When a clinician hits a snag in an Electronic Health Record (EHR), what happens next matters. Someone must own the problem, and the fix must reach the front line quickly. Every hour spent chasing a workaround is an hour not spent with a Veteran.
Finding the right solution fast is the job of the EHR Issue Management Process, and at its core is the Tiered Hub Process, the structure the Department of Veterans Affairs (VA) uses to resolve EHR issues at the most local level possible, escalating only the problems that need broader attention.
Aptive supports the EHR Issue Management Process, and the overarching Electronic Health Record Modernization (EHRM) effort to deploy VA’s Federal EHR across the enterprise by 2031, by strengthening the operating model, so the program delivers measurable value, not just a system change.
To give Federal EHR sites one predictable way to troubleshoot problems and suggest improvements, VA launched the EHR Issue Management Process in August 2024. The THP is the engine inside that process. Sites input issues into ServiceNow, where it is triaged and routed through a series of tiered hubs for resolution:
Tier 0. Facility and Veterans Integrated Service Network (VISN) Hubs
Tier 0. Facility and Veterans Integrated Service Network (VISN) Hubs
Facility hubs are the first touchpoint, where facility informatics staff receive, investigate and triage the problem; VISN hubs take what they can’t solve, weighing enterprise-wide impact.
Tier 1. The National Hub
Tier 1. The National Hub
Where subject matter expert (SME) teams triage and solution problems the lower tiers couldn’t resolve.
Tier 2. The EHR Executive Council
Tier 2. The EHR Executive Council
Where VA executives resolve what remains, focusing on people, process and workflow.
The THP makes sure problems get solved by the people closest to the work whenever possible, and because it is EHR agnostic, sites can use it while they are still working in VA’s legacy EHR systems, well before their Federal EHR deployment.
The process also supports a larger goal: standardization. Fewer one-off issue management processes leads to a more consistent record and a clearer path to a single standard of care across VA.
Standing up this process across the country takes more than a flowchart. VA is moving from more than 130 separate instances of the Veterans Health Information Systems and Technology Architecture (VistA) and Computerized Patient Record System (CPRS) to a single Federal EHR shared across 1,380 sites of care, the largest integrated health care system in the Nation. At that scale, an inconsistent decision path or a slow escalation does not stay a local problem for long.
The Aptive team’s role in this work started at the design state. Aptive contributed to the original architecture of the THP, shaping the tiered structure, escalation pathways and governance model now deployed across the enterprise. That foundational work continues through Project IMPROVE, an OCI-led initiative Aptive supports to define the optimal state for VA’s end-to-end issue management process, spanning both the Federal EHR and legacy VistA/CPRS environments, so the entire pipeline from first submission to final resolution operates from a single, coherent standard.
Today, the team supports VHA’s Office of Clinical Informatics (OCI) and Client Portfolio Management Office (CPMO) by strengthening the operating model for the THP. That means standardizing how issues are taken in, triaged, escalated and resolved, and routing each one to the lowest appropriate level, the same foundation local-first principle for the EHR Issue Management Process.
The team also strengthens how risks and unresolved issues are tracked across the enterprise, using a structured, four-step framework so roadblocks surface earlier, mitigation starts sooner and patient-safety issues get coordinated attention. Aptive built an award-winning strategic communications plan (informed by the Federal EHR User Experience Survey) to cut through communications fatigue, and pairs it with role-based, “use it tomorrow” training that helps site leaders and staff adopt new workflows without losing time at the bedside. Throughout, the team works in two-week Scaled Agile Framework (SAFe) sprints, adjusting as priorities shift instead of waiting for perfect stability.
Facility Hubs meet twice a week and have built a new best practice: members scrub each request on arrival, confirming every required element is present and sending requests for additional information back to the facility before the issue is dispositioned to the appropriate solutioning body. The payoff is a more polished product moving through the pipeline and requestors who learn to bring the right documentation the first time. Reviewing issues together at the Facility Hub before they reach the VISN level has reduced workload and an early worry about the time commitment proved unfounded. With the process established and the team meeting weekly, overall meeting time has actually gone down.
The work isn’t finished. The network still escalates roughly 80% of issues to the National Hub, a rate sites expect to lower as the recently added Run the Business request process matures, the Joint Sustainment and Adoption Board (JSaAB) catalog continues to be enhanced and updated with pre-approved change requests, and prioritization sharpens at the local level. The honest takeaway from the field: real progress, with room to simplify and no waiting for perfect to get in the way of good.
The THP is scaling fast. More than 300 facility and VISN informatics and leadership staff joined the January kickoff sessions for sites going live between calendar years 2027 and 2031. Between go-live milestones, Aptive run webinars, regular office hours and communities of practice that connect informatics staff across markets to share what’s working, surface what isn’t, and build the peer knowledge base that no training curriculum can fully replace. At the same time, the team continuously evaluates the process itself – identifying where workflows can be simplified, where tools can be improved, and where the next round of reinforcement needs to go – so the THP gets sharper with every deployment.
Aptive helps federal agencies stand up the governance, communications, and training that turn a complex transition into steady progress. The payoff is the one that started the whole effort: when an issue surfaces in the EHR, the people closest to it can fix it – fast – and get back to caring for Veterans.
Strategic communications manager Jillian Gates brings deep experience translating complex health IT modernization into clear, human-centered stories that drive adoption and trust. At Artemis ARC (a teaming partner of Aptive’s), she leads an award-winning communications team supporting VA Electronic Health Record Modernization. As a SAFe 6 Agilist Certification, Jillian adapts SAFe methodologies into agile processes for communications and change teams.
Spencer Esty is a Senior Manager at Aptive leading the Tiered Hub Process work for VA’s Electronic Health Record Modernization program. An experienced federal strategist across health, defense and civilian agencies, he specializes in enterprise governance design, operational process improvement and large-scale program execution. A Certified SAFe 6 Agilist, Spencer has led the national redesign of VHA’s EHR issue management framework across the enterprise.
