Years After a Historic EHR Switch, Clinicians Say Workarounds Rule Their Workday

When the U.S. Department of Veterans Affairs began replacing its long-serving, homegrown electronic health record with a single-vendor commercial system, it launched what researchers describe as the largest electronic health record transition in history. The switch was meant to modernize care for millions of veterans by connecting VA facilities to a shared federal platform. But a new qualitative study published in the Journal of General Internal Medicine suggests that, years after the new system went live at the first sites, many clinicians are still struggling to make it work — and that a quiet culture of improvisation has taken hold. In interviews conducted roughly one and a half to four years after implementation, clinicians at the first five VA medical sites to transition described a daily reality in which official workflows are routinely abandoned in favor of informal, self-devised solutions. One participant captured the situation bluntly: most of what they do, the clinician said, is a workaround now.

The research team, led by Sarah C. Keithly of the VA Puget Sound Healthcare System’s Center of Innovation for Veteran-Centered and Value-Driven Care, set out to fill a gap in the scientific record. Early studies of the VA transition documented profound disruption to care during the initial implementation phase, including clinician burnout, frustrated patients, and confusion over redefined roles. Far less was known about what happened after the dust settled. To find out, the investigators used a mix of purposive and snowball sampling to recruit direct care clinicians across a range of professions at the first five sites to adopt the new federal system. Of 104 clinicians invited, 30 — a participation rate of 28.8 percent — agreed to semi-structured interviews. The team then applied a hybrid inductive-deductive content analysis, combining templated summaries with matrix analysis, a method designed to surface both expected and unexpected patterns in qualitative data.

What emerged was a portrait of a workforce that has learned to survive a difficult technology by routing around it. The analysis generated four interlocking themes. First, ongoing EHR-related challenges continued to impede clinicians’ job performance long after go-live. Second, workarounds emerged in direct response to those persistent challenges. Third, clinicians perceived these workarounds as necessary but risky — to patients, to users themselves, and to the health care system as a whole. Fourth, and perhaps most troubling, as the underlying EHR problems persisted, the workarounds stopped feeling like temporary fixes and became routine practice. In other words, the improvisations that clinicians adopted to keep care moving were not fading away as the system matured; they were hardening into standard operating procedure.

The concept of the workaround occupies a well-studied niche in health informatics research. Prior work, including Koppel and colleagues’ influential analysis of barcode medication administration systems and subsequent scoping reviews of EHR workarounds, has shown that clinicians frequently develop alternate pathways when technology conflicts with clinical reality. These can range from harmless efficiency tricks to genuinely dangerous practices, such as documenting medication administration before it occurs or sharing login credentials to save time. The sociotechnical perspective, formalized in frameworks like Sittig and Singh’s model for studying health information technology in complex adaptive systems, holds that such behavior is rarely a simple failure of individual discipline. Instead, workarounds are signals — diagnostic clues that the interaction between technology, workflow, and organization has broken down somewhere. The new VA study treats them exactly that way, as a window into where the federal EHR is still failing its users.

The technical stakes of an EHR-to-EHR transition are considerable. Unlike a first-time implementation, a transition requires migrating years of clinical data, rebuilding decision-support rules, recreating order sets and documentation templates, and retraining a workforce that had achieved fluency in the old system. Systematic reviews of EHR transitions, including a 2023 review in the same journal, have catalogued recurring pitfalls: data loss during migration, mismatched workflows, degraded usability, and communication breakdowns. The VA’s homegrown system, known as VistA, had decades of local customization and a devoted user base, which made the switch to a commercial vendor product especially jarring. Previous mixed-methods evaluations of the transition documented clinicians fighting burnout for the first time, struggling with role-specific workflows, and fielding frustrated patients who bore the brunt of scheduling and documentation errors. The new study extends that timeline, showing that the problems did not resolve once the initial crisis passed.

The persistence of workarounds years into implementation carries specific safety implications. When a clinician devises an informal path around a system limitation, that path typically bypasses the safeguards built into the official workflow — the hard stops, the required fields, the verification steps. A workaround that saves thirty seconds on an order entry screen may also skip a drug-interaction check. One that speeds up documentation may leave critical information in a place where the next clinician cannot find it. The study’s participants were acutely aware of this tension. They described their workarounds as necessary to deliver care at all, yet simultaneously risky to patients and to the integrity of the medical record. That dual perception — beneficial and dangerous at once — is precisely what makes workarounds so difficult to manage through policy alone. Banning them without fixing the underlying problems simply pushes the improvisation further underground, where it becomes invisible to safety monitoring.

The normalization of workarounds also has implications for how health systems evaluate technology. If informal practices become routine, then the data flowing into the EHR increasingly reflects not actual clinical processes but the distorted output of patched-together workflows. Quality metrics, utilization data, and clinical decision support all depend on the assumption that documentation mirrors reality. When that assumption erodes, the organization loses visibility into its own operations. The VA researchers argue that this is why evaluating the role and impact of workarounds should be a formal part of EHR-to-EHR transitions, not an afterthought. Systematic workaround analysis, such as the SEWA framework for sociotechnical analysis of EHR workarounds, can identify which workarounds indicate design flaws that need engineering fixes, which reflect training gaps, and which reveal workflow mismatches that require organizational redesign rather than software changes.

The timing of these findings matters for the VA’s broader modernization program. The department has paused and restarted rollouts in recent years, and officials have announced early-stage planning for the next phase of federal EHR deployment while continuing improvement efforts at existing sites. The study’s conclusions suggest that the lessons from the first five sites should inform those decisions. If persistent EHR challenges continue to generate workaround reliance years after go-live, then simply extending the same implementation model to new sites risks replicating the same pattern. The authors emphasize that many of the transition’s challenges have persisted beyond the initial implementation phase, and that this persistence — not the transition itself — is what sustains the workaround culture. That distinction reframes the problem from a temporary disruption to be endured into a chronic condition to be treated.

For the wider health informatics community, the study adds an important longitudinal dimension to a literature dominated by snapshots taken during or immediately after implementation. Most organizations that swap one EHR for another — hospitals consolidating, health systems merging, national programs modernizing — face the same technical and human factors: interface usability, documentation burden, workflow fragmentation, and the sheer cognitive cost of relearning. The VA experience, documented with methodological care through information-power-guided sampling and rigorous qualitative analysis, offers a preview of what the years after a big-bang implementation can look like when problems are not fully resolved. The message from clinicians is not that the new system is unusable, but that using it as designed has become the exception rather than the rule. Closing that gap, the researchers argue, requires treating workarounds not as clinician misbehavior but as actionable intelligence — a map, drawn by the people closest to the work, of exactly where the system still needs to be fixed.

Subject of Research: Clinician workarounds and persistent challenges following the VA's transition to a federal electronic health record system

Article Title: “Most of what I do is a workaround now”: Clinician Use of Workarounds Following an EHR Transition

Article References: Keithly, S. C., Sulc, C., Cole, E., Sterling, R., Lin, Y.-L., Obara, E., Shirley, S., Wong, E. S., Rinne, S. T., & Young, J. (2026). “Most of what I do is a workaround now”: Clinician Use of Workarounds Following an EHR Transition. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10840-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10840-6

Keywords: electronic health record, EHR transition, workarounds, Veterans Affairs, health informatics, clinician burnout, patient safety, workflow, qualitative research, health IT, documentation burden, sociotechnical systems