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2023 HSR&D/QUERI National Conference Abstract

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1010 — Key findings and lessons learned from initial clinician experiences with VA electronic health record modernization

Lead/Presenter: Seppo Rinne
All Authors: Rinne ST (VA Bedford Healthcare System), Brunner J (Center for the Study of Healthcare Innovation, Implementation and Policy; Los Angeles CA) Anderson E (Center for Healthcare Organization & Implementation Research, Bedford MA) Ball S (Cleveland VAMC, Cleveland OH) Cohen-Bearak A (Center for Healthcare Organization & Implementation Research, Bedford MA) Cutrona S (Center for Healthcare Organization & Implementation Research, Bedford MA) Helfrich C (Center of Innovation for Veteran Centered and Value Driven Care, Seattle WA) Kim B (Center for Healthcare Organization & Implementation Research, Bedford MA) Mohr DC (Center for Healthcare Organization & Implementation Research, Boston MA) Moldestad M (Center of Innovation for Veteran Centered and Value Driven Care, Seattle WA) Molloy-Paolillo B (Center for Healthcare Organization & Implementation Research, Bedford MA) Sayre G (Center of Innovation for Veteran Centered and Value Driven Care, Seattle WA)

Objectives:
Department of Veterans Affairs (VA) is beginning a time-consuming and arduous process of replacing the longstanding, home-grown electronic health record (EHR) (VistA/CPRS) with a new commercial EHR (Cerner) in a nationwide, rolling-wave transition that is expected to take ten years and cost more than $16 billion. EHR transitions are complex undertakings that affect multiple sociotechnical systems and disrupt existing practice norms. Most change management for EHR transitions are led by commercial systems and there is limited published literature on best practices. We evaluated frontline clinician experiences at the Mann Grandstaff VA Medical Center in Spokane, WA, the initial VA site to go live, with a goal of identifying key lessons that can improve the future VA EHR transition rollout.

Methods:
We used longitudinal mixed methods during 9/2020 to 11/2021 to understand clinician experiences with the EHR transition. We focused on primary care and specialty care clinical teams that were comprised of 68 MGVAMC providers, nurses, and medical support assistants. We conducted semi-structured interviews before, during, and after go-live with 25 individuals, who contributed to a total of 91 interviews. We also conducted surveys approximately one month prior to go-live, two months after go-live, and approximately one year after go-live and consistently received 30-40% response rate across the three surveys. Across qualitative and quantitative data, we identified key findings that were summarized as lessons learned.

Results:
The initial EHR transition was profoundly disruptive, impacting work satisfaction and burnout. Participants described major challenges across different stages of implementation, including with pre-implementation activities and EHR training, implementation and adaptation to new care delivery systems, and sustainment of the transition with product optimization and support systems. Respondents indicated that the transition created hazardous conditions that impacted patient safety. Many of these challenges persisted a year after go-live, with ongoing issues with the new EHR system and the change management process.

Implications:
There are clear opportunities to improve the ongoing VA EHR transition. We worked with VA leadership to identify five change management recommendations: (1) Leadership and preparation for the EHR transition that provides adequate protected time and ensures a comprehensive review of employee roles; (2) Information exchange through clear communication channels to appropriately manage expectations about the EHR transition; (3) Training that offers opportunities for self-directed learning and continued optimization training; (4) Support systems that are readily accessible, reinforce peer networks, and provide clear feedback on the status of EHR issues; and (5) Continuous improvement efforts that expand evaluation and empower end users to help optimize change management.

Impacts:
We worked directly with VA leadership to establish specific recommendations to improve the new EHR rollout in VA, which may mitigate challenges during the EHR transition, decrease its impact on burnout and turnover, improve adaptation to the new EHR, and avert patient safety hazards.