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EMPIRIC seeks to optimize EHRM outcomes by identifying and promoting practices that clinical teams can employ to complement existing EHR change management approaches. Our specific aims are to evaluate pre-implementation, implementation, and sustainment at initial EHRM sites. We identify effective practices leading to improvement in EHRM outcomes and provide practice recommendations that VA clinical teams can use to improve EHRM. We are conducting formative evaluations that use mixed methods, including (1) workflow evaluation to compare current versus new EHR workflows; (2) surveys to assess clinical teams’ change readiness, user experience, and EHR proficiency; (3) interviews, reflections, and observations with clinical team members to identify strategies used to support EHRM; and (4) EHR log data to assess EHR proficiency. We conduct current state and gap analyses and develop site-specific action plans. Information from frontline clinicians undergoing EHRM can guide best practices to improve EHRM outcomes. This project directly addresses a top VA priority to modernize the EHR and will provide specific recommendations to engage clinicians and improve EHRM outcomes.
The VHA National EHRM Supplemental Staffing Unit (NESSU) is a group of VHA clinicians who support facilities going live on the new EHR by providing:
1) peer support to help facility employees understand and use the new EHR,
2) direct patient care to offload facility employee work while they adjust to the new EHR
3) assistance with manual data migration to ease the burden on facility employees
Most NESSU services are provided remotely, from clinicians located across the country, but some NESSU clinicians provide assistance in person.
NESSU was originally created to provide direct patient care and data migration assistance yet came to provide peer support based on their experience using the new EHR at multiple facilities and their familiarity with the legacy system.
NESSU has partnered with EMPIRIC QUERI to study the impact of NESSU peer support on EHRM outcomes. This evaluation was prompted in part by EMPIRIC qualitative findings indicating that users at early transition sites valued NESSU support and found it to be an important complement to vendor-led training and troubleshooting. This project is being conducted at multiple VA medical centers nationwide and is led by Drs. Seppo Rinne, Julian Brunner, and Sarah Cutrona.
Our partnered work aims to identify the mechanisms of NESSU’s peer support for EHR learning at the individual and group levels. We also will measure the impact of NESSU exposure (at the group and individual levels) on EHR perceptions and on actual EHR use.
In partnership with the Office of Clinical Informatics (OCI), EMPIRIC QUERI is establishing mechanisms for rapidly collecting, analyzing, and interpreting data from early EHRM implementation sites and communicating knowledge to inform evidence-based recommendations for EHRM practice improvement. Activities include examining the impact of EHRM Reset activities on user experience, developing and adapting an observational surveillance framework for detection of workflow deviations and workarounds, and synthesizing evidence to develop resources for EHRM leadership to support evidence-based decision making.
In spring 2024, a survey was fielded to examine the impact of Reset activities at five sites that had deployed the new Federal EHR. In September 2024, we repeated survey data collection at the same five sites as in the spring and expanded data collection to five CPRS/VistA sites. Both surveys assessed the impact of ongoing Reset interventions to improve user experience and allow comparisons of the experience of VA EHR users with other health care organizations using Oracle Health, including the Department of Defense. Findings from this survey are being used to track impacts of improvement initiatives.
Another line of partnered work with OCI focuses on secondary usage of electronic health record data to understand workflow patterns. This work is focused within the consult and referral space to help elucidate current workflows, consult usage, and related factors and uses a combination of process mining tools, statistical analyses, and modeling to assess for differences in the consult referral workflow or in consult usage patterns for both internal VA consults and community care consults. The goal is to use this information to guide standardization efforts and identify possible bottlenecks in the process.
Lastly, our OCI partnered work also includes a systematic review addressing the topic of measuring frontline user satisfaction or experience with their EHR system. The review focuses on the methodologies being used in routine health care system settings, the cadence and motivation for data collection (e.g., routine process, part of a specific implementation or event), and how these data are used. The literature database searches are complete and identified over 7,000 citations. The review is currently underway; findings from the review will inform OCI’s enterprise UX measurement strategy.
The Simulation Learning, Evaluation, Assessment, and Research Network (SimLEARN) is the VHA's program for simulation in health care training. It provides an ever-growing body of curricula and best practices that improve health care for our nation's Veterans. The use of innovative technologies in a safe learning environment enhances diagnostic, procedural and communication skills to support quality care and the best possible outcomes. For more information about SimLEARN’s work within VHA: www.innovation.va.gov/simlearn/index.html
In 2023, SimLEARN partnered with EMPIRIC to understand clinicians’ experiences with the EHR, characterize workflow challenges, and identify effective strategies that can optimize SimLEARN EHRM efforts while informing local and national VA leadership.
We aim to assess end user experience with high priority workflow changes before (VistA/CPRS), during, and after the transition to the new EHR. We will also compare user experience and EHR use among clinicians who participate in new workflow simulations vs. those who do not participate in the simulations. Ultimately, our partnered work is designed to assess how we can improve simulation processes and how to best integrate simulation to support EHRM.
Examination of Open New Service Requests
The EMPIRIC team analyzed 50 new service requests (NSRs) related to IT issues with the EHRM that were deemed high priority by National Councils and VHA Program Offices in spring 2023 and were not fully addressed (as of spring 2024). Given the high-priority nature of these NSRs and of related reports on IT needs, SimLEARN is dedicated to identifying instances where simulation can help address the problem.
Impact of Simulation Training
Staff at several sites that have transitioned to the new EHRM (Columbus and FHCC Lovell) participated in half-day simulation training implemented by SimLEARN. Information from interviews along with EHRM use metrics were analyzed to evaluate the impact of simulation for staff transitioning to the new EHRM. Based on these results, SimLEARN is looking to develop more curricula.
