Clinical Standardization Across a National Health System

BACKGROUND: Clinical standardization is widely debated. Advocates emphasize its potential to reduce unwarranted variation and improve quality, while critics warn it may constrain professional judgment or undermine local innovation. These tensions become especially salient during enterprise-wide electronic health record (EHR) transitions, when configuration and workflow decisions can institutionalize practices across facilities. The Department of Veterans Affairs (VA), undertaking the largest EHR transition in history, provides a critical case for understanding how frontline staff perceive system-wide standardization. OBJECTIVES: To assess VA employee attitudes toward care process standardization during VA's enterprise-wide EHR transition and identify implementation challenges and opportunities. RESEARCH DESIGN: Cross-sectional survey with mixed-methods analysis of a survey fielded in September 2024. SUBJECTS: We surveyed n=1748 EHR users at the first 5 VA sites implementing a new EHR. MEASURES: Awareness of and support for VA's Enterprise Standardization Initiative, assessed using 5-point Likert items; free-text comments were analyzed thematically to identify perspectives on standardization. RESULTS: Among respondents, 43% reported awareness of VA's standardization initiative, and 65% supported standardizing care processes across facilities. Qualitative analysis revealed 3 themes: (1) support for standardization as complementary to EHR transition; (2) preference for decoupling standardization from technical change; and (3) emphasis on appropriately targeting standardization to preserve innovation capacity. CONCLUSIONS: VA employees expressed support for standardization with important caveats about implementation approach and scope. Findings support iterative standardization that balances consistency with local adaptation, while carefully sequencing standardization relative to technical change.