRGs at discharge to 11.6% from 15.3%.
The study also proved the existence of a perverse misalignment of financial incentives in reimbursements, according to James.
"We figured out about three-quarters of the time that as your cost dropped, your reimbursement dropped even further," James said. While the cost of care fell by 12.3%, "We discovered our revenues had fallen 17.5%."
While Intermountain has one of the nation's most advanced clinical computing systems, James advises healthcare leaders to not wait until their own IT systems are in place, but to begin a program with the tools they have on hand. Virtually all new improvement projects at Intermountain still begin on paper, he said.
"We nearly always start them out as manual systems, but the volume of it forces you into computerization," James said. "There is a limit on how much you can do manually.
"When you are designing them, you design on paper before you lock it down in code," he said. "And the other thing is, if you don't have automated data systems (installed), that will force you to do it. And that will help you buy and design your system. Suddenly, the need will become glaring, and when you get your IT in, you'll be able to track it right to the bottom line."
When James started at Utah in 1986, all of this was bleeding-edge stuff with few adherents, but no more. In 1992, Intermountain founded the Advanced Training Program in Health Care Delivery Improvement, part of the Institute for Health Care Delivery Research that James heads. Today, the program offers two-day, 12-day and 20-day courses at Salt Lake City. Thus far, more than 1,200 physicians from 14 countries have been exposed to Intermountain quality-improvement methods through the programs.
"Hopefully, we're making some progress," he said. "What the award really means is that it is now mainstream and the industry is really understanding it."
In addition, the Howard Phillips Center for Children & Families, Orlando, Fla., was a Codman winner in the hospital category while two awards were given in the behavioral health category to Grandfather Home for Children, Banner Elk, N.C.; and Henry Ford Behavioral Health Services, Detroit.
The Howard Phillips Center was recognized for its HUG-Me -- Help Understand and Guide Me -- initiative to prevent transmission of HIV from infected mothers to their newborns. According to the JCAHO, there have been no HIV infections from a mother to a newborn in the program for eight consecutive years.
Grandfather Home was honored for improving placement opportunities for children who have suffered abuse, have sexual-behavior problems or exhibit acute physical aggression that makes them more difficult to place in less-restrictive environments. Grandfather Home achieved nearly a tenfold increase in the percentage of children served in their home communities.
Henry Ford was named for achieving a 71% reduction in the suicide rate of its patients diagnosed with depression.
The awards are named for Boston surgeon Ernest Amory Codman, (1869–1940), a pioneer in the field of outcomes research, and were presented during the JCAHO's National Conference on Quality and Patient Safety in Chicago. What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.