Why Your Informatics Governance Structure Matters More Than Your EHR Vendor

I've worked with five different EHR systems across four health systems. The best clinical experience I've seen was at a community hospital running a mid-tier EHR with excellent governance. The worst was at an academic medical center running a top-tier EHR with no governance at all.

The software matters. But the decision-making structure around the software matters more.

What Informatics Governance Actually Means

Governance is who gets to decide what. In clinical informatics, that means: who approves new order sets? Who decides when to add a documentation element? Who prioritizes the build queue? Who can request a change to a clinical workflow, and who reviews that change before it goes live?

At many hospitals, the answer to all of these questions is "whoever asks the loudest" or "whoever has the most administrative authority." That's not governance — that's chaos with hierarchy.

The Three Problems Bad Governance Creates

Configuration bloat. Without governance, every department, every physician, and every compliance initiative adds documentation elements, alerts, and order sets. Nothing ever gets removed. Over time, the system accumulates cruft that slows everyone down. I've seen EHR instances with over 800 active order sets, fewer than 200 of which were used in the past year.

Inconsistent clinical practice. When individual departments can configure their own workflows without oversight, you get five different ways to document a fall risk assessment across five units. That's not just inefficient — it's a patient safety issue when a nurse floats to an unfamiliar unit.

Build team burnout. Without governance to triage and prioritize requests, the informatics build team is pulled in every direction. Everything is urgent. Nothing is strategic. The best analysts leave for organizations that have their act together.

What Good Governance Looks Like

The structure doesn't need to be complicated. At my health system, we have:

• A clinical informatics steering committee that meets monthly to review and prioritize requests. Chaired by the CMIO, with representation from nursing, pharmacy, and key specialty departments.
• A clinical review requirement for every configuration change that affects clinical workflows. No change goes live without sign-off from a clinician who understands the downstream impact.
• A standardization policy that requires enterprise-wide solutions for enterprise-wide problems. One falls risk assessment. One sepsis screening tool. One medication reconciliation workflow. Departments can request variations, but the burden of justification is on them.
• A regular sunset review that examines order sets, alerts, and documentation elements for usage. If it hasn't been used in 12 months, it goes to committee for retirement.

Getting Started

If your organization doesn't have informatics governance, start small. You don't need a committee — you need a gatekeeper. One clinical informaticist who reviews every build request before it enters the queue and asks: Is this clinically necessary? Is there already something that does this? Will this create work for other departments?

That single checkpoint will transform how your EHR evolves. Because the most expensive EHR problem isn't the wrong software — it's the right software managed poorly.