JMIR FORMATIVE RESEARCH

Anderson et al

Original Paper

User Experiences of Transitioning From a Homegrown Electronic
Health Record to a Vendor-Based Product in the Department of
Veterans Affairs: Qualitative Findings From a Mixed Methods
Evaluation
Ekaterina Anderson1,2, MA, PhD; Megan Moldestad3, MS, CCC-SLP; Julian Brunner4, PhD; Sherry Ball5, PhD;
Christian Helfrich3,6, PhD; Jay Orlander7,8, MD, MPH; Seppo Rinne1,9, MD, PhD; George Sayre3,6, PsyD
1

Center for Health Optimization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States

2

Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts
Chan Medical School, Worcester, MA, United States
3

Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System,
Seattle, WA, United States
4

Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System,
North Hills, CA, United States
5

Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, United States

6

School of Public Health, University of Washington, Seattle, WA, United States

7

Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States

8

Veterans Affairs Boston Healthcare System, Boston, MA, United States

9

The Pulmonary Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States

Corresponding Author:
Ekaterina Anderson, MA, PhD
Center for Health Optimization and Implementation Research
Veterans Affairs Bedford Healthcare System
200 Springs Road
Bedford, MA, 01730
United States
Phone: 1 7816874936
Email: Ekaterina.Anderson@va.gov

Abstract
Background: The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States,
is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences ofthe first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research arelacking.
Objective: We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored
EHR to a vendor-based product.
Methods: As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the
EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after
going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments.
Results: Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition.
However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor’s understanding of VA’s
needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the newvendor-based EHR system and VA’s characteristic approach to care. As much as a year after going live, participants reiterated
these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the valueof continuing with the transition.
Conclusions: VA’s transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges,
both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e46901 | p. 1
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Anderson et al

EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers,
vendors, informaticists, and others involved in large-scale health information technology implementations.
(JMIR Form Res 2024;8:e46901) doi: 10.2196/46901
KEYWORDS
electronic health records; United States Department of Veterans Affairs; Veterans Affairs; organizational change; delivery ofhealth care; integrated; medical informatics

Introduction
Background
Driven by the Health Information Technology for Economic
and Clinical Health Act and other policies and incentives [1],in the past 15 to 20 years, health care organizations in the UnitedStates have almost universally replaced paper-based healthrecord systems with electronic health records (EHRs) [2,3].
Fueled by ever-increasing technological embeddedness in healthcare, transitions from one EHR to another have become morecommon [4]. These transitions are in part driven by the EHR
vendor market that is undergoing rapid consolidation [2,5], as
well as health systems’ own quest to improve the efficiency andquality of care delivered. Notwithstanding the wave of
paper-to-EHR implementations that gave rise to a rich body ofliterature [6-10], research on EHR-to-EHR transitions has so
far been limited [11,12], producing relatively few qualitative
case studies that explore leadership or employees’ experiences
and perspectives in depth [13,14]. This lack of literature limits
the ability of health care organizations to learn from theirpredecessors’ experiences when attempting similar large-scale
health information technology (HIT) implementations.
In 2020, the Department of Veterans Affairs (VA) began amultiyear “rolling wave” replacement of its homegrown EHRwith a vendor-based product. VA is the largest nationallyintegrated system in the United States, and a sweeping
undertaking like the current EHR transition is an inherent matterof public interest. The EHR modernization has alreadyaffected—and will continue to affect—the ability of VA toprovide high-quality, safe, and timely care to the veterans thatit serves [15]. The transition also has direct implications for the
morale and organizational commitment of VA’s considerable
workforce. Finally, the cost of the EHR modernization,
originally estimated at US $10 billion [16,17], is now projected
to reach US $50 billion over the next decades [18-20].
The VA has a long history of using information technology (IT)to meet the health care needs of veterans. VA’s computational
infrastructure [21] comprises the Veterans Health Information
Systems and Technology Architecture (VistA) and VistA’s
interface, the Computerized Patient Record System (CPRS).
VistA/CPRS have their origins in the late 1970s, when a groupof doctors and IT staff at VA began developing HIT solutions
independently of the national office [22]. This approach led toa highly decentralized system where each individual HIT
product was tailored to provider and staff workflows andpractices, including programs common in current commercial
EHRs but revolutionary at the time, such as scheduling tools,
mental-health assessments, and provider order entry systems[22,23].
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

In the 1990s, after decades of increasing complexity within thesystem, VA underwent sweeping systemic change to improve
care quality, service, and overall operations, including upgrading
the HIT infrastructure to ensure connectivity across theenterprise [23,24]. As part of this extensive series of reforms,
VA moved to implement VistA/CPRS as a national-level,
integrated EHR, replacing site-level EHR systems that had beendeveloped by local informaticists in close collaboration withclinicians and administration. VistA/CPRS has demonstrated
high rates of user satisfaction [25] and, as a publicly available
system, has been adopted by over 30 health care systems
worldwide [26].
In early 2017, then VA secretary David Shulkin announced that
VistA did not have the infrastructure, security, or interoperability
required for its continued use [27]. Shulkin and other top-level
VA officials advocated for a single electronic medical recordthat would follow servicemembers from active to retired service,
enabled by an EHR system shared by the Department of Defense(DoD) and Veterans Health Administration (VHA). In June of2017, Shulkin announced his decision to move forward withadopting what was described as a next-generation EHR system[28]. The Veterans’ Electronic Health Record Modernization
Oversight Act (2017) directed VA to provide Congress with
documentation of the effort’s progress and costs. In May of
2018, then acting VA secretary Robert Wilkie announced that
the VA had signed a US $10 billion contract with Cerner
Corporation and that VA would transition to the Cerner EHR(referred to under its current name of “Oracle Cerner” in therest of the paper). In June of 2018, the VA established the Officeof Electronic Health Record Modernization, an office whose
focus was to ensure a successful transition from VA’s legacy
EHR to Oracle Cerner. The DoD began Oracle Cerner
deployment earlier that same year.
The decision to switch from the VA’s homegrown, legacy
system to a commercial EHR sparked conflicting views within
the VHA as well as in political circles. Proponents argued themove would bring the federal health care system up to date withother health care systems, reduce costs, and support
interoperability with the DoD records, thus providing
servicemembers with a seamless health care experience when
they transitioned to VHA care [29,30]. Opponents criticized theno-bid contract awarded to Oracle Cerner [30], citing CPRS’s
ongoing positive ratings by physicians as being more usefulthan commercial systems, more provider and staff friendly, andcustomized for VHA use [25,31]. Despite these reservations,
the VA proceeded with the transition.

JMIR Form Res 2024 | vol. 8 | e46901 | p. 2
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Anderson et al

Objective

Recruitment and Data Collection

In this paper, we report on the perspectives of employees at thefirst VA site to undergo the EHR transition—Mann-Grandstaff
VA Medical Center (MGVAMC) in Spokane, Washington. We
focus, specifically, on employees’ diverse and shifting
perspectives regarding the rationale for and value oftransitioning from a homegrown EHR that was custom-built
for VA and highly tailored to its organizational culture andprocesses to a vendor-based product. The inaugural site’s
experiences, widely reported on in the press [32-35], may havealready set the tone for how VA’s EHR transition is perceived
by VA’s frontline employees, leaders, and the public—becoming
a benchmark for subsequent sites to compare themselves against.
We believe that it is important to add nuance to this discourse
by reporting on the first-hand employee perspectives that werecollected using rigorous methods during the course of thetransition. By presenting a case study from one of the largest
and most influential health systems in the United States, weseek to contribute to the growing literature on the dynamics,
challenges, and impact of EHR-to-EHR transitions.

We used a snowball sampling approach to recruit participants.
Several months before “go-live” (the date on which all staff
would begin using the new system for patient care), principal
investigators (GS and SR) held multiple stakeholder engagement
meetings with local leaders to identify groups of individuals
who routinely work together across clinical services that may
be willing to participate. During subsequent interview rounds,
participants were asked to identify additional individuals forour team to approach.

Methods
Research Design
Since 2020, our team of VA researchers and clinicians withinterdisciplinary expertise in implementation science, quality
improvement, informatics, and organizational change has been
conducting a concurrent mixed methods, multisite, formativeevaluation to understand VA clinician and staff experienceswith the EHR transition [36-38]. Our methods and findings aredescribed in line with the COREQ (Consolidated Criteria for
Reporting Qualitative Research) [39], with additional
information provided in Multimedia Appendix 1.

Setting
For this manuscript, we report on the qualitative data obtained
between September 2020 and November 2021 at MGVAMC
as the first VA site to undergo the EHR transition, with thego-live on October 24, 2020. With 1354 full-time employees,
MGVAMC and its associated community-based outpatient
clinics provide primary and secondary care to approximately
35,000 veterans in the Spokane area of Washington. The main
campus includes a 36-bed acute care hospital and a 34-bed
community living center (a VA term for a facility that provides
subacute rehabilitation and long-term care, including hospicecare at some VA Medical Centers. Additional outpatient careis available at associated sites (2 multispecialty, 2 rural, and 1
mobile clinic) [40].

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Semistructured interviews were used to explore end user EHR
transition experiences. The interview guide (Multimedia
Appendix 2) was iteratively developed to include open-ended,
nonleading questions to capture rich data on domains of interest,
including EHR usability, EHR training and support, impressionsof the VA’s decision to switch to Oracle Cerner, employee
burnout, and well-being. The interview guide was pilot-tested
with staff members at a different site that was initially supposed
to go live, but the decision was reversed. We interviewed
participants at multiple points in time: before go-live (September2020), during go-live (October 2020), 2 months after go-live(December 2020), and 10+ months after go-live. Interviews
conducted during go-live (“check-ins”) were kept brief(approximately 15 min) and focused to minimize the burden on
participants. The remaining were approximately 60 minutes inlength. Interviews were conducted by team members in bothprincipal investigator and staff roles over the phone or Microsoft
Teams (Microsoft Corporation), due to the public healthemergency restrictions related to the COVID-19 pandemic at
the time. The interviews were recorded and transcribed verbatim.
Interview guides were modified iteratively for clarity and to
expand the focus of exploration, reflecting emergent data.
Whenever possible, participants were paired with the sameinterviewer across data collection points to increase comfort,
consistency, and trust. All interviewers were trained inqualitative research and semistructured interviewing. Following
each interview, interviewers completed notes summarizing theinterview content and capturing initial reflections. These notes
were subsequently referred to during team discussions to inform
analysis.
In total, we completed 122 interviews with 26 individuals,
including providers, nurses, and other clinical staff (eg, medical
support assistants), as well as a smaller number of clinicaladministrators and leaders across multiple departments anddisciplines at MGVAMC (Table 1).

JMIR Form Res 2024 | vol. 8 | e46901 | p. 3
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Anderson et al

Table 1. Participants and data collection (interviews: n=122; total participants: n=26a).
Stakeholder engagement
meetings (n=11), n (%)

Prego interviews before Check-ins
go-live (n=21), n (%)(n=47), n (%)

Interviews after golive (n=23), n (%)

Interviews 1 year after
go-live (n=20), n (%)

Total, n(%)

11 (100)

11 (52)22 (47)14 (61)13 (65)71 (58)Nursesc

0 (0)6 (29)

12 (25)4 (17)

5 (25)

27 (22)

Staffd0 (0)4 (19)

13 (28)5 (22)

2 (10)

24 (19)

Leadership andbprovidersa

Only the total sample size provided as a more specific breakdown of how many individuals within each participant category were interviewed at eachstage may endanger participant anonymity given the site’s small employee body.
bPhysicians, clinical pharmacists, and psychologists.

c

Registered nurses and licensed practical nurses.

dMedical assistants, phlebotomists, counselors, audiologists, and physical therapists.

Data Analysis
We initially used deductive and inductive content analysis [41],followed by reflexive thematic analysis [42,43] to generate amore in-depth understanding of the data. The full team first
generated a list of a priori categories reflecting the project’s
aims (eg, impressions of the VA’s decision to switch to Cerner,
EHR support, EHR training, software functionality, and impact
on veterans). A subset of 8 team members conducted line-by-line
coding using a qualitative data analysis software program(version 9, ATLAS.ti; ATLAS.ti Scientific Software
Development GmbH). New codes and code groups were added
throughout the coding process to reflect emergent concepts that
did not fit the existing schema. Analytic memos reflected coders’impressions of patterns and contrasts in the data. The coding
team met weekly to troubleshoot issues with the coding processlogistics and discuss emerging analytical insights.
During these meetings, we identified topics warranting in-depth
exploration, which included participant reflections on how wellthe VA’s homegrown EHR versus the commercial one fit theirpractice and VA’s needs as an organization. At that point, thefirst author conducted an iterative review of relevant code
categories and codes, as well as reread individual interviews tobetter understand the context in which the Oracle Cerner versus
VistA/CPRS contrast was invoked and identify the range ofexperiences. After the preliminary themes were generated andoutlined by the first author, the themes were then iteratively
refined with input from the full team of coauthors. In line withan inductive, critical, constructivist approach to reflexive
thematic analysis as defined by Braun and Clarke [44,45], weavoided imposing a theory on our themes and closely attended
to the discursive and rhetorical means through which participants
constructed meaning around their experiences. We reachedinductive thematic saturation [46] in the sense that no new codes
or themes emerged during the final analytic stage.

Ethical Considerations
The VA Bedford Healthcare System Institutional Review Board
designated this evaluation as nonresearch quality improvement,that is, not subject to the institutional review board oversight.
During recruitment, potential participants received information
about the evaluation’s objective and methods, their right not toparticipate without any repercussions, as well as their rights as
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

participants, including the right to withdraw at any point. Before
the initial interview, participants provided verbal consent, which
was audio recorded. Participants were asked to confirm their
willingness to participate and reminded about the option towithdraw at each subsequent interview. In accordance with VA
policy on privacy and data security, interview recordings,
transcripts, and notes are kept behind a firewall on a secure VA
server and only accessible to the project team to protect theparticipants’ privacy and confidentiality; all files were assigned
code names that could not be traced to individual participants.
Participants were not compensated for their participation in thisevaluation, as VA rules prohibit VA employees from receiving
compensation for participating in VA research or quality
improvement while on duty.

Results
Overview
Here, we present 4 themes that capture end users’ experiences
across time: cautious optimism about the new commercial EHR,
tempered by apprehension; disappointment with the vendor’s
limited understanding of the VA; the tenuous fit between the
new EHR and VA’s needs; and desire to change course. Themes
are supported with illustrative quotes. For each quote, we
provide a 3-part ID consisting of the nonidentifiable participant
number, their general role (provider or leader, nurse, or staff),
and the timing of the interview (with “pre” referring tointerviews before go-live, “during” for briefer check-ins
conducted during the go-live, “post” for interviews done 1-3
months after the go-live, and “10 m” for interviews done 10-12
months after the go-live).

Cautious Optimism About the New Commercial EHR,
Tempered by Apprehension
Before go-live, participants rarely invoked the homegrownversus vendor-based EHR dichotomy; instead, they primarily
contrasted the new and the old EHRs as outdated versus modern.
Specifically, some participants expressed a sense of cautious
optimism about the upcoming transition to the new EHR, citing
both what they perceived as outdated features of the
VistA/CPRS system and the attractive characteristics of its more
modern replacement:

JMIR Form Res 2024 | vol. 8 | e46901 | p. 4
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
We [VA] had the first electronic health record, which
was great. But now it’s the oldest electronic healthrecord, and it hasn’t been updated, and it’s clunky.
[P18_Provider_Pre]
There’s lots of layers to do one task [in CPRS]. And
then do not even get [me] started on the current
scheduling system, the current scheduling system ishorrible. Horrible. ... I’m not sure if everybody’spleased that it’s going to be Cerner, but I feel likeeverybody is pleased that it’s going to be switched.
[P17_Provider_Pre]
I’m glad that we’re finally going to something that’smore modern and user friendly. [P23_Nurse_Pre]
For a few of the participants who were positive about thetransition, the outdated versus modern dichotomy even offereda language for setting themselves apart from colleagues whothey perceived to be less forward-looking and more resistant tochange:The VA, in my humble opinion, has a bunch ofdinosaurs. ... The 15 year plus employees...like what
they were doing, they’re comfortable with what they
were doing, change is bad. ...And then there’s thenewer employees that are like, ‘come on, man, let me
help get this taken care of. [P18_Provider_Pre]
I wish more people were a little bit more openminded,
you know, with, ‘hey, we’re doing it, let’s see how it
goes.’Rather than a ‘bah humbug’type of an attitude.
That would be helpful. But nobody could control that
but each individual. ... But I’m excited.
[P15_Staff_Pre]
However, even these early accounts contained someapprehension about the change to a new EHR system. Some
expressed doubts about the quality of the new EHR itself. For
example, one participant endorsed the need for modernization
yet took issue with the very assumption that Oracle Cerner
would constitute a more “modern” alternative to CPRS:
I think the decision to modernize is good. ... So, I thinkthat was a good decision and a long time coming.
Personally, Cerner, especially now that I’ve actuallyseen it...I would say to me it looks very outdated aswell. ... To me, I’m not really impressed with it so far.
... But I’m sure, obviously, there’s so much that went
into that. So, so far not overly impressed with Cernerspecifically, but we’ll see. [P5_Provider_Pre]
In contrast to this general criticism, other participants raised
their concerns about the ability of the new EHR to support VA’s
established roles and practices:
I know [Cerner’s] a great accounting system, and allof the coding stuff, but how do I do what I need to
do? I don’t really care about how somebody else gets
through Cerner... [P21_Provider_Pre][In CPRS], we probably have a couple dozen
templates that make documentation a little easier....
I do feel like that’s going to be a bit of a switch when
we go to Cerner, because it sounds like they really

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al
don’t have any templates, or very minimal templates.
[P17_Provider_Pre]
In sum, while before going live, some participants saw the new
EHR as a more modern alternative to the older EHR and apotentially good option for VA, the concern about the new
product’s ability to meet VA’s particular needs was noticeable
even at this early stage.

Disappointment With the Vendor’s Limited
Understanding of the VA
As go-live drew near and then came and went, participants
voiced concerns that the vendor was insufficiently
knowledgeable about and attentive to VA’s manner of providing
care, as in the following example before go-live:
I really don’t know how much information (Cerner)
had about what different services did, and it felt tome in the initial stage like...they were just giving us
their stuff with no sense that VA care is very different
than care in the community or private care. But I
think it’s better now. [P14_Provider_Pre]
Following go-live, this concern about the vendor was expressedmuch more forcefully by a few participants. In the example
here, the participant—perhaps anticipating the “some people
don’t like change” critique—implied that the vendor not doing
its due diligence to learn about VA contributed to difficulties
that went beyond the regular level of “hardship” that is to be“expected” during EHR transitions:...there’s hardship that should be expected with anytransition. I just...question the understanding of thecomplexity of the VA system prior to launch.
[P13_Provider_Post]
The sense of disappointment with the vendor’s understandingof VA often came up in the context of training. Many
participants felt that the training in the new EHR was poorly or
not at all tailored to VA’s needs. One specific complaint,
expressed by several participants, was that Oracle Cerner trainers
were unaware of the nuances of various roles in the VA:
Having someone that can really train you in
accordance to your specifications of your job would
be better. ... Because the Cerner trainers said, ‘I don’tknow what you do. This is what I know about thesystem. [P24_Provider_Pre]
While the insufficient number of vendor training staff with aclinical background was invoked by some participants as theroot of the training problems, even having a trainer with aclinical background was not necessarily a panacea if they were
not familiar with VA’s context:
They should have had providers training providers,nurses training nurses, etc. Instead, they had people
with really no medical background that were justcomputer people, that did not have a good sense of
day-to-day clinic flow and things like that, and reallywere not able to answer any of the questions I had.
... But I know even [Cerner’s trainer with a physician
background] was pretty frustrated, because he was

JMIR Form Res 2024 | vol. 8 | e46901 | p. 5
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
just like, ‘I’ve never seen it like this before, why is
the VA system so weird... [P5_Leader_Post]
Some participants also conjectured that trainers had a poor grasp
of VA’s workflows and were thus unable to draw
CPRS-to-Oracle Cerner parallels or analogies that VA
employees would likely have found useful while learning to
use the new system:...a lot of the issue was the people that built Cernerfor our VA System had never even opened CPRS. So,
there’s a lot of things where we’ll say, ‘how would
you do this in CPRS’? And they don’t know what
we’re talking about, because they don’t know what
CPRS looks like. So, I feel like if there had been
input... how Cerner can be modified to what we needfor our workflow, that would’ve been helpful along
the way. [P8_Nurse_Pre]
For a few participants, the lack of attunement was also seen in
the language gap between the vendor and the VA. Participants
described divergences between how the same or similar
operations or functions are named in CPRS versus Oracle
Cerner—for example, “consult” (CPRS) versus “referral”(Oracle Cerner)—pointing out that the similarities between the
2 were poorly clarified:...nobody gave us a language. We didn’t learn how
to speak Cerner, and that’s what should’ve come first.
[P6_Provider_During]
Reflecting on the trajectory of the EHR transition almost a year
following the go-live, one participant highlighted both thequality of training and the lack of understanding of VA’s
approach to care embodied in the EHR itself as 2 main
challenges—a sentiment that aptly provides a bridge to the next
theme:[What made things difficult is] the fact that Cerner
didn’t seem to take the time to really understand thework we do, and then be able to wed their product toour work. And then having training that wascompletely abysmal. These were all things that madeit a disastrous implementation in my opinion.
[P1_Leader_10M]

The Tenuous Fit Between the New EHR and VA’s
Needs
Overview
In addition to taking issue with the vendor’s degree of familiarity
with VA’s context, many participants also questioned the fit
between the functionality of the Oracle Cerner EHR and VA’s
needs. Some of these statements were general in nature. For
example, several participants complained that Oracle Cerner
was poorly suited to helping them complete their daily
workflow, as in the following example from the participant who
characterized the new EHR as unintuitive:
I am still struggling with this program. ... There’s a
lot of things that I still don’t know how to do that arebasic functions of my job that aren’t built yet and notworking well...I’m seeing...about 5 patients a day, I
work 10-hour days. And it’s not easy, and I am putting
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al
in extra time to try to get everything done, but it’shappening. Do I like it? No. I think this program...isvery not intuitive. It doesn’t make any pathway
sensible to me or easy, I have to follow a list of steps
still for the things that I’m not doing five times a day.
And, I’m really surprised VA bought this thing, buthere we are. ... If they’re expecting it to save moneyor make things easier, I think they got sold a pig in ap o ke, t h a t ’s k i n d o f m y 2 c e n t s .
[P14_Provider_During]
Another participant made a similar claim, pointing to theparadox of the “older” EHR (CPRS/VistA) being both simpler
and more efficient than the more “modern” Oracle Cerner:...they should’ve sat with people that were reallyexperienced and seen exactly what they do every
day...And how simplified [CPRS is] compared to thisthing that they built...if they sat with...an experienced
end user for a week, I think their eyes would’ve been
open as to the amount of work that is done bysomeone in my position. Or even a provider. And each
person, just to see exactly what is done and how
efficient they are with that old program, and how
streamlined, believe it or not it was, even though it
was old, compared to this one. Because we’ll tell you,get ready for a lot of clicks. [P10_Staff_Post]
Notably, however, we recorded numerous versions of the ideathat Oracle Cerner may be a poor fit for VA as an integrated
delivery system with robust interdisciplinary coordination andthe ability to provide wrap-around services for a clinically andsocially complex patient population. A few interviewees
explicitly juxtaposed VA and those health systems where billingis more central to workflows, arguing that Oracle Cerner is abetter fit for the latter:...I don’t think that it was looked at strongly enough,whether it would be compatible with the VA or not.
It’s a system that...works well in...money-making
systems, where you need to link everything to anencounter for compensation purposes, and VA doesn’t
work like that. [P5_Leader_10M]
So, Cerner is an off-the-shelf [EHR]. The VA is not[a] ... for-profit doctor’s office or hospital system.
It’s its own Garanimal. And it is not malleable. It is
not massageable. ... the VA makes us have to do thingsa certain way, accomplish certain goals, and reallywork at lickety split speed with precision.
[P6_Provider_10M]
Several specific concerns about the fit between the new EHR
functionality and VA’s needs were also discussed, as outlinedin the following paragraphs.

Documenting the Work of Care
Many participants expressed concern about additional discrete
steps for documenting care, that is, tasks done during andbetween formal appointments. This concern was raised primarily
in the context of the requirement—absent in VistA/CPRS yet
present in Cerner—to document “between-visit encounters”(eg, any interactions related to veteran care happening outside
JMIR Form Res 2024 | vol. 8 | e46901 | p. 6
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
of appointments, such as phone calls or secure messages) as“encounters,” as opposed to simply adding notes to the veteranfile. Multiple frontline staff participants complained about therequirement to create between-visit encounters as confusing
and cumbersome. Interestingly, opinions as to why the
between-visit encounter functionality created so manydifficulties diverged. One participant took issue with the very
idea of capturing the work done between veteran appointments
as “encounters,” portraying it as a time-consuming requirementthat was better suited to private health systems:
So, what the ‘between visit encounter’is...in the worldof generating income for the private practice...theywant to account for every minute of every day what
you’re doing ... We now have to do all of this work...toshow what we’re doing with our time.
[P6_Provider_During]
A different participant with a leadership role opined that the
between-visit encounter functionality was not problematic perse, as it provided a manner for more accurately capturing andproviding credit for employees’ workload, yet acknowledgedthat how that functionality was set up was deeply flawed—slow
and poorly automated:
The goal is good, they’re trying to capture the work
people do between visits, because there’s a ton ofwork done for patients between visits. But the process
just is not good. It needs to be a smart system thatknows who you are, because the system knows who
you are, and it...should be able to generate a pop-up
that tells you that you need to generate a new
encounter, and then just say, click here, and click,and then you have a new encounter. But right now
it’s just this dumb system that isn’t smart, it doesn’t
help you at all. [P2_Leader_Post]
Finally, another participant, also with a leadership role, echoed
the idea that the Cerner between-visit encounter functionality
was set up in an inefficient manner. This participant provided
further insight by arguing VA care involves a particularly large
amount of workload done between formal appointments andthat this fact was poorly understood by the vendor. The
participant described their successful efforts in advocating for
greater clarity around the new workflow while acknowledging
that it still left much to be desired:...for some reason, Cerner was not able to truly
determine how we do our work and be able to createan [EHR] that allows us to do that work smoothly...
I’m sure commercial clients are very different, [but]the VA has a very specific way of doing
things...because of the way we do things in PACT
(patient-aligned care teams), we might not see thepatient for a year, and then there’s a ton of stuff that
goes on within that year, but it’s not in the form of avisit. So they’re like, ‘ok, so we have to create thisbetween visit type of encounter so that we can capturethat work...’ ... So we got this very confusing kind of
workflow about how you create this between visit
encounter...I really pushed on hard to get them tofigure out, what are we supposed to do here...athttps://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al
first...it was not even clear to the various change
management and solution experts in Cerner, which
is a little disappointing. So, we finally got to the point
now where we kind of get when and how to do it, but
it’s still terrible. [P1_Leader_Post]
The difficulties of documenting care were mentioned in othercontexts as well. For example, one participant explained thatveteran appointments in the VA often have multiple components,
combining visits with different professionals—to accommodate
veterans who may want to have multiple problems addressedon the same occasion after traveling long distances. Thisparticipant indicated that Cerner makes multicomponent
appointments more cumbersome by requiring different providers
to “check in” and “check out” the Veteran for each new elementof their outpatient visit. Interestingly, the participant attributed
this phenomenon to Cerner being supposedly built for“inpatient” settings—another example of our participants
offering their opinions about reasons for the strained fit between
the new EHR and VA:
The reason it’s a problem is because Cerner was built
as an inpatient product. They are an inpatient facility
product. Outpatient operates differently, especiallywithin the VA, right? ... Here, they come in and theydrove 3 hours, so they’re going to get their eyes
tested, they’re going to get their ears tested, and theywant to see their PT and maybe the Mental Health.
‘Oh, and by the way, I may as well get my shots
because I drove 3 hours to get here.’ ... That’s
problematic, because... now we have to watch it, sothey have to make sure that they check him out. Checkhim in for the first appointment, then check him out,
then check him in for the second appointment, andcheck him out. And then check him in for the third
appointment if he has a third one. It’s hairy.
[P18_Provider_During]

Communication and Coordination
Another area where the new EHR was perceived as inadequate
for VA was in facilitating interprofessional communication andcoordination within and across teams. VA facilities typicallyoffer a substantially broader array of specialized mental healthand social support services than other health systems, withextensive programs for posttraumatic stress disorder and otherconditions with high prevalence among veterans [47,48]. The
provision of such programs is facilitated by closeinterdisciplinary communication and coordination within andacross facilities, as well as between the VA and community careproviders. One participant suggested that VA’s homegrown
EHR enabled robust and continuous multidisciplinary
cooperation to a much greater extent than Cerner’s EHR did:
I do not think Cerner is right for the VA...with the VA,[veterans] have, like, their annual, and in between
we have such great ancillary services. ... So sometimes
even these very medically complicated patients may
only need to see their Primary Care Provider onceor twice a year because they have all of these great
ancillary
services.
And...there’s
constant
communication back and forth between those services.
JMIR Form Res 2024 | vol. 8 | e46901 | p. 7
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH... And in CPRS, that’s a lot of back and forth on one
chain. ... In Cerner, those create new between visit
encounters every time. It adds another document, it’s
just kind of jumbled in there. ... So, our way ofcommunicating, the way we do it, doesn’t work ...
[Cerner’s] more [of a] production-based system.
And...that’s just not how the VA works.
[P5_Leader_10M]
Another aspect of Cerner seen by some as inadequate incomparison with CPRS/VistA was the limitations it sets on
interprofessional collaboration within teams—a prominent
feature of VA’s approach to care—due to the notable interface
differences for users with different roles:
Everybody is somewhat annoyed by that because we
all do not have the same pages that we are looking
at. ... And it does not allow us to be able tocollaborate and help one another in the way that weused to. Because it’s all specific to service lines.
That’s a little frustrating. ... we’re collaborating
less...we’re talking about clients—veterans—lessholistically and working together as a team [less]because of the way this chart is set up.
[P9_Provider_10M]

Chronic Care and Population Health
Finally, we found references to Oracle Cerner having inadequate
functionalities to support providing care to VA’s patient
population, which was perceived to have a large proportion ofindividuals with multiple complex chronic conditions. For
example, one participant felt that VA’s version of Oracle Cernerexposed this medically vulnerable population to potential harmor delayed care:[There are] orders that went where they shouldn’t
have gone or orders that didn’t go where theyshould’ve gone. ...We think that it’s essential forpatient safety that if you got an order that went
somewhere it shouldn’t, or didn’t go somewhere it
should’ve, that it actually gets found and getscorrected or acted on. We have patients who are a
lot more vulnerable (than DoD patients). They’reolder, [have] multisystem failure, and not everybody
is older with multisystem failure, but we certainly
have a much larger portion of that than the DoD does.
[P25_Leader_10M]
On a related topic, one participant expressed concern with thepoor functioning of registries to keep track of veterans withchronic health issues—a historically important feature of VA’s
approach to population health that enables VA employees toreview various indexes of health in their patient population to
identify and proactively contact veterans with specific healthcare needs who may need care but may not otherwise seek it:
I know the nurses are struggling with the registries
right now, trying to catch back up with those, andhow it’s laid out. ... they’re having a hard time
catching back up...that was something I know we werealways really on top of, I know my team was. We
always were really on top of patients that had chronic
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al
health conditions like diabetes, like hypertension, of
keeping track of those. So that’s been a frustrationfrom the nursing side of trying to play catch up withthat and trying to get the correct information withthat. [P16_Staff_10M]

Desire to Change Course
In the interviews done after go-live—and especially 10 to 12
months later—participants continued to share reflections on theperceived inadequacy between the new EHR and VA’s needs.
In addition, participants started to raise concerns about the future
course of the EHR transition and reflect on the lessons learned
from their experience as the first site.
Several participants invoked and dismissed the idea that
continued difficulties experienced at their site may be due topoor training of staff members. Instead, they asserted that the
EHR itself was flawed due to its insufficient tailoring to VA’s
context. One participant noted feeling especially affronted giventhat Cerner had asked for input early on, only to seemingly
ignore it in the actual build:
I personally do not feel as though we need any
additional training. We have been trained on how toutilize this system. The system is just crappy. That’s
the bottom line. ... The biggest, to me, kind of slap in
the face is knowing that we had Cerner techs comeand sit side by side with people for several months as
we discussed, ‘hey, this is what the current CPRS
charting system does, and this is what we don’t like,and this is what we would like for it to do.’ And, I
mean, it’s just like, did they use any of that
information when they created this charting system?
I mean it’s really just ridiculous. [P9_Provider_10M]
A few individuals went so far as to suggest that the decision to
adopt Cerner was a mistake and that VA needs to go back to
CPRS/VistA:
They need to take it back, and this is the reason why.
Cerner is not a system that can be molded to the VA.
And the VA is not a system that could be molded to
Cerner. [P6_Provider_10M]... if I really could tell you what I really wish, I wish
that the American people and Congress would say,this was unfortunate that we dumped this much money
into this program, but I think they need to scrap it. I
actually think that this program is not the rightprogram. I don’t think it’s good for our Veterans, andI don’t think it’s good for our workers. ... CPRS was
100 times better than this. That’s what’s sad.
[P17_Provider_10M]
For others, however, the solution was less radical and involved
strengthening VA staff’s ability to make necessary changes tothe EHR system. One participant, who had a relatively positive
view of the new EHR and the EHR transition, pointed out that,while most of what they perceived to be major problems with
the new system had been resolved, staff lost communication
channels for addressing any new issues they might encounterin the process of becoming more proficient in the new EHR:

JMIR Form Res 2024 | vol. 8 | e46901 | p. 8
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
The main issue that we are having now is the big
problems that we had initially were all addressed andfixed, or they are in the process of being fixed, but
now that all the urgent work stoppage type of issues
have been resolved, all of our other issues, there’s
no one to contact about them. Or we are not getting
any kind of follow up when we do send in tickets. ...
So I don’t really know what the solution is for that.
... Because as we get more familiar with the system,
we’re going to have more issues that we didn’t know
existed before, or things that we would likecustomized, but we just don’t know where to go withall of that information. [P8_Nurse_Post]
Another participant explicitly framed going back to thehomegrown system as impossible and undesirable yet argued
that the vendor should be responsible for improving its product,with substantive input from frontline employees in thedecision-making:I think to have invested so much already financially,
mentally, physically, emotionally...that there’s nogoing back...we still need to be involved in advanced
electronic health records. But it’s kind of like, until
they get this stuff taken care of. ... It’s just continuing
to add to workload, frustration, people leaving. ...
Get it done right, not [at] the expense of thegovernment. At the expense of the company. ... Anda lesson learned, but at the highest echelon where
this was determined, that’s where you need thatcommittee of individual actual worker bees to be
involved in the decision-making. Or at least listened
to and a part of the decision-making.
[P19_Nurse_10M]
Another participant echoed the need for greater accountabilityof the vendor to the VA, yet also attributed some of the
difficulties with implementing the necessary changes to thelaborious, multistakeholder decision-making process:I feel like it’s basically been...VA people trying tocome up with solutions. And there may or may not be
Cerner people on calls when we’re talking about
issues. Sometimes it seems like we just come up withthese workarounds, and no one is holding Cerner to
fix the problems. And some of that may be justbecause of the structure that VA created with this,where we have these national councils and then allof these agreements where it has to match between
DoD and VA. So it just becomes this hugebureaucratic black hole. So, if we identify that there’s
an issue, everybody has to agree that it’s an issue andthat we need to find a solution, and then we have toagree on the solution. [P3_Leader_10M]
Interestingly, not all participants supported the view that the
new EHR can or should be perfectly tailored to VA’s needs.
For example, one participant argued that the vendor needs tohave better awareness of how the homegrown system works to
be able to warn VA’s superusers about concrete workflow
differences that might create challenges for the frontline staff:

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al...I never said [to Cerner], ‘you need to understandwhat we do so you can build your [EHR] to suit it.’
It was more like, we need to see what the [EHR] is
so we can understand how we have to change ourworkflows. But that should’ve been done in advanceso that at go live you have people, super-users, youknow, supervisors, people like that, who actually cansay, look, this is how we used to do it in CPRS, thisis how we have to do it now. And that goes way
beyond ‘here’s how you order something’and ‘here’s
how you write a note.’ These are like, you know,
higher level workflows that they had no idea
about...but someone has to know...so we could teachpeople how to do it, and how we’re going to get things
done at go live. Not figure it out at go live.
[P1_Leader_Post]

Discussion
Principal Findings
Our findings tell a story of end users’ initial cautiously
optimistic attitude toward transitioning to a new EHR, giving
way to a concern that the vendor did not understand VA’s needs,
values, and routines and a perception that the new EHR did not
fit the VA’s approach to care, consistent with the results of ageneral survey of Mann-Grand staff end users [37]. Moreover,a year after go-live, participants reiterated these concerns andexpressed a strong desire for substantive changes to the courseof the EHR transition, although they differed in their preference
for the nature of these changes. In addition to reporting on a
momentous development within the largest integrated healthsystem in the United States that is important in its own right,
our work also contains important implications for health-system
leadership, EHR vendors, researchers, and other groups withan interest in understanding and optimizing EHR transitions,as well as large-scale HIT implementations more broadly.
Previous studies about transitions from legacy (generally
homegrown) to newer (generally commercial or vendor-based)
EHRs [13,14,49,50] note that users frequently express apreference for the original EHR. In a few cases, authors briefly
posit that this may be due to users’ loyalty to the older systemor a perception that an EHR that has been in use for a long time
is more likely than a newer product to reflect the health system’s
workflows and practices [13,49]. However, none of the previous
nonqualitative studies of EHR transitions assessed this issue,
and the existing qualitative studies did not explore it in depth.
Our study supports these previous authors’ conclusions and,furthermore, describes why employees may perceive a misfit
between the new EHR and the health system’s needs, even ayear following the new system’s implementation.
While acknowledging that a new EHR does not need to be
perfectly tailored, the frontline employees we followed in ourevaluation experienced the new EHR as a poorly tailored toolthat made their work in VA cumbersome, inefficient, or
downright impossible, when compared with the homegrownsystem. VistA /CPRS has been in continuous use in VA for
almost 30 years, undergoing numerous changes to tailor it to
VA’s specific needs at the organization and local site level.
JMIR Form Res 2024 | vol. 8 | e46901 | p. 9
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
These needs reflect VA’s unique characteristics: complex andheterogeneous work involved in caring for individual veterans,
caring for a population with generally more complex medical
and behavioral needs than the nonveteran population [51,52],
robust interprofessional communication and coordination, and,last but not the least, mission-driven emphasis on bothpatient-centered care and population health management[47,53,54]. For end users, transitioning to a vendor-based system
has thrown into sharp relief both the benefits of a highly tailoredlegacy system and the challenges of transitioning to acommercial-based EHR. Focusing broadly on the challengesof replacing legacy software with commercial products in the
public sector, a group of United Kingdom–based researchers
argued that such transitions are exceptionally difficult because
government agencies are risk-averse, burdened by bureaucratic
structures, and excessively eager to hold on to their establishedwork models [55]. This framing, however, implicitly assumes
the older approach, congruent with the legacy software, to beinadequate and the newer manner of working, embodied incommercial technology, as preferable. The VA experiencehighlights a different possibility: What if, instead of introducing
business-driven innovation, a commercial product disrupts thevery elements of the organizational culture that are valuable
and worth maintaining?
As we write, the future of VA’s EHR transition is surroundedby uncertainty. In October 2022, in the wake of critical reportsby the VA’s Office of Inspector General about the effects of
MGVAMC’s EHR transition on patient care issued in thepreceding months [56-58], VA announced an extended pause
in the EHR transition. Summer 2023 was suggested as theprovisional date when the transition might resume, assumingthat issues with the system’s functionality and safety are
addressed [59]. In January 2023, a bill (HR608), “To Terminate
the Electronic Health Record Modernization Program of the
Department of Veterans Affairs,” was introduced in Congress.
The following month, VA pushed back the EHR transition dateat the next planned VA site, Saginaw Healthcare System inMichigan, to late 2023 or early 2024 [60]. On its end, Oracle
Cerner indicated that it was looking to improve the training at
future sites by signing a contract with Accenture & company
that had been working with the DoD on its EHR transition [61].
However, in April 2023, as the previously stated deadline forresuming the EHR transition drew closer, VA issued a statementthat no subsequent VA sites will go live with Oracle Cerner
until safe use of the EHR system can be ascertained inmeasurable manners, with no specific dates provided [62]. One
exception to that decision was the James A Lovell Federal
Health Care Center in North Chicago, Illinois, which is an
integrated VA and DoD health care system. Lovell Federal
Health Care Center went live in March 2024.
If the EHR transition is resumed on a broader scale, it may beworked out in several distinct manners. First, it is possible that
the VA and vendor will succeed in finding solutions formodifying the new EHR to better fit the VA’s practices andculture. Alternatively, we may see VA’s norms, workflows, androutines gradually change to fit the nonmodifiable features ofOracle Cerner. This could have difficult-to-anticipate
consequences; it remains to be seen how such changes would
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al
impact VA’s mission as a veteran-centered system and a modelof innovation and patient-centeredness. Finally, we could
encounter a “holding pattern,” with employees developing andrelying on workarounds to bridge the gap between the older
manner of working and the new EHR. Like the previous
scenario, this situation is also rife with uncertainty; literature
has shown that while some workarounds may endanger thesafety of clinical care, others may ultimately help improveexisting workflows by offering creative alternatives toestablished processes and highlighting gaps in those processes[63,64]. It is indeed possible that all 3 scenarios may play out,
depending on the specific issue at hand and the degree ofleverage that each side exercises at a given moment.
Moving forward, it is essential that researchers continue to trace
the dynamics and consequences of this mutual adjustment. VA
has already created an infrastructure for ongoing research on
EHR modernization, with plans to expand it in the near future[65,66]. Even if the transition to a new EHR were to beterminated, this would still present profound challenges.
VistA/CPRS would need to be updated to address the issues
that Oracle Cerner was contracted to address in the first place.
Alternatively, if a different EHR vendor is contracted, this new
relationship would also need to move forward while being
mindful of the challenges encountered during the current
transition. Any of the paths forward will present a classicallywicked problem requiring “nuance, negotiation, and care” [67].
Beyond VA’s context, our findings have several important
implications. First and most fundamentally, they reinforce aninsight that is commonplace in social scientific studies oftechnology yet deserves wider recognition in health informatics
and change management circles. Namely, EHR systems, likeany IT product, are not neutral instruments—instead, theyembody specific norms, values, and assumptions [68-70]. EHR
transitions, therefore, are not a trivial matter of adjusting to an
unfamiliar interface or learning a new manner of completingtasks—they are large-scale sociotechnical transformations [67]that may have a profound impact on the entire system of
institutional practices, routines, and norms. The scope andcomplexity of the change may be even more pronounced for
health systems that are preparing to replace their homegrown
EHR with a commercial product.
While it may not be possible to anticipate all the wide-ranging
and disruptive consequences of the EHR transition ahead oftime, organizational leadership must understand that alarge-scale, possibly prolonged disruption will happen. The
literature shows that when users interact with an information
system over time, they start to take its features for granted[68,70,71]. In the context of our study, it appears that the users
may, in fact, become aware of the valuable characteristics ofthe legacy product because of having to adjust to a lesswell-tailored system. In such situations, users may struggle withthe transition to a new product more than they would if the older
EHR had also been vendor-based with limited customization
at the organization and site level. It is essential that leadershipclearly and proactively communicates the rationale behindadopting a product that may be less well-tailored to theorganization’s perceived needs in some ways, providing a
JMIR Form Res 2024 | vol. 8 | e46901 | p. 10(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
realistic picture of both challenges to come and benefits to bereaped.
Another implication of our findings is that health-system leaders
would do well to take stock of how their organization’s values,
principles, and priorities had been built into the older EHR. This
insight is echoed by a recent case study of digitaltransformations in several European public-sector settings,
which found that implementation was easier when an effort wasmade to understand the legacy system—its technical and cultural
aspects alike [72]. Building on this inference, we also proposethat health systems must consider how to optimize the fit
between the new EHR and the organizational culture. Whichfeatures of the organization’s approach to care are nonnegotiable
and must be reflected by the new EHR, and which ones can bechanged if the new EHR functionality demands, so would bean essential distinction to make. Using a robust theoreticalframework—for example, attending to which affordances(possibilities for action) are enabled or constrained by theinteraction between the new versus old EHR and the health careorganization’s specific context [10]—can be a promising
direction. Leadership may also consider innovative tools andapproaches informed by complex systems science and humanfactors engineering, such as human-in-the-loop simulation andtabletop exercises [73-75]. If modifying the organizationalroutines, practices, and values to enable the use of the new EHR
is inevitable, the benefits of such changes must be clearlycommunicated to end users.
Finally, we advise that leadership leverage the in-depthorganizational knowledge and first-hand experiences of end
users to inform and improve homegrown-to-vendor EHR
transitions. Here, learning health systems, like the VA, may
have a head start given their long-standing history of involving
clinicians first-hand in innovation and quality improvement
initiatives, including informatics projects [76-78]. In VA, in
particular, there are tremendous and largely yet-untapped
opportunities for peer learning and support across sites as themultiyear EHR transition continues to move across the country.
The community of practice [79] model, where sites can share

Anderson et al
knowledge, experiences, and support on an ongoing basis, may
be particularly relevant for systems where a “rolling-wave”
approach is adopted. Admittedly, the prospect of tailoring the
new EHR to better meet the organization’s needs may pose achallenge if the organization is also confronted with the needfor greater standardization [80], or if limited organizational
resources are available for such tailoring. Future research shouldshed light on how various health systems navigate this dilemma.

Limitations
Due to the use of snowball sampling for recruitment, employees
who volunteered to participate constitute a self-selected subsetthat may not be representative of the site’s staff, and it ispossible that alternative perspectives on the subject matter were
not captured. However, as noted, the findings are generally
consistent with the results of a survey with a large sample
conducted as part of the same mixed methods project,strengthening the trustworthiness of the findings.

Conclusions
VA’s transition from a highly tailored, homegrown EHR system
to a vendor-based one is a high-profile development importantin its own right and relevant for health-system leadership, EHR
vendors, researchers, and other groups with an interest inunderstanding and optimizing EHR transitions and large-scale
HIT implementations more broadly. We found that this transition
has been not only a logistical challenge but a sociotechnicaltransformation that has had a profound impact on organizational
culture and practices, perceived by many as undesirable andfraught with unintended consequences. The perceived lack offit between the new EHR and VA’s institutional mission is aparticular source of misgivings. In any health-system seeking
to replace a highly tailored EHR with a different product,leadership must anticipate and proactively communicate about
the disruptive nature of the transition, systematically assess andstrive to improve the alignment between the new EHR’s
functionalities and the organization’s needs, and leverage theorganizational knowledge and insights of users at all levels
during the implementation process.

Acknowledgments
This work was supported by funding from the US Department of Veterans Affairs, Veterans Health Administration, HealthServices Research and Development Quality Enhancement Research Initiative (PEC 20-168). This material is the result of work
supported by resources and the use of facilities at the Bedford, Boston, Seattle, and Northeast Ohio Veterans Affairs Health Care
Systems.
The authors acknowledge that the copyright of this study is held under the provisions of the United States Government’s contract
rights.

Disclaimer
The contents of this evaluation do not represent the views of the United States Department of Veterans Affairs or the UnitedStates Government.

Data Availability
The data sets generated and analyzed during this evaluation are not publicly available due to the fact that the data for this work
consists of in-depth interviews with Veterans Health Administration (VHA) employees conducted at a single, nonanonymoussite. Due to the highly specific contextual information they contain, the transcripts cannot be more anonymized. Because of thesensitive nature of the subject matter and concern about participant privacy, we are unable to share our data set.
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e46901 | p. 11(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Anderson et al

Authors' Contributions
GS, SR, EA, MM, and JB were responsible for conceptualization. MM was responsible for data curation. All the authors were
responsible for the formal analysis and writing review and editing. SR and GS were responsible for funding acquisition. EA,
MM, JB, SB, GS, and SR were responsible for the investigation. GS, SR, EA, MM, JB, and SB were responsible for the
methodology. EA and MM were responsible for project administration. GS, SR, and JO provided project supervision. GS, EA,
MM, and JB were responsible for writing the original draft. All authors have read and approved the final version of the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.
[DOCX File , 27 KB-Multimedia Appendix 1]

Multimedia Appendix 2Interview guides.
[DOCX File , 29 KB-Multimedia Appendix 2]

References
1.

2.
3.

4.

5.
6.
7.
8.
9.
10.
11.

12.
13.

14.

15.

Marcotte L, Seidman J, Trudel K, Berwick DM, Blumenthal D, Mostashari F, et al. Achieving meaningful use of healthinformation technology: a guide for physicians to the EHR incentive programs. Arch Intern Med. May 14,
2012;172(9):731-736. [doi: 10.1001/archinternmed.2012.872] [Medline: 22782203]
Adler-Milstein J, Jha AK. HITECH act drove large gains in hospital electronic health record adoption. Health Aff (Millwood).
Aug 01, 2017;36(8):1416-1422. [FREE Full text] [doi: 10.1377/hlthaff.2016.1651] [Medline: 28784734]
Everson J, Rubin JC, Friedman CP. Reconsidering hospital EHR adoption at the dawn of HITECH: implications of thereported 9% adoption of a "basic" EHR. J Am Med Inform Assoc. Aug 01, 2020;27(8):1198-1205. [FREE Full text] [doi:10.1093/jamia/ocaa090] [Medline: 32585689]
Huang C, Koppel R, McGreevey JD, Craven CK, Schreiber R. Transitions from one electronic health record to another:challenges, pitfalls, and recommendations. Appl Clin Inform. Oct 2020;11(5):742-754. [FREE Full text] [doi:10.1055/s-0040-1718535] [Medline: 33176389]
Penrod LE. Electronic health record transition considerations. PM R. May 2017;9(5S):S13-S18. [doi:10.1016/j.pmrj.2017.01.009] [Medline: 28527498]
Ventres W, Kooienga S, Vuckovic N, Marlin R, Nygren P, Stewart V. Physicians, patients, and the electronic health record:
an ethnographic analysis. Ann Fam Med. 2006;4(2):124-131. [FREE Full text] [doi: 10.1370/afm.425] [Medline: 16569715]
Mishra AN, Anderson C, Angst CM, Agarwal R. Electronic health records assimilation and physician identity evolution:
an identity theory perspective. Inf Syst Res. Sep 2012;23(3-part-1):738-760. [FREE Full text] [doi: 10.1287/isre.1110.0407]
Cresswell K, Worth A, Sheikh A. Implementing and adopting electronic health record systems: how actor-network theory
can support evaluation. Clin Gov Int J. 2011;16(4):320-336. [FREE Full text] [doi: 10.1108/14777271111175369]
Goorman E, Berg M. Modelling nursing activities: electronic patient records and their discontents. Nurs Inq. Mar
2000;7(1):3-9. [doi: 10.1046/j.1440-1800.2000.00053.x] [Medline: 11022530]
Strong DM, Volkoff O, Johnson SA, Pelletier LR, Tulu B, Bar-On I, et al. A theory of organization-EHR affordance
actualization. J Assoc Inf Syst. Feb 25, 2014;15(2):53-85. [doi: 10.17705/1jais.00353]
Miake-Lye IM, Cogan AM, Mak S, Brunner J, Rinne S, Brayton CE, et al. Transitioning from one electronic health record
to another: a systematic review. J Gen Intern Med. Oct 2023;38(Suppl 4):956-964. [FREE Full text] [doi:10.1007/s11606-023-08276-3] [Medline: 37798580]
Weiner M, Rinne ST, Haggstrom DA, Yano EM. Advancing the science of electronic health record transitions. J Gen Intern
Med. Oct 2023;38(Suppl 4):931-933. [FREE Full text] [doi: 10.1007/s11606-023-08333-x] [Medline: 37798585]
Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation inelectronic- versus paper-based office practices. J Gen Intern Med. Jun 2008;23(6):755-761. [FREE Full text] [doi:10.1007/s11606-008-0573-5] [Medline: 18369679]
Abramson EL, Patel V, Malhotra S, Pfoh ER, Nena Osorio S, Cheriff A, et al. Physician experiences transitioning between
an older versus newer electronic health record for electronic prescribing. Int J Med Inform. Aug 2012;81(8):539-548. [doi:10.1016/j.ijmedinf.2012.02.010] [Medline: 22465355]
The new electronic health record’s unknown queue caused multiple events of patient harm. Veterans Affairs Office of theInspector General. Jul 14, 2022. URL: https://psnet.ahrq.gov/issue/
new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm [accessed 2023-11-20]

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e46901 | p. 12(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
16.

17.

18.

19.
20.

21.

22.
23.
24.
25.
26.
27.

28.

29.
30.
31.
32.

33.
34.

35.
36.

37.

38.

Sisk R. VA signs $10B contract with Cerner for electronic health care records. Military.com Network. May 17, 2018. URL:
https://www.military.com/daily-news/2018/05/17/va-signs-10b-contract-cerner-electronic-health-care-records.html [accessed2023-11-24]
Unreliable information technology infrastructure cost estimates for the electronic health record modernization program.
US Department of Veterans Affairs, Office of Inspector General. 2021. URL: https://www.vaoig.gov/sites/default/files/
reports/2021-07/VAOIG-20-03185-151.pdf [accessed 2023-11-20]
Landi H. Oracle plans to 'rewrite' VA's Cerner EHR system to fix outages amid increased scrutiny from Congress. Fierce
Healthcare. Sep 22, 2022. URL: https://www.fiercehealthcare.com/health-tech/oracle-plans-rewrite-vas-cerner-ehr-system-fix-outages-amid-increased-scrutiny-congress [accessed 2023-11-20]
Schwartz N. Oracle Cerner VA rollout set to pick up in mid-2023. Becker's Health IT. Dec 30, 2022. URL: https://www.
beckershospitalreview.com/ehrs/oracle-cerner-va-rollout-set-to-pick-up-in-mid-2023.html [accessed 2023-11-20]
Leonard B. The VA’s new medical records system has gone haywire. Congress is alarmed. Politico. Jul 21, 2023. URL:
https://www.politico.com/news/2023/07/21/
the-vas-new-medical-records-system-has-gone-haywire-congress-is-alarmed-00107655 [accessed 2023-11-20]
Rajeevan N, Niehoff KM, Charpentier P, Levin FL, Justice A, Brandt CA, et al. Utilizing patient data from the veteransadministration electronic health record to support web-based clinical decision support: informatics challenges and issues
from three clinical domains. BMC Med Inform Decis Mak. Jul 19, 2017;17(1):111. [FREE Full text] [doi:10.1186/s12911-017-0501-x] [Medline: 28724368]
Brown SH, Lincoln MJ, Groen PJ, Kolodner RM. VistA—U.S. Department of Veterans Affairs national-scale HIS. Int J
Med Inform. Mar 2003;69(2-3):135-156. [doi: 10.1016/S1386-5056(02)00131-4]
Weir C, McCarthy C, Gohlinghorst S, Crockett R. Assessing the implementation process. Proc AMIA Symp. 2000:908-912.
[FREE Full text] [Medline: 11080016]
Kizer KW, Dudley RA. Extreme makeover: transformation of the veterans health care system. Annu Rev Public Health.
2009;30:313-339. [doi: 10.1146/annurev.publhealth.29.020907.090940] [Medline: 19296778]
Peckham C, Kane L, Rosensteel S. Medscape EHR report 2016: physicians rate top EHRs. Medscape. Aug 25, 2016. URL:
https://www.medscape.com/features/slideshow/public/ehr2016 [accessed 2023-11-20]
History of IT at VA. DigitalVA. 2022. URL: https://www.oit.va.gov/about/history.cfm [accessed 2023-11-20]
Van Wagenen J. VA secretary Shulkin pinpoints need for open-architecture EHR system. HealthTeach. Mar 22, 2017.
URL: https://healthtechmagazine.net/article/2017/03/va-secretary-shulkin-pinpoints-need-open-architecture-ehr-system[accessed 2023-11-20]
VA secretary announces decision on next-generation electronic health record. VA EHR Modernization. Jun 05, 2017. URL:
https://digital.va.gov/ehr-modernization/news-releases/
va-secretary-announces-decision-on-next-generation-electronic-health-record/ [accessed 2023-11-20]
Geppert CM. The best of 2018 is also the worst. Fed Pract. Feb 2019;36(2):54-55. [FREE Full text] [Medline: 30867624]
Phillips D. Hidden costs and flawed training plague the V.A.’s huge software upgrade. The New York Times. Jul 21, 2021.
URL: https://www.nytimes.com/2021/07/09/us/va-health-software-problems.html [accessed 2023-11-20]
Allen A. A 40-year 'conspiracy' at the VA. Politico. Mar 19, 2017. URL: https://www.politico.com/agenda/story/2017/03/
vista-computer-history-va-conspiracy-000367/ [accessed 2023-11-20]
Samora S. Congresswoman asks for delay of new VA health record system after computer outage at Spokane hospital.
Stars and Stripes. Mar 10, 2022. URL: https://www.stripes.com/veterans/2022-03-10/
veterans-affairs-health-records-spokane-hospital-computer-outage-5298088.html [accessed 2023-11-20]
Jones JH. VA and Cerner to investigate cause of Spokane electronic health records outage. FedScoop. Mar 21, 2022. URL:
https://fedscoop.com/spokane-va-ehr-cerner-bug/ [accessed 2023-11-20]
Nelson H. Cerner EHR has gone down 50 times since 2020 VA implementation EHR intelligence. TechTarget. May 10,2022. URL: https://ehrintelligence.com/news/va-cerner-ehr-has-gone-down-50-times-since-2020-implementation [accessed2023-11-20]
Spotswood S. VA ceases all new EHR activities until at least next summer. US Medicine. Nov 09, 2022. URL: https://www.
usmedicine.com/current-issue/va-ceases-all-new-ehr-activities-until-at-least-next-summer/ [accessed 2023-11-20]
Rucci JM, Ball S, Brunner J, Moldestad M, Cutrona SL, Sayre G, et al. "Like one long battle:" employee perspectives ofthe simultaneous impact of COVID-19 and an electronic health record transition. J Gen Intern Med. Oct 2023;38(Suppl4):1040-1048. [FREE Full text] [doi: 10.1007/s11606-023-08284-3] [Medline: 37798583]
Molloy-Paolillo B, Mohr D, Levy DR, Cutrona SL, Anderson E, Rucci J, et al. Assessing electronic health record (EHR)
use during a major EHR transition: an innovative mixed methods approach. J Gen Intern Med. Oct 2023;38(Suppl4):999-1006. [FREE Full text] [doi: 10.1007/s11606-023-08318-w] [Medline: 37798584]
Ahlness EA, Orlander J, Brunner J, Cutrona SL, Kim B, Molloy-Paolillo BK, et al. "Everything's so role-specific": VA
employee perspectives' on electronic health record (EHR) transition implications for roles and responsibilities. J Gen Intern
Med. Oct 2023;38(Suppl 4):991-998. [FREE Full text] [doi: 10.1007/s11606-023-08282-5] [Medline: 37798577]

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al

JMIR Form Res 2024 | vol. 8 | e46901 | p. 13(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
39.

40.
41.
42.

43.
44.
45.
46.

47.

48.

49.

50.

51.

52.
53.

54.

55.

56.

57.

58.

59.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist forinterviews and focus groups. Int J Qual Health Care. Dec 2007;19(6):349-357. [doi: 10.1093/intqhc/mzm042] [Medline:
17872937]
VA Spokane Health Care. US Department of Veterans Affairs. URL: https://www.va.gov/spokane-health-care/about-us/[accessed 2023-11-20]
Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. Apr 2008;62(1):107-115. [doi:10.1111/j.1365-2648.2007.04569.x] [Medline: 18352969]
Braun V, Clarke V. Thematic Analysis. In: Cooper H, Camic PM, Long DL, Panter AT, Rindskopf D, Sher KJ, editors.
APA Handbook of Research Methods in Psychology, Vol. 2. Research Designs: Quantitative, Qualitative, Neuropsychological,
and Biological. Washington, DC. American Psychological Association; 2012:57-71.
Braun V, Clarke V. Thematic analysis. In: Teo TR, editor. Encyclopedia of Critical Psychology. New York, NY. Springer;
2014:1847-1952.
Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol.
Aug 12, 2020;18(3):328-352. [FREE Full text] [doi: 10.1080/14780887.2020.1769238]
Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant. Jun 26,
2021;56(3):1391-1412. [FREE Full text] [doi: 10.1007/s11135-021-01182-y]
Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its
conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907. [FREE Full text] [doi:10.1007/s11135-017-0574-8] [Medline: 29937585]
Moldestad M, Stryczek KC, Haverhals L, Kenney R, Lee M, Ball S, et al. Competing demands: scheduling challenges inbeing veteran-centric in the setting of health system initiatives to improve access. Mil Med. Nov 02,
2021;186(11-12):e1233-e1240. [doi: 10.1093/milmed/usaa520] [Medline: 33289838]
Eibner C, Krull H, Brown KM, Cefalu M, Mulcahy AW, Pollard M, et al. Current and projected characteristics and uniquehealth care needs of the patient population served by the Department of Veterans Affairs. Rand Health Q. May 09,
2016;5(4):13. [FREE Full text] [Medline: 28083423]
Wong A, Wright A, Seger DL, Amato MG, Fiskio JM, Bates D. Comparison of overridden medication-related clinicaldecision support in the intensive care unit between a commercial system and a legacy system. Appl Clin Inform. Aug 23,
2017;8(3):866-879. [FREE Full text] [doi: 10.4338/ACI-2017-04-RA-0059] [Medline: 28832067]
Ellingsen G, Hertzum M, Melby L. The tension between national and local concerns in preparing for large-scale genericsystems in healthcare. Comput Support Coop Work. 2022;31(3):411-441. [FREE Full text] [doi: 10.1007/s10606-022-09424-9][Medline: 35313648]
Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at Veterans Affairs medical centers sicker? A comparative
analysis of health status and medical resource use. Arch Intern Med. Nov 27, 2000;160(21):3252-3257. [doi:10.1001/archinte.160.21.3252] [Medline: 11088086]
Bloeser K, Lipkowitz-Eaton J. Disproportionate multimorbidity among veterans in middle age. J Public Health (Oxf). Mar
07, 2022;44(1):28-35. [doi: 10.1093/pubmed/fdab149] [Medline: 34056660]
Moldestad M, Sayre G, Rinne S, Kaboli PJ, Reddy A, Sanders KM, et al. Perspectives on training and working in the VHA:
implications for primary care physician recruitment and retention. Acad Med. Aug 01, 2022;97(8):1175-1183. [doi:10.1097/ACM.0000000000004619] [Medline: 35139527]
Clancy C. Creating world-class care and service for our nation's finest: how veterans health administration diffusion of
excellence initiative is innovating and transforming veterans affairs health care. Perm J. 2019;23(4):18.301. [FREE Fulltext] [doi: 10.7812/TPP/18.301] [Medline: 31634111]
Alexandrova A, Rapanotti L, Horrocks I. The legacy problem in government agencies: an exploratory study. In: Proceedingsof the 16th Annual International Conference on Digital Government Research. 2015. Presented at: dg.o '15; May 27-30,
2015; Phoenix, AZ. [doi: 10.1145/2757401.2757406]
Care coordination deficiencies after the new electronic health record go-live at the Mann-Grandstaff VA Medical Centerin Spokane, Washington. Department of Veterans Affairs Office of Inspector General. Mar 17, 2022. URL: https://www.
vaoig.gov/reports/hotline-healthcare-inspection/care-coordination-deficiencies-after-new-electronic-health [accessed2023-11-20]
Ticket process concerns and underlying factors contributing to deficiencies after the new electronic health record go-liveat the Mann-Grandstaff VA Medical Center in Spokane, Washington. Department of Veterans Affairs Office of Inspector
General. Mar 17, 2022. URL: https://www.vaoig.gov/reports/hotline-healthcare-inspection/
ticket-process-concerns-and-underlying-factors-contributing [accessed 2023-11-20]
Medication management deficiencies after the new electronic health record go-live at the Mann-Grandstaff VA Medical
Center in Spokane, Washington. Department of Veterans Affairs Office of Inspector General. Mar 17, 2022. URL: https://www.oversight.gov/sites/default/files/oig-reports/VA/VAOIG-21-00656-110.pdf [accessed 2023-11-20]
Jones JH. Department of Veterans Affairs delays all future EHR deployments until June 2023. FedScoop. Oct 13, 2022.
URL: https://fedscoop.com/department-of-veterans-affairs-delays-all-future-ehr-deployments-until-june-2023/ [accessed2023-11-20]

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

Anderson et al

JMIR Form Res 2024 | vol. 8 | e46901 | p. 14(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
60.

61.

62.

63.
64.
65.
66.

67.

68.
69.
70.
71.
72.

73.

74.

75.

76.

77.
78.
79.
80.

Anderson et al

Krishan N. VA pushes back rollout of Oracle Cerner EHR at Ann Arbor health system. FedScoop. Feb 16, 2023. URL:
https://fedscoop.com/va-pushes-back-rollout-of-oracle-cerner-ehr-at-ann-arbor-health-system/?_thumbnail_id=42549[accessed 2023-11-20]
Krishan N. Oracle Cerner signs contract with Accenture to provide extra electronic health record training for VA clinicians.
FedScoop. Feb 14, 2023. URL: https://fedscoop.com/
oracle-cerner-signs-contract-with-accenture-to-provide-extra-electronic-health-record-training-for-va-clinicians/ [accessed2023-11-20]
Heckman J. VA’s new EHR ‘not ready’ for next go-live, extending pause in rollout. Federal News Network. Apr 6, 2023.
URL: https://federalnewsnetwork.com/veterans-affairs/2023/04/
vas-new-ehr-not-ready-for-next-go-live-extending-pause-in-rollouts/ [accessed 2023-11-24]
Patterson ES. Workarounds to intended use of health information technology: a narrative review of the human factors
engineering literature. Hum Factors. May 13, 2018;60(3):281-292. [doi: 10.1177/0018720818762546] [Medline: 29533682]
Petrides L, McClelland S, Nodine TR. Costs and benefits of the workaround: inventive solution or costly alternative. Int J
Educ Manage. 2004;18(2):100-108. [doi: 10.1108/09513540410522234]
About the PROVEN Hub. US Department of Veterans Affairs. URL: https://www.hsrd.research.va.gov/centers/proven/[accessed 2023-11-24]
Cogan AM, Rinne ST, Weiner M, Simon S, Davila J, Yano EM. Using research to transform electronic health record
modernization: advancing a VA partnered research agenda to increase research impacts. J Gen Intern Med. Oct 05,
2023;38(Suppl 4):965-973. [FREE Full text] [doi: 10.1007/s11606-023-08289-y] [Medline: 37798575]
Schmidt T, Nøhr C, Vingtoft S, Turner P. Next generation EHRs-what problems are these systems aiming to solve? In:
Lau F, Bartle-Clar JA, Bliss G, Borycki EM, Courtney KL, Kuo AM, et al, editors. Improving Usability, Safety and Patient
Outcomes with Health Information Technology: From Research to Practice. Amsterdam, The Netherlands. IOS Press;
2019:370-374.
Orlikowski W, Iacono C. Research commentary: desperately seeking the “IT” in IT research—a call to theorizing the IT
artifact. Inf Syst Res. Jun 2001;12(2):121-134. [FREE Full text] [doi: 10.1287/isre.12.2.121.9700]
Baird A, Maruping LM. The next generation of research on IS use: a theoretical framework of delegation to and fromagentic IS artifacts. MIS Q. 2021;45:315-341. [doi: 10.25300/MISQ/2021/15882]
Gosain S. Enterprise information systems as objects and carriers of institutional forces: the new iron cage? J Assoc Inf Syst.
Apr 2004;5(4):151-182. [doi: 10.17705/1jais.00049]
Robey D, Ross JW, Boudreau MC. Learning to implement enterprise systems: an exploratory study of the dialectics ofchange. J Manag Inf Syst. Dec 23, 2014;19(1):17-46. [doi: 10.1080/07421222.2002.11045713]
Irani Z, Abril RM, Weerakkody V, Omar A, Sivarajah U. The impact of legacy systems on digital transformation in European
public administration: lesson learned from a multi case analysis. Gov Inf Q. Jan 2023;40(1):101784. [FREE Full text] [doi:10.1016/j.giq.2022.101784]
Neville KJ, Pires B, Madhavan P, Booth M, Rosfjord K, Patterson ES. The TRUSTS work system resilience framework:
a foundation for resilience-aware development and transition. Proc Hum Factors Ergon Soc Annu Meet. Oct 27,2022;66(1):2067-2071. [FREE Full text] [doi: 10.1177/1071181322661177]
Abbott PA, Foster J, Marin Hde H, Dykes PC. Complexity and the science of implementation in health IT--knowledge
gaps and future visions. Int J Med Inform. Jul 2014;83(7):e12-e22. [doi: 10.1016/j.ijmedinf.2013.10.009] [Medline:
24444700]
Sittig DF, Singh H. A new socio-technical model for studying health information technology in complex adaptive healthcare
systems. In: Patel VL, Kannampallil TG, Kaufman DR, editors. Cognitive Informatics for Biomedicine: Human Computer
Interaction in Healthcare. Cham, Switzerland. Springer; 2015:59-80.
Colicchio TK, Cimino JJ, Del Fiol G. Unintended consequences of nationwide electronic health record adoption: challenges
and opportunities in the post-meaningful use era. J Med Internet Res. Jun 03, 2019;21(6):e13313. [FREE Full text] [doi:10.2196/13313] [Medline: 31162125]
Atkins D, Clancy CM. Advancing high performance in Veterans Affairs Health Care. JAMA. Nov 21,
2017;318(19):1927-1928. [doi: 10.1001/jama.2017.17667] [Medline: 29164241]
McQueen L, Mittman BS, Demakis JG. Overview of the Veterans Health Administration (VHA) Quality Enhancement
Research Initiative (QUERI). J Am Med Inform Assoc. Sep 01, 2004;11(5):339-343. [doi: 10.1197/jamia.m1499]
Merciera B. What is a community of practice? In: McDonald J, Cater-Steel A, editors. Communities of Practice: Facilitating
Social Learning in Higher Education. Singapore. Springer; 2017:3-25.
Bansler JP. Challenges in user-driven optimization of EHR: a case study of a large Epic implementation in Denmark. Int
J Med Inform. Apr 2021;148:104394. [doi: 10.1016/j.ijmedinf.2021.104394] [Medline: 33485217]

Abbreviations
COREQ: Consolidated Criteria for Reporting Qualitative Research
CPRS: Computerized Patient Record System
https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e46901 | p. 15(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Anderson et al

DoD: Department of Defense
EHR: electronic health record
HIT: health information technology
IT: information technology
MGVAMC: Mann-Grandstaff Veterans Affairs Medical Center
VA: Veterans Affairs
VHA: Veterans Health Administration
VistA: Veterans Health Information Systems and Technology Architecture

Edited by A Mavragani; submitted 03.03.23; peer-reviewed by Y Chu, S Yoon, M Braunstein, E Patterson; comments to author
16.08.23; revised version received 24.11.23; accepted 26.06.24; published 10.09.24
Please cite as:Anderson E, Moldestad M, Brunner J, Ball S, Helfrich C, Orlander J, Rinne S, Sayre G
User Experiences of Transitioning From a Homegrown Electronic Health Record to a Vendor-Based Product in the Department of
Veterans Affairs: Qualitative Findings From a Mixed Methods Evaluation
JMIR Form Res 2024;8:e46901
URL: https://formative.jmir.org/2024/1/e46901
doi: 10.2196/46901
PMID: 39255006©Ekaterina Anderson, Megan Moldestad, Julian Brunner, Sherry Ball, Christian Helfrich, Jay Orlander, Seppo Rinne, George
Sayre. Originally published in JMIR Formative Research (https://formative.jmir.org), 10.09.2024. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR
Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on
https://formative.jmir.org, as well as this copyright and license information must be included.

https://formative.jmir.org/2024/1/e46901

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e46901 | p. 16(page number not for citation purposes)