1146 — Early organizational impacts of VA’s electronic health record modernization on employee roles

Lead/Presenter: Ekaterina Anderson,  COIN - Bedford/Boston
All Authors: Anderson E (Center for Healthcare Organization & Implementation Research, Bedford, MA), Moldestad M (Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA) Molloy-Paolillo B (Center for Healthcare Organization & Implementation Research, Bedford, MA) Ahlness Abdulmuminov E (Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA) Brunner J (Center for the Study of Healthcare Innovation, Implementation & Policy, North Hills, CA) Ball S (VA Northeast Ohio Healthcare System, Cleveland, OH) Kim B (Center for Healthcare Organization & Implementation Research, Boston, MA) Cutrona S (Center for Healthcare Organization & Implementation Research, Bedford, MA) Rinne S (Center for Healthcare Organization & Implementation Research, Bedford, MA) Sayre G (Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA)

Objectives:
Transitions between electronic health records (EHR) inevitably affect various aspects of an organization’s culture and routines. VA’s ongoing EHR modernization (EHRM) is the largest EHR transition to date, with vast organizational ramifications. Our evaluation team sought to understand how the transition from VA’s homegrown EHR (CPRS/Vista) to a commercial one (Cerner Millennium) affected employees’ roles, including their ability to communicate and work together.

Methods:
We completed 50 brief “check-ins” (~15 mins) and 23 full-length interviews (30-60 mins) with clinicians (N = 19) and staff (N = 5) at the first VA site to go live to understand their experiences with EHRM. Transcripts were coded using a combination of a priori codes derived from the literature on EHR transitions and preliminary research, as well as emergent concepts. All coded passages relevant to roles were extracted and analyzed separately to generate themes.

Results:
We identified several ways in which EHRM affected VA employees' roles. Three of these had to do with Cerner's use of the role-based approach in assigning privileges to groups of users: (1) EHR roles for users were often assigned incorrectly, resulting in inappropriate loss/gain of privileges. (2) Individuals with unique/dual roles had trouble obtaining their full set of privileges in the new EHR. (3) Role-based differences in the EHR interface and functions both inhibited and enhanced teamwork and communication. Two additional phenomena had to do with roles more broadly rather than with regards to role-based access: (4) Scopes of practice for some clinicians, especially licensed practical nurses (LPNs), underwent enduring changes, causing confusion and frustration. (5) A de-facto expansion of roles for certain categories of staff took place because of added EHRM-related tasks, such as manual data re-entry.

Implications:
EHRM at VA’s first go live site resulted in profound shifts in employees’ ability to perform their roles, individually and collectively.

Impacts:
As more VA sites undergo EHRM, it is essential to anticipate and mitigate challenges related to employees’ work roles. This should include: (1) addressing issues related to incorrectly defined and/or assigned roles/privileges in a timely fashion; (2) communicating early and clearly forthcoming changes in scope of practice for specific categories of clinicians; (3) acknowledging and equitably distributing the added burden of new tasks associated with EHRM; and (4) keeping track of complex changes in teams’ ability to communicate and coordinate work so that challenges can be addressed and emerging best practices capitalized on.