1105 — Governance of the VA’s new Electronic Health Record: the Underappreciated Role of Standardization

Lead/Presenter: Julian Brunner,  COIN - Los Angeles
All Authors: Brunner J (HSR&D Center for the Study of Healthcare Innovation Implementation & Policy, Los Angeles), Cannedy S (HSR&D Center for the Study of Healthcare Innovation Implementation & Policy, Los Angeles) McCoy M (HSR&D Center for the Study of Healthcare Innovation Implementation & Policy, Los Angeles) Shelton J (VA National Surgery Office)

Objectives:
The Department of Veterans Affairs (VA) is in the midst of replacing its electronic health record (EHR) system, and established national governance bodies (“EHR modernization councils”) to guide the configuration of the new system. We conducted a formative evaluation of these councils in order to uncover their role in the EHR transformation, understand the challenges they face, and identify approaches that could improve governance.

Methods:
We conducted telephone interviews with council members from July-December 2020. Interviews were transcribed and analyzed using combination inductive/deductive methods. Participants (n = 29) included chairs of each council, with additional council members identified by snowball sampling. Councils include a mix of field-based clinicians and national VA leadership.

Results:
A key emergent theme was the magnitude of cross-facility standardization occurring as part of the EHR transition. Participants indicated that a substantial proportion of council work was directed toward the goal of “enforc[ing] standardization across all VAs,” and treated the EHR transition as “an opportunity to do national standardization” of clinical practices (e.g., “you can’t just change the way you’re asking a question regarding pain within your service … that [will be] standard). Participants expressed concerns about the implications of this standardization, noting that if the EHR is implemented “into a place that doesn't have the structure to support the way you've designed the workflow … it's gonna crash; it's not gonna work.” Interviews also identified considerations for the composition of governance bodies (e.g., inclusion of members with exposure to several EHR systems), and offered perspectives on best practices for governance, including carefully cultivating council members’ engagement, and clearly communicating council members’ roles and responsibilities.

Implications:
The VA’s 170 hospitals have historically functioned with a high degree of autonomy, and each hospital’s clinical policies are largely enshrined in separate versions of the VA’s legacy EHR system. As VA implements a single “universal” EHR, clinical policies and processes will be increasingly standardized across hospitals with dramatically different contexts and services. The process of arriving at a standard national set of clinical processes and policies emerged as the core governance challenge of the VA’s EHR transition, above and beyond the other technical and organizational challenges of implementing a new EHR system.

Impacts:
VA is overhauling governance of the EHR transition, and a growing recognition of the EHR’s far-reaching impact on clinical practices has spurred further involvement of clinical leadership. Our findings suggest that EHR implementation in large organizations with diverse facilities and services need to carefully consider the role of cross-facility standardization in implementation.