VA EHR Implementation Training Limits Clinical Workflow Usability

The Department of Veterans Affairs’ (VA) Office of the Electronic Health Record Modernization’s (OEHRM) EHR implementation training has not adequately prepared end-users to leverage the health IT within their clinical workflows, according to an OIG review.

OIG’s review of EHR training practices at Mann-Grandstaff VA Medical Center in Spokane, Washington revealed that the VA’s OEHRM EHR training curriculum did not provide opportunities to test proficiency in navigating clinical scenarios.

Instead, training sessions focused on the steps required to complete specific tasks. Facility leaders even coined the term “button-ology” to describe applications training content, as the focus of the training was on which button to press to get a desired outcome.

A facility staff training coordinator told OIG, “It was just people sitting down and learning to use the buttons and not having any context for what they were doing.”

The OIG review found significant training gaps for clinical workflows that prevented facility staff from putting the EHR training into action.

Additionally, facility leaders and staff reported having insufficient time to cover complex training topics. Staff and facility leaders added that balancing EHR training with their clinical duties during COVID-19 was especially challenging.

An OIG survey administered two to three months after the go-live revealed that 62 percent of respondents disagreed or strongly disagreed with the statement, “Relevant patient information is readily available within new VA EHR.”

The survey also found that 53 percent of respondents are unable to share patient information with other clinicians within the new VA EHR without difficulty. What’s more, 65 percent of respondents said they are not able to navigate the different applications of the new EHR without difficulty, and 55 percent cannot easily document patient care in the EHR.

Just five percent of survey respondents reported being able to access, share, and document patient health data without difficulty while navigating the new EHR.

The VA OEHRM Director of Change Management acknowledged the following deficiencies in training: underestimating processes oriented around the legacy EHR, failing to address users’ expectations of how long it would take to feel comfortable with the new system, and not training end users in the context of their teams and day-to-day functioning.

Additionally, the OIG team found that while the VA OEHRM Executive Director asserted having a “strong baseline” of metrics to evaluate training, the VA OEHRM plan did not include an actionable way to evaluate training processes.

VA OEHRM did not follow the available plan, which the VA OEHRM Director of Change Management described as in its “infancy.” However, the VA OEHRM Executive Director asserted in congressional testimony of “constantly conducting surveys to see whether we are, in fact, evaluating the right things.”

Five months post go-live, the VA OEHRM Director of Change Management told the OIG “in terms of having an actual, well-thought-out designed plan at this point, no we don’t.”

As of March 2021, VA OEHRM’s Office of Change Management is working on creating a substantive plan to evaluate training within the next three to six months.

OIG also found that VA OEHRM withheld some training data requested by the agency and altered other data points.

“The integrity and thoroughness of information provided by VA is required by law and is critical to the OIG’s mission. The OIG has notified VA senior leaders of this issue and is further pursuing the matter,” John D. Daigh, Jr, MD, Assistant Inspector General for Healthcare Inspections, wrote.

Since OIG did not have complete information, it could not fully evaluate the end user training experience.

During the inspection, OIG identified signs of EHR burnout. Facility leaders and staff reported feeling exhausted and cited feelings of decreased morale following the EHR implementation.

“VA and VHA leaders face enormous challenges in this mammoth endeavor,” Daigh wrote. “Effective training is just one of them, but it affects many of the other issues. Moreover, without proper training, the quality of health care could suffer.”