HIStalk Interviews Kevin Johnson, MD, Chief Informatics Officer, Vanderbilt University Medical Center

Kevin Johnson, MD is chief informatics officer at Vanderbilt University Medical Center (TN), professor and chair of biomedical informatics and professor of pediatrics at Vanderbilt University, and a filmmaker.

Why is VUMC moving from McKesson Horizon to Epic instead of to McKesson Paragon?

We have enjoyed a long history with Epic as one of their first revenue cycle clients dating back to 1995. We had made a decision to upgrade our revenue cycle and billing system to a more recent Epic version for inpatient and outpatient billing. We also have Cerner’s lab system.

Our decision, therefore, was to migrate our revenue cycle, clinical, and lab environment to Epic/Epic/Cerner or Epic/Cerner/Cerner. Paragon is a system constructed with a different size and complexity health system in mind. Both Cerner and Epic were good choices for us, and after a thorough evaluation, we chose Epic for our clinical system.

What is your Epic implementation timeline?

One of Epic’s strengths is that they provide a timeline and coaching to help our team configure, test, train, and go live. We are following that timeline with a plan to go live with Epic in a big bang fashion in November 2017.

We are fortunate to have a large and talented IT group, of whom about 50 percent are migrating to the Epic project. We think that their knowledge about Vanderbilt systems and infrastructure, coupled with their knowledge about our leadership and their relationships with customers, will help us deliver this system on time.

How will the Epic system help VUMC with its current and future patient care initiatives?

We have big plans for this. I will say right off the bat that Vanderbilt is a lot like other organizations that have constructed a leading IT infrastructure. We have areas with better adoption and areas that still have unmet needs. We have dependencies on individuals, rather than teams, that put some of our best innovations at risk. And we have workflow challenges related to the need to interface, rather than integrate, some of our system components.

Going live with Epic will usher in an era with a more unified patient bill, better access to mobile tools for patients and providers, and point-of-care access to reports and other aggregate data. Epic will be a high-reliability transaction processing and core clinical system for us.

Vanderbilt has always had a distinctive strategy for IT. We are retaining our vendor-neutral operational record, so that we will have three ways to potentially extend our infrastructure.

First, we plan to work with Epic to solve new problems and to innovate when possible. Second, we are capable of adding onto Epic through the use of SMART/FHIR apps and anticipate doing so. For example, to pilot student and trainee projects. Third, we will use our vendor-neutral record, if need be, to bring up specific complex functionality not yet supported by Epic.

Our plan, though, is to use this to free up our most talented developers to innovate on unsolved challenges rather than using their expertise to keep up with regulatory or reporting demands.

Is Vanderbilt still doing work to match genetic and EHR information?

Very much so. We are actively involved with the EMERGE (electronic medical records and genomics) Consortium, as are a number of academic centers around the country. Probably the biggest innovation we’ve been able to demonstrate is how to weave drug-genome interactions into the point of care through a project called PREDICT that was internally funded.

We were incredibly honored to host the second of the Precision Medicine Initiative workshops last spring and to push on the agenda of interoperability while also considering numerous approaches to abstracting EHR information for this program. Through the efforts of Josh Denny, MD, the PheWAS method, where we use NLP on clinical documents — in addition to using structured data in the EHR — to figure out phenotypes and then scan for variants associated these phenotypes we have convincingly demonstrated the power of combining genomic and EHR data.

The world of developing predictive models for disease is literally exploding, as we know, and will continue to evolve as new and more relevant data types, such as images and sensor data, are added to the analytic ecosystem.

What is VUMC doing with population health management?

Like almost everyone, we’re learning how best to do anything in population health management. I think the key point we all must address is how little technology really does to improve population health management. What technology does well, so far, is help with the aggregation and communication of data and knowledge around performance.

What we need to do is move from communication to active decision support at the point of care, better involvement of patients in their health management, and hardwired processes to act on information being distributed that requires manual interventions. The people and process parts of managing health are simply underappreciated.  

What we’re doing at this point is building that infrastructure, in addition to scaling work people have done with diseases like ventilator-associated pneumonia and asthma across the enterprise. We are excited about working with Epic users who have done a lot with that environment and population health, such as the work Geisinger has led for years. We have a few innovative ideas that may or may not pan out.  

I do have to share with you one story. When I got my Apple Watch, the first thing I imagined is how we could push reminders to clinical providers of care, using an in-room beacon to know which patient and which provider were engaged in the encounter. Very cool, until I first looked at my watch in front of a patient, who said, “I’ll only be a minute. Sorry to keep you.” The watch, unfortunately, has a lot of baggage we would have to overcome.

It’s clear that there are some great opportunities afforded by technology, but that in the era of widespread EHR adoption and dissatisfaction, we need to be very careful.

What innovative products or companies have you seen lately that excite you?

Other than my fascination with the Watch? Along the same vein, I have great expectations for the Amazon Echo. It just feels like the right interface to do what I described above  — real-time reminders and query/response decision support — in a way that could be easily integrated into the encounter.

I’m also very intrigued by work being done to demonstrate SMART and FHIR’s potential. There are a ton of startups creating wonderful apps and data visualizations. I hope we can harness some of this energy to impact the provider- and patient-facing health information technology systems.

Another thing that really excites and scares me is the phenomenon of big data. There’s a great little video from the ACLU called “Scary Pizza.” It shows one side of a very interesting issue, which is how simple systems can evolve using data from a number of sources. The goal of the ACLU piece is to scare us into fear about a loss of privacy. That’s one angle.

Another angle is to view it as an informatics challenge. How can we provide this level of decision support in a more acceptable fashion? For example, what if there was a way to use data about a house configuration to decide that the house might be difficult for rehab after a stroke? What if there was a way to know that the home’s electricity had been off on a few occasions, thereby changing the suitability for a home ventilator? I imagine that these types of data will truly transform the patient-provider interaction in the next decade.

What has been the response to your movie "No Matter Where?"

The movie tries to help lay audiences understand the issues surrounding information sharing. It’s been a very successful run so far. We had showings in Ann Arbor, Wisconsin, Tennessee, and San Francisco as a part of the AMIA meeting last fall. We have screenings being planned now in Indiana, Oregon, and Oklahoma. We have sold more than 100 copies of the DVD and are working on getting the film shown on public television. I’ve been pleased by the response so far.  We’ll see how 2016 treats us.