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Putting People at the Center: How Human Systems Integration Is Reshaping Federal Health IT

Posted on 04.30.26

As federal agencies modernize their health IT systems, a growing discipline is making sure the human element doesn’t get left behind.

When a new electronic health record system rolls out across a hospital or health network, the technology itself is only part of the story. How does a nurse navigate a new interface during a high-stress shift? What happens when a clinician’s workflow doesn’t map cleanly onto a system designed by those who may not understand and appreciate the complexities of “healthcare in the trenches”? These are not software problems. They are human problems, and they require a discipline specifically designed to address them.

That discipline is human systems integration, or HSI, and it is quietly becoming one of the most important frameworks in federal health information technology.

What Is Human Systems Integration?

Human systems integration is a holistic, systems-level approach to understanding the interaction between people (as individuals and organizations), technology and processes. Rather than treating a healthcare system as a collection of software components, HSI looks at the full sociotechnical picture: the patients and caregivers who use the system, clinicians, support staff and administrative personnel, alongside the tools, training, environments and organizational structures that shape how work actually gets done.

The discipline draws on human factors engineering, which the International Ergonomics Association defines as the scientific discipline focused on understanding the interactions of humans and other elements of a system. The human factors profession applies theory, principles, data and methods to design for the purpose of optimizing human well-being and overall system performance. The application of human factors centered principles and methods has long been recognized in aviation, nuclear power and manufacturing as essential to safety and reliability. In healthcare, adoption has been slower, but that is changing.

“It’s not just technology and change management. Recognizing the human component is what allows us to optimize processes and systems. Human systems integration provides a necessary bridge between technology, clinical work and organizational realities, ensuring that healthcare systems are designed optimally for use by humans.”

– Dr. Lynda Hoeksema, Director of Health Informatics and Clinical Quality, Aptive

HSI brings in systems engineering concepts and expands on traditional human factors engineering by examining additional interconnected domains including: manpower, personnel, training, safety and occupational health, habitability and environment, and force protection and survivability. Together, these domains provide a framework for understanding how the configuration of human elements shapes system performance.

One goal is to make design trade-offs related to humans explicit and integrated early in the development process. An example is during the nation’s transition to the Federal Electronic Health Record across the Veterans Health Administration (VHA). Integration of HSI concepts facilitates decisions incorporating the human aspect being made intentionally up front as much as possible, rather than discovered after deployment.

From the Military to VA: A Discipline on the Rise

HSI has its deepest roots in the Department of Defense. The Army in particular has spent decades developing mature HSI frameworks, embedding human factors considerations into weapons systems, training pipelines and operational readiness planning. The Army’s approach treats HSI not as an afterthought but as a core systems engineering requirement, with defined processes for each domain integrated throughout a program’s lifecycle. NASA also adopted HSI activities within their systems engineering framework. Health related agencies in the federal government are also now moving in the same direction. The Food and Drug Administration, the Centers for Medicare & Medicaid Services and the National Institutes of Health have all recognized the need for human-centered approaches to technology design. As health IT systems grow more complex and more consequential, the question of whether they are optimally usable by the people who depend on them is no longer optional.

The Veterans Health Administration is also in an earlier, but accelerating, stage of this evolution. VHA’s Office of Clinical Informatics houses an HSI division specifically focused on improving the usability, safety and supportability of VA systems through tailored analysis and timely insight into design trade-offs. The division’s mandate covers everything from how those who provide care (clinicians and support staff) interact with health IT interfaces to how those who receive care (Veterans) experience more consumer-facing technology and processes.

A Growing Field with Urgent Stakes

The stakes in healthcare are different from those in other sectors. An unintuitive interface in a shopping application costs time. An unintuitive interface in a clinical setting can cost lives. Research consistently shows that poor health IT usability contributes to clinician burnout, workaround behaviors that introduce new risks, documentation errors and adverse patient safety events.

This is why the investment in HSI at VHA is not simply a matter of user experience optimization. Application of HSI principles enhances patient safety and resilience, workforce retention and is a foundational requirement for getting the most out of the billions of dollars being invested in electronic health record modernization.

Aptive’s Work Supporting HSI at VHA

Aptive, through its joint venture with Artemis ARC called Argent ARC, supports VHA’s HSI division through the Human Systems Services initiative, a broad-scope effort that spans roughly a dozen concurrent projects. The work is deliberately varied. Projects, also referred to as HSI studies, may involve literature consultation, focus groups, user surveys or application of other human factors engineering methods. Some studies include heuristic reviews conducted by human factors experts who evaluate a system against established usability principles to identify potential problems. Others require multiple in-person observations at multiple VA medical centers and community-based outpatient clinics, with dozens of clinical staff participating in structured interviews, workflow assessments and usability testing sessions.

The common thread is the human-centered design process, an iterative methodology grounded in International Organization for Standardization (ISO) 9241 standards that provide principles, requirements and guidance for the design, evaluation and use of interactive systems. The ultimate goal is ensuring usability, effectiveness, efficiency, accessibility and user well‑being.

The scope of methods the team applies reflects the breadth of the HSI mandate with the appropriate approach used for each situation carefully selected to ensure optimal outcomes. The team’s toolkit can contain many common human factors engineering options including: applied cognitive task analysis, participatory design sessions, rapid ethnography, formative or summative usability testing, mapping of the human experience, application of modeling techniques and performing training needs analyses or training effectiveness evaluations. The teams coordinate efforts with their government partners and gather information, provide detailed analysis and make recommendations to assist in supporting VHA’s goals. This is done through collaborative interactions and developing and executing study plans and with work outcomes detailed in study reports.

Executing that work requires practitioners who can move fluidly between research design and fieldwork. Jacob Huffman, a human factors engineer and UX researcher with experience supporting VHA clinical workflow improvement, brings that combination of skills to the initiative. Huffman’s background conducting onsite observations, clinician interviews and usability evaluations within VA medical centers means the team approaches each study with an understanding of how VA clinical environments actually operate, not just how they are intended to.

Competency Development: Building the Human Factors Workforce

One of the initiative’s most forward-looking areas of work is competency development. As VA’s EHR modernization effort matures, the organization needs clinical and IT staff who understand human factors principles, not just the consultants and researchers who study them. Defining what those competencies look like, and how to build them at scale, is itself a significant research and design challenge.

Abe dela Paz, a study lead for the competency development domain, focuses specifically on defining the human factors skills required to support the future-state EHR issue management process. His background as a respiratory therapist before moving into health informatics and federal consulting gives him a perspective that bridges the clinical, operational and technical dimensions of the work.

“I’ve supported EHR implementation throughout my career as an end user, super user, informaticist and now in consulting,” dela Paz said. “It’s been a consistent thread in my professional journey.” That longitudinal view of how health IT evolves from the point of adoption to mature enterprise use is exactly the kind of insight that human systems integration work requires.

“In EHR implementation, I’ve seen that improving outcomes isn’t just about the technology, it’s about understanding how people, workflows and systems come together in practice.”

– Abe dela Paz, Senior Program Analyst, Informatics, Artemis ARC

The Clinician-Informaticist Advantage

Leading the broader HSI initiative for Aptive is Dr. Lynda Hoeksema, whose background is unusual even in a field that prizes interdisciplinary expertise. A dual board-certified family nurse practitioner and informaticist, recognized for her expertise by the American Medical Informatics Association (AMIA) and with decades of clinical experience, Dr. Hoeksema brings a perspective that is rare in federal consulting. She has been the user.

“After working in both ambulatory and hospital settings for many years, I went into informatics about 15 years ago because of frustration with the current state, especially the end user experience with electronic health records. I felt ‘somebody has to make this better’, so I devoted my career to being part of the solution and became that ‘somebody’.”

Before joining Aptive, Dr. Hoeksema spent more than four years at MITRE supporting VHA’s HSI division as a strategic adviser, in addition to work supporting FDA, CMS and NIH. Her doctoral project at Ohio State University focused on human factors and cognitive informatics competencies, connecting her academic work directly to some of the problems her team now addresses in practice.

Her dual clinical and informatics credentials matter operationally. She helps provide subject matter expertise and perspective to the teams who are collaborating to optimize systems and processes that will impact informatics personnel, clinical staff and patients. That synthesis is central to the value an HSI approach brings.

What Effective HSI Actually Looks Like

VA’s HSI division is focused on providing expertise and support across VHA clinical and operational areas in addition to the organization within VA responsible for electronic health record modernization (EHRM) and implementation of the Federal EHR.

A project or study applying HSI approaches typically begins with a kick-off meeting to document the context of need: what problem is being investigated, who the users are, what systems or processes are involved and the objectives of the business owner. From there, the team develops a study proposal that is reviewed and approved by both the HSI division government lead and the sponsoring program office before any work begins. This concurrence process ensures that the study is designed to answer the questions that actually matter to decision-makers.

Depending on the study type, execution might involve traveling to a VA medical center to observe clinicians in their actual work environment, conducting structured interviews with users across multiple roles and time zones, or numerous other techniques to capture the human experience. All of it is documented in a standardized format that can inform future design decisions and contribute to VHA’s institutional knowledge base.

The results are not just limited to reports. The entire process of embedding HSI experts along with the operational VHA and EHRM processes as work is done, including on agile teams, helps to further the vision of systems designed to address the real needs of humans. Over time, this body of work and the integration of human centered principles into multiple organizational layers becomes a resource for the entire enterprise.

“In high-stakes environments, the gap between how a system is designed
and how it is actually used can have real consequences.
Our job is to close that gap before it becomes a problem, not after.”

-Jacob Huffman, Senior Human Factors Engineer, Aptive

The Broader Significance

Improved outcomes and transformation happen when those providing and receiving care can use an information system effectively, when workflows align with how care is actually delivered and when the people responsible for the system have the knowledge and tools for the earliest possible identification and resolution of potential usability problems. This is true for any technology, not just electronic health records.

The HSI approach provides the framework and the methodology to make that transformation real. The Army proved over decades that building human factors into systems engineering from the start produces better outcomes, fewer errors and lower lifecycle costs. The Veterans Health Administration is now applying those lessons to one of the largest and most complex healthcare systems in the world.

The work is incremental by design. For this team, it may look like a dozen or more concurrent projects, each addressing a different dimension of the human-system relationship, each contributing to a broader understanding of how people and technology interact in clinical settings. It is not a single solution. It is a practice, and it is one that more federal agencies are beginning to recognize as essential.

A dual board-certified family nurse practitioner and informaticist, Dr. Hoeksema brings more than 30 years of clinical experience and 15 years in regional and national health informatics to Aptive's Human System Services initiative. She previously served as a strategic adviser to VHA's HSI division at MITRE and holds a Doctor of Nursing Practice from The Ohio State University, with a focus in her doctoral project on human factors and cognitive informatics competencies for health systems.

Dr. Lynda Hoeksema, DNP, FNP-BC, NI-BC, FAMIA, ACHIP Director of Health Informatics and Clinical Quality, Aptive

Abe dela Paz brings over 18 years of experience across clinical care, health informatics and federal consulting, supporting large-scale initiatives focused on EHR modernization, digital transformation and informatics strategy. He previously served as a clinical strategy and informatics leader at MITRE, focusing on bridging clinical, operational and technical teams to deliver practical, workflow-driven solutions that improve decision-making and system adoption. On the HSI initiative, he provides his expertise for competency development work efforts, focused on defining the human factors skills required to support the future-state EHR issue management process.

Abe dela Paz, MSHIA, RRT-ACCS, PMP, CPPS Senior Program Analyst, Informatics, Artemis ARC

Jacob Huffman is a human factors engineer and UX researcher specializing in safety-critical systems and healthcare environments. His research background includes large-scale usability studies at the Transportation Security Administration, as well as VA after-visit summary optimization work that reduced documentation burdens for both patients and providers. On the HSI initiative, he applies qualitative and quantitative methods to identify user needs and inform system design across VA clinical programs.

Jacob Huffman Senior Human Factors Engineer, Aptive

Putting People at the Center: How Human Systems Integration Is Reshaping Federal Health IT