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Government IT Modernization and Organizational Change – The Case of VA’s Electronic Health Records

Updated: Mar 25, 2022

Electronic Health Records (EHRs) have long been an elusive target for both private and public sector health care providers. EHRs are real-time, patient-centered records that make information available instantly across care providers. At first glance, implementing EHRs seems like a no-brainer. They improve patient care, care coordination, diagnostics, efficiencies, and result in long term cost savings. But, transitioning to EHRs can bring major challenges to healthcare providers including increased costs as well as technical, standardization, and organizational limits and constraints.

The Department of Veterans Affairs (VA) operates the largest health care system in the United States and is well aware of both the challenges and potential benefits of EHR implementation. In fact, the VA was an early EHR adopter with its VistA system dating back to the early 1980s. While VistA won praise from doctors for its ease of use, the once groundbreaking system began to show its limitations as the years passed and newer EHR systems were developed. VA eventually concluded it was time to transition to a new system in order to share information more easily with the Department of Defense and private hospitals.

In fact, the U.S. Government Accountability Office (GAO) specifically cited the need for VA and Department of Defense EHR interoperability when it first placed VA Health Care on its High Risk List in 2015. At the time, GAO stated, “VA and the Department of Defense (DoD) lack electronic health record systems that permit the efficient electronic exchange of patient health information as military servicemembers transition from DOD to VA health care systems.” Heeding that call, VA chose a new commercial, off-the-shelf (COTS) EHR in 2018 that was designed to work seamlessly with the DoD’s patient records.

Yet, in hindsight, it has become clear that picking a new EHR system was the easy part. VA was about to face the daunting task of implementing a new COTS system to replace a legacy system developed in-house that had been in place for decades. Undertaking this level of effort in a government agency – or any large organization – requires an incredibly high degree of administrative know-how from the project team, strong political management from leadership, and skillful change management to minimize disruption to end users. Obstacles that must be overcome include cultural inertia, leadership buy-in, and user adoption resistance. These challenges must be met with a robust program of workflow analysis, user training, and, above all, change management that must be in place well before the switch to a new system is scheduled. Of course, technical challenges will always exist when implementing a new EHR system, but the organizational challenges are arguably greater in large organizations and can pose an even more serious threat to adoption.

With that in mind, VA’s effort to implement a massive, multi-billion-dollar and decade-long EHR system upgrade was bound to run into a few bumps. VA has the benefit of being staffed by public servants who are absolutely committed to the care of the veterans they serve. Yet, any bureaucracy of VA’s size will undoubtedly face difficulties when a situation calls for agility and rapid change. In recent testimony before Congress, VA Deputy Secretary Donald Remy acknowledged that “a broad range of issues” existed with VA’s EHR rollout, but he pledged to Congress that VA was redoubling its efforts to implement the new system and that “we will get this right.”

Over the past year, VA has shown it now understands that the key to successfully implementing its new EHR system lies with solving the organizational challenges inherent in this effort, and VA leadership has begun to pivot accordingly. VA Secretary Dennis McDonough stated that the challenges in implementing VA’s new EHR system are not merely technological, but also a matter of governance and management. This is why VA is currently realigning the management structure of its entire EHR modernization effort. Laying this groundwork now should set the VA up for a smoother deployment as the new EHR system is implemented at future Ambulatory Care Centers on a rolling basis.

While EHR modernization efforts at VA remain a work in progress, successfully implementing a new governance and management structure and achieving user buy-in through change management will be key to ensuring the EHR system crosses the finish line. Given that VA’s EHR modernization will impact the care of U.S. Veterans across their lifetimes, getting this right is absolutely essential.

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