The problem. The explosion in the availability and capacity of information technologies in recent years has had profound implications for the practice of medicine.
“I believe that health care is delivered better when information-needing physicians and patients partner with information-providing technologies,” said Kevin B. Johnson, MD, MS, Cornelius Vanderbilt professor and chair of biomedical informatics, and professor of pediatrics at Vanderbilt University School of Medicine. Johnson, an alumnus of the Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program, has spent his career working on ways to integrate information technology into health care in such a way that the quality of care is enhanced rather than degraded. The program provides four-year awards for postdoctoral research to physicians and dentists from historically underrepresented groups. (See the Program Results Report for more information.)
From becoming a vet to “regular” medicine. Johnson was born in Baltimore and grew up in one of its suburbs, Pikesville. Early on Johnson dreamed of becoming a veterinarian—he was one of those pet-crazy kids whose home menagerie included everything from snakes and gerbils to an octopus.
Johnson changed his goal to “regular” medicine after he witnessed the insensitive care a good friend in college received while being treated for severe depression. After earning an undergraduate degree in biology at Dickinson College in Carlisle, Pa., he received his MD from Johns Hopkins University in 1987. Johnson completed his residency in pediatrics at Johns Hopkins Hospital. He chose pediatrics because he loved the people who worked in it and the relationships it offered with children and their parents.
Johnson earned a master’s degree in medical informatics at Stanford University (1992). Then he returned to Baltimore as chief resident in the Department of Pediatrics at the Johns Hopkins University School of Medicine. It was there that he embarked on the path he’s pursued ever since: the intersection of medicine and information technology. After completing his residency, he joined the Johns Hopkins faculty.
Making the Harold Amos connection: Johnson learned about the Harold Amos Medical Faculty Development Program through one of his mentors, cardiac surgeon Levi Watkins Jr., an original member of the program’s advisory committee who also happened to be an associate dean of the Johns Hopkins University School of Medicine. “At that point in my research, it was clear that I could use the kind of mentoring and financial backing that the program could provide,” Johnson says. He was accepted as a program fellow in 1997.
Studying computers and doctor–patient communication. During his Amos fellowship, Johnson studied the impact of computer-based guidelines for pediatric health maintenance visits on the quality of those visits. He and his colleagues recorded—mostly on audiotape, some on videotape—health maintenance visits between residents and the parents or caregivers of 240 pediatric patients at Johns Hopkins. Residents used either a desktop computer or paper forms to guide their questions and record answers.
The goal of the study was to determine whether using a computer would help or hinder both the quality of communication between health care providers and parents, and the documentation of the visit. It also sought to assess health care provider and parent satisfaction with the visit; residents and parents completed post-visit surveys to determine their satisfaction.
“The results were very positive,” Johnson says. “We were able to show that there was no significant difference between the types of communication occurring with computer technology versus without computer technology. We were also able to show that satisfaction didn’t change one bit, either from the parents’ perspective or from the provider perspective.” Using computer documentation made the visits slightly longer, but resulted in more detailed and patient-centered discussions between residents and parents. (Archives of Pediatrics & Adolescent Medicine, 2005, 159:250–254; Pediatrics, 2008, 122:590–598.)
Based on these results, Johns Hopkins management decided to proceed with implementing computer-based documentation throughout its various institutions. The system Johnson and his colleagues designed for the study remained in use there for more than a decade.
Earlier in his career, Johnson wanted to learn through his research whether computers could be integrated into medicine without dehumanizing it. He now says that he and his colleagues in the field are “cautiously optimistic” that the answer to that question is yes. His caution hinges in part on the degree to which physicians, nurses, and other health care providers make the effort to effectively use the technologies at their disposal. Ultimately, he believes medicine can have it both ways: personal care with more information, and thus more safety.
Moving medicine into the “information age.” Since moving to Vanderbilt University in 2001, Johnson has focused his research on two overlapping areas of biomedical informatics: prescriptions and personal health records. Johnson has spearheaded several projects related to these areas.
- RxStar is a software application, developed by Johnson and colleagues in Vanderbilt’s Informatics Center, aimed at reducing errors in drug prescriptions for adults and children. Used at Vanderbilt since 2004, RxStar automatically checks each new prescription against a patient’s known problems and other medications, looking for contraindications such as allergies and inappropriate dosages. The system supports pediatric dosing and generates an alert when anything seems amiss. RxStar can transmit prescription orders and refill requests to pharmacies electronically.
- STEPStools is another medication management tool, designed to help pediatricians determine appropriate prescriptions for their young patients. This is complex because of the variability in children’s development and physical ability.
STEPStools automatically completes the calculations that are required in order to determine the appropriate dosage for a given child, taking into account his or her age, weight, and other factors. Among the program’s features is an algorithm for rounding of medication doses and a pediatric medication knowledgebase.
Johnson led this project, working closely with the American Academy of Pediatrics and with funding from the federal Agency for Healthcare Research and Quality. As of September 2013, the transfer of the program to the American Academy of Pediatrics was pending.
- My-Medi-Health is a personal medication management program created to give children the power to manage their own medications. The device reminds kids to take medications at established intervals and notifies caregivers, school personnel, and others if there is no response to a reminder. It also manages refills.
Johnson and colleagues designed the initial program in 2009 for cystic fibrosis patients between the ages of 5 and 9. They subsequently completed a randomized trial of the application tailored for pediatric asthma patients and as of September 2013 were analyzing the data. Also at that time, they were upgrading My-Medi-Health to be an iPad application. More studies and further funding are necessary before the program becomes available for use.
The Robert Wood Johnson Foundation funded the My-Medi-Health project as part of its Project HealthDesign: Rethinking the Power and Potential of Personal Health Records national program, in which teams design prototype personal health record applications tailored to the needs, preferences, and daily habits of patients.
Balancing responsibilities. Johnson’s work on these and other projects has brought him widespread recognition as a leader in his field. He received the 2008 American Academy of Pediatrics’ Byron Oberst Award, which honors those who have made outstanding contributions to the use of technology in pediatrics. Johnson is an associate editor of the Journal of the American Medical Informatics Association and an elected member of the Institute of Medicine, the Academic Pediatrics Society, and the Johns Hopkins Society of Scholars. He is the author of more than 100 journal articles and books or book chapters.
Johnson’s appointment in 2012 as chair of Vanderbilt’s Department of Biomedical Informatics ranks as a significant honor in and of itself. With 65 faculty members, it is the largest such department in the country, which means Johnson now spends the bulk of his time on administrative duties, rather than on research, clinical practice, or mentoring students. “My role as mentor at this point is creating an environment that’s conducive to other mentors,” he says.
There’s a hint of regret in Johnson’s voice as he acknowledges giving up research, clinical practice, and direct mentoring—in part because of his appreciation for the mentors who have guided him through the course of his career. Many of those mentors have been connected to the Harold Amos program, and Johnson now returns the favor as a member of the program’s national advisory committee. He describes the Harold Amos staff and his fellow alumni as a “family” and cites several decision points at which their advice proved crucial. “Everything that’s happened to me since about the mid 1990s has been because of Robert Wood Johnson and the Amos Fellowship,” he says.
RWJF perspective: The Harold Amos Medical Faculty Development Program is a four-year postdoctoral fellowship launched by RWJF in 1983. Its purpose is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry. A commitment to eliminating health disparities is among the selection criteria.
The program supports one of RWJF’s major objectives: To increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.
Of Amos program scholars, RWJF Senior Program Officer David M. Krol, MD, MPH, says:
Ultimately, we would like to see these individuals from disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder.
Kevin B. Johnson is one of more than 180 Amos program alumni in academic medicine today. His career and research exemplify the academic achievement and professional contributions that the program was designed to stimulate.
“The measure of the success of the program is the success of the individuals who participate in it,” says Krol.