Background Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).Methods This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).Results In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants' daily workload and their concern for patients' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.Conclusions Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Objectives The Department of Veterans Affairs (VA) is transitioning from its legacy electronic health record (EHR) to a new commercial EHR in a nationwide, rolling-wave transition. We evaluated clinician and staff experiences to identify strategies to improve future EHR rollouts.Materials and Methods We completed a convergent mixed-methods formative evaluation collecting survey and interview data to measure and describe clinician and staff experiences. Survey responses were analyzed using descriptive statistics; interview transcripts were coded using a combination of a priori and emergent codes followed by qualitative content analysis. Qualitative and quantitative findings were compared to provide a more comprehensive understanding of participant experience. Employees of specialty and primary care teams at the first nationwide EHR transition site agreed to participate in our study. We distributed surveys at 1-month pre-transition, 2 months post-transition, and 10 months post-transition to each of the 68 identified team members and completed longitudinal interviews with 30 of these individuals totaling 122 semi-structured interviews.Results Interview participants reported profoundly disruptive experiences during the EHR transition that persisted at 1-year post implementation. Survey responses indicated training difficulties throughout the transition, and sharp declines (P <= .05) between pre- and post-go-live measures of EHR usability and increase in EHR burden that were perceived to be due in part to system inefficiencies, discordant positive messaging that initially ignored user challenges, and inadequate support for and attention to ongoing EHR issues. Participants described persistent high levels of stress associated with these disruptions.Discussion Our findings highlight strategies to improve employee experiences during EHR transitions: (1) working with Oracle Cerner to resolve known issues and improve usability; (2) role-based training with opportunities for self-directed learning; (3) peer-led support systems and timely feedback on issues; (4) messaging that responds to challenges and successes; and (5) continuous efforts to support staff with issues and address clinician and staff stress and burnout.Conclusion Our findings provide relevant strategies to navigate future EHR transitions while supporting clinical teams. The Veterans Affairs (VA) hospitals are replacing the software that stores their electronic patient medical information. Their current software was made within the VA. The new software was purchased from a company. This replacement process will require big changes to how VA medical staff work. We wanted to understand what staff went through at the VA; we wanted to help make this process easier. VA staff told us about huge work upsets and negative experiences during and after this change. Some problems were related to a lack of specific training specific about how they would use the software for their jobs. Another problem was related to delays in getting help using the system. Staff also had problems telling their leaders about how the system was not working. This article is about how to improve employee experience when other hospitals switch to the new EHR.

AbstractIntroductionThe Department of Veterans Affairs (VA) is undergoing an unprecedented electronic health record (EHR) transition, switching from its homegrown EHR to a commercial system. The transition affects nearly every clinical employee but is particularly disruptive to health professions trainees (HPTs)—an often‐overlooked population in EHR transitions. To better understand and address trainee challenges with the EHR transition, we formed a multistakeholder learning community. In this study, we describe the findings of this learning community and the practices and policies developed in response.MethodsIn the qualitative study designed and executed by our learning community, we conducted 51 interviews with HPTs, program leaders, and preceptors before and multiple times after an EHR transition site's go‐live (February 16, 2022 to April 7, 2023). We merged interview transcripts with 125 survey free‐text responses from a survey conducted with preceptors 2 months post‐go‐live and conducted thematic analysis to identify key themes. To complement qualitative findings, we also include a quantitative survey finding, and, where applicable, we note policy and practice responses spurred by our learning community.ResultsInterviews yielded six key themes: (1) High satisfaction with HPT programs, despite negative impacts of the EHR transition; (2) early delays, then substantial improvements, in HPTs' EHR access; (3) persistent challenges with HPTs' EHR training and support, mitigated by local and national efforts; (4) the challenge of learning to use a rapidly evolving EHR during clinical training; (5) reduced visit volume as a continuing barrier to education; and (6) an impression that HPTs' relative lack of exposure to the prior EHR facilitated their proficiency with the new EHR.ConclusionsFindings highlighted challenges for HPT programs related to the EHR transition, which spurred important changes including the creation of a national VA council to represent the needs of HPTs in the EHR transition, and improvements to HPTs' EHR training and access.

Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees’ (HPTs) ability to learn and conduct work. Veterans Health Administration’s (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions. To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site. A formative mixed-method evaluation of HPT experiences with VHA’s EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before ( 60 min), during (15–30 min), and after ( 60 min) go-live (December 2021–July 2022). We also conducted pre- (March 2022–April 2022) and post-go live (May 2022–June 2022) HPT and employee surveys. We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys. We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams. Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention. Understanding HPTs’ challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

Background Electronic health record (EHR) transitions are increasingly widespread and often highly disruptive. It is imperative we learn from past experiences to anticipate and mitigate such disruptions. Veterans Affairs (VA) is undergoing a large-scale transition from its homegrown EHR (CPRS/Vista) to a commercial EHR (Cerner), creating a unique opportunity of shedding light on large-scale EHR-to-EHR transition challenges. Objective To explore one facet of the organizational impact of VA’s EHR transition: its implications for employees’ roles and responsibilities at the first VA site to implement Cerner Millennium EHR. Design As part of a formative evaluation of frontline staff experiences with VA’s EHR transition, we conducted brief (~ 15 min) and full-length interviews (~ 60 min) with clinicians and staff at Mann-Grandstaff VA Medical Center in Spokane, WA, before, during, and after transition (July 2020-November 2021). Participants We conducted 111 interviews with 26 Spokane clinicians and staff, recruited via snowball sampling. Approach We conducted audio interviews using a semi-structured guide with grounded prompts. We coded interview transcripts using a priori and emergent codes, followed by qualitative content analysis. Key Results Unlike VA’s previous EHR, Cerner imposes additional restrictions on access to its EHR functionality based upon “roles” assigned to users. Participants described a mismatch between established institutional duties and their EHR permissions, unanticipated changes in scope of duties brought upon by the transition, as well as impediments to communication and collaboration due to different role-based views. Conclusions Health systems should anticipate substantive impacts on professional workflows when EHR role settings do not reflect prior workflows. Such changes may increase user error, dissatisfaction, and patient care disruptions. To mitigate employee dissatisfaction and safety risks, health systems should proactively plan for and communicate about expected modifications and monitor for unintended role-related consequences of EHR transitions, while vendors should ensure accurate role configuration and assignment.

BackgroundWe investigated the impacts of workload, resources, organizational satisfaction, and psychological safety on changes in physician burnout and moral distress among physicians during the early pandemic.MethodsWe obtained national administrative and survey data on burnout, moral distress, organizational satisfaction, psychological safety, COVID-19 burden, and state-level restrictions for 11,877-14,246 Veterans Health Administration (VA) physicians from 2019 and 2020. We regressed the changes in burnout and moral distress on the changes in reasonable workload, appropriate job resources, organizational satisfaction, and psychological safety, controlling for COVID-19 burden and restrictions, and individual and medical center characteristics.ResultsBurnout and moral distress were not related to COVID-19 cases or restrictions but were reduced by improvements in workload, organizational satisfaction, and psychological safety.ConclusionsHealth systems should be conscious of factors that can harm or improve physician well-being, especially in the context of external stressors.

Background Electronic health record (EHR) transitions are inherently disruptive to healthcare workers who must rapidly learn a new EHR and adapt to altered clinical workflows. Healthcare workers’ perceptions of EHR usability and their EHR use patterns following transitions are poorly understood. The Department of Veterans Affairs (VA) is currently replacing its homegrown EHR with a commercial Cerner EHR, presenting a unique opportunity to examine EHR use trends and usability perceptions. Objective To assess EHR usability and uptake up to 1-year post-transition at the first VA EHR transition site using a novel longitudinal, mixed methods approach. Design A concurrent mixed methods strategy using EHR use metrics and qualitative interview data. Participants 141 clinicians with data from select EHR use metrics in Cerner Lights On Network®. Interviews with 25 healthcare workers in various clinical and administrative roles. Approach We assessed changes in total EHR time, documentation time, and order time per patient post-transition. Interview transcripts (n = 90) were coded and analyzed for content specific to EHR usability. Key Results Total EHR time, documentation time, and order time all decreased precipitously within the first four months after go-live and demonstrated gradual improvements over 12 months. Interview participants expressed ongoing concerns with the EHR’s usability and functionality up to a year after go-live such as tasks taking longer than the old system and inefficiencies related to inadequate training and inherent features of the new system. These sentiments did not seem to reflect the observed improvements in EHR use metrics. Conclusions The integration of quantitative and qualitative data yielded a complex picture of EHR usability. Participants described persistent challenges with EHR usability 1 year after go-live contrasting with observed improvements in EHR use metrics. Combining findings across methods can provide a clearer, contextualized understanding of EHR adoption and use patterns during EHR transitions.

Rationale: Telemedicine consults, including video consults, telephone consults, electronic consults, and virtual conferences, may be particularly valuable in the management of chronic pulmonary diseases, but there is limited guidance on best practices for pulmonary telemedicine consults. Objectives: This scoping review aims to identify, characterize, and analyze gaps in the published literature on telemedicine consults health providers use to manage patients with chronic pulmonary diseases. Methods: We searched PubMed, Embase, Web of Science, and Cochrane Library from database origin through July 10, 2021. We included manuscripts describing applications of telemedicine consults for patients with chronic pulmonary diseases (asthma, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and interstitial lung disease). We restricted our review to full-length articles published in English about providerled (as opposed to nurse-led) telemedicine consults. Results: Our search yielded 3,118 unique articles; 27 articles met the inclusion criteria. All telemedicine consult modalities and chronic pulmonary conditions were well represented in the review except for pulmonary hypertension and interstitial lung disease, which were represented by one and no articles, respectively. Most articles described a small, single-center, observational study that focused on the acceptability, feasibility, use, and/or clinical effectiveness of the telemedicine consult. Few studies had objectively measured clinical outcomes or included a comparator group, and none compared telemedicine consult modalities against one another. Conclusions: Our scoping review identified limited literature describing pulmonary telemedicine consults and highlighted several gaps in the literature that warrant increased attention. Providers treating chronic pulmonary diseases are left with limited guidance on best practices for telemedicine consults.

BACKGROUND:The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation. OBJECTIVES:We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions. DESIGN:We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis. KEY RESULTS:Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services. CONCLUSIONS:Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

The need for person-centered care that promotes well-being and empowers patients is well-recognized. The Veterans Health Administration (VA), the largest U.S. healthcare system, is undergoing an enterprise-wide cultural transformation toward a Whole Health (WH) model of care that addresses this imperative. VA clinicians are asked to elicit what really matters to patients (Veterans) and help them set personal health goals, i.e., engage in WH personal health planning (WH-PHP). To inform ongoing implementation efforts, we sought to understand clinicians’ perspectives on WH-PHP for patients with chronic obstructive pulmonary disease (COPD), a widespread and debilitating condition. Between 10/2020-11/2021, we conducted 22 semi-structured interviews with clinicians in primary, pulmonary, mental health, and palliative care services at a large urban VA site. After coding transcripts for barriers and facilitators to implementing WH-PHP, we applied inductive thematic analysis to generate themes. Staff generally viewed WH-PHP as appropriate for patients with COPD, with nuances by service: Palliative and mental health clinicians questioned the “value added” of WH-PHP compared to their established practices. Their primary care counterparts worried about feasibility. Staff in pulmonary clinics had concerns about operationalizing WH-PHP in their work. These perspectives are nested in broader themes of interrelated individual and organizational factors we identified: (1) individual clinicians’ openness to practicing patient-centered, proactive care approaches, as influenced by prior education and professional socialization, (2) alignment of the service’s culture with the principles of patient-centered care and patient empowerment, and (3) availability of organizational support for implementing WH-PHP. The concept of WH-PHP was both attractive and ambiguous for clinicians. It is vital for patients with complex chronic conditions like COPD to be supported in pursuing personally meaningful health and wellbeing goals. For approaches like WH-PHP to become normalized, implementation efforts must account for the dynamic interplay of relevant individual and organizational factors.