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Advancing EHR Implementation Science and Research at VA

Key Points

  • Although the new system promises to modernize the delivery of health care to our nation’s Veterans and to bring better integration of Veteran health information across a broader range of systems and agencies, the road from here to there will be long, complex, and challenging.
  • As VHA prepares to embark on this challenging, decade-long journey, HSR&D, QUERI, and our corps of infor­matics and implementation science research experts will provide the lead­ership, strategy, and guidance needed to ensure a successful transition.

The Veterans Health Administration (VHA) is approaching a health information technology (HIT) crossroads as the organization looks to transition beyond the familiar, reliable, but ultimately limited combination of the Veterans Health Information Systems and Technology Architecture (VistA) and the Computerized Patient Record System (CPRS) to a new, commercial electronic health record (EHR) system developed by an external organization, Cerner Corporation. After years of iterative planning, projects, and initiatives, the nation’s largest integrated health care system now faces the daunting task of implementing a new EHR, one that will undeniably be very different than the one its practitioners, researchers, and HIT specialists have adapted and grown accustomed to over many years.

There is no standard blueprint for implementing an EHR system in one hospital, much less a nationwide network of interconnected medical centers and outpatient facilities. The implementation of EHR systems is a complex matter involving a wide range of factors, including organizational structure and culture, technical infrastructure, fnancial resources, and coordination. Installation of EHR systems in hospital settings has produced a growing body of literature on the science of EHR implementation, and researchers in different settings—including but by no means limited to VHA—have applied quantitative and qualitative research methods to better understand aspects of EHR implementation that increase the likelihood of success. What have we learned from this research?

A thorough systematic review, published in 2014,1 revealed that the existing literature is diffuse, and with few exceptions published articles generally failed to build on earlier studies to increase the theoretical knowledge on EHR implementation. Nevertheless, the review offers an initial framework of interventions that can help address typical implementation challenges. These interventions, several of which were developed and/or studied within VHA, could be used as a guide for organizations to increase the likelihood of successful EHR implementation. An effort such as the one about to be undertaken at VHA also represents an opportunity to substantially build on the existing knowledge base.

Primarily through its embedded intramural research programs in HSR&D and QUERI, VHA has been able to cultivate an impressive ensemble of informatics health services researchers and implementation scientists across the country with the experience and expertise to support this enormous HIT implementation challenge. VHA can and should utilize this opportunity to connect these research groups with relevant operational partners to design implementation strategies and to create a pipeline of new evidence to support future EHR implementations.

Two key strengths have contributed to the success of the informatics health services and implementation science research programs supported through HSR&D and QUERI, both of which can serve this broad new implementation effort well. The frst is the historically strong grounding of VHA research in theoretical frameworks—the principles, constructs, and concepts of a theory that form the foundation upon which research is constructed and established as credible and generalizable.2 A signifcant portion of EHR implementation research has not used a particular theoretical approach to identify and categorize its fndings.1 By partnering with HSR&D and QUERI investigators well-versed in theoretical constructs and frameworks, VHA’s upcoming EHR implementation efforts can be designed to be more productive, lead to more useful, actionable, and generalizable knowledge, and further establish VHA investigators as clear leaders in this emerging feld.

The second strength is the growing emphasis and necessity within VHA on partnerships between researchers and operational groups. Through these partnerships, researchers are better able to connect with front-line providers, identify the most pressing areas of need for investigation or intervention, and generate fndings that have a greater potential for rapid impact. At the same time, by working together these groups have a better opportunity to set national priorities and establish initiatives.

With regard to the transition away from VistA and CPRS, groups within VHA such as the Offce of EHR Modernization (OEHRM), working with the Department of Defense and Cerner Corporation, offer opportunities for researchers to collaborate with key groups to help establish implementation goals and priorities. Working together, they can contribute to new solutions and services and ensure that the new EHR implementation not only continues to support research needs, but also supports investigations that can take advantage of the more sophisticated computing environment.

Through the application of rigorous quantitative and qualitative methodologies, grounded in strong theoretical frameworks of informatics and implementation science, a research-operations collaboration can drive the EHR transition in ways that generate a profusion of new knowledge, advance the science, and guide ensuing installations. Further, this collaboration has the potential to affrm VHA as the leader in the science and practice of EHR implementation.

  1. Boonstra et al. “Implementing Electronic Health Records in Hospitals: a Systematic Literature Review,” BMC Health Services Research 2014; 14:370.
  2. Adom, Dickson & Hussein, Emad & Joe, Adu--Agyem. “Theoretical and Conceptual Framework: Mandatory Ingredients of a Quality Research,” International Journal of Scientifc Research 2018; 7:438-441.

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