TY - JOUR
AU - Volpe,, Gwen
AB - Purpose A standardized blueprint for use when harmonizing or standardizing pharmacy automation and technology resources across individual institutions or an integrated delivery network (IDN) of institutions is described. Summary Whether to strive for standardization (use of the same vendors and equipment) versus harmonization (use of various technologies to meet patient-specific needs and organizational stability requirements) and how to coordinate activities across IDNs consisting of 3–30 or more hospitals are common questions due to consolidations in the healthcare industry. For most IDNs with legacy systems, harmonization may be the better option. Large-scale harmonization initiatives require significant planning and coordination involving all affected parties. Detailed project plans should include the compiling of all associated harmonization costs that involve human resources, information on ongoing services and equipment, and program schedules for multiple concurrent projects in order to provide a framework for planning and coordination. Part of the planning process for harmonization efforts should include an extensive current-state analysis that includes review of contracts and vendors. Final harmonization decisions should be based on a mix of vendor recommendations, best practices, and accommodation of current practices that result in the lowest complexity of system redesign with regard to existing systems. When harmonizing existing technologies, planning must also consider the impact of the change to both the organization and individual users. Conclusion Harmonization is an evaluative process whereby process variation due to automation and technology variability can be reduced and organizational interoperability to meet patient-specific needs can be promoted. automation, harmonization, pharmacy, pharmaceutical services, quality, standardization KEY POINTS Integrated delivery networks have a need to standardize or harmonize vast amounts of technology across the enterprise for reasons of patient safety, cost control, and improved efficiency. Standardization of technology is the ultimate goal, but harmonization of certain technologies across the enterprise may be necessary if it is difficult to use the same vendor for all sites or the technologies used are narrow in scope. Technology standardization or harmonization requires effort and diligence to ensure that systems are working together to help achieve optimal outcomes. Powerful market forces are radically altering the U.S. healthcare landscape and leading to industry consolidation. Accordingly, the pharmacy enterprise must clearly develop clinical, operational, and financial strategic accountability across integrated delivery networks (IDNs) in order to optimize existing resources through either consolidation or streamlining.1,2 Organizational success can then be evaluated and related to patient safety, efficiency, workflow, and cost-effectiveness targets through resource optimization.3 Even for small hospital systems or individual hospitals, alignment of organizational streamlining goals should be balanced by patient care, patient safety, and workflow needs. Therefore, the purpose of this article is to offer a standardized yet adaptable blueprint for consideration by healthcare organizations attempting to harmonize or standardize technology resources across individual institutions or an IDN. Process variation can be reduced through either systemwide standardization or harmonization of existing resources. In the context of pharmacy automation and technology, the term standardization refers to a deliberate process whereby organizational decisions to purchase or use the same vendors and equipment are coordinated across IDNs consisting of 3 to 30 or more hospitals4 in order to promote organizational interoperability. In reality, few organizations have the luxuries of sufficient time and sufficient resources to achieve complete standardization. Harmonization, on the other hand, refers to an evaluative process whereby variability is seen as vital to patient-specific needs and organizational stability. For most IDNs with legacy systems, harmonization may be the better option. Automation and technology can be standardized whenever that is logical, but when all systems need to work together and function interoperably, harmonization will likely be the better avenue to pursue because it involves minimal disruption of service. Finally, for harmonization across complex systems, it is important to consider the breadth of technology in use, in addition to operational, clinical, and financial needs for automated processes. Since most institutions will choose to harmonize processes and associated technologies, the following guidelines are focused on the harmonization process. Planning and implementing a harmonization strategy Strategic planning. A clear and effective harmonization strategy will be highly dependent on an exhaustive “current-state variation evaluation” of automation and technology.3 Therefore, the following important elements should be evaluated across any pharmacy department that must be responsive to IDN strategic goals: Medication management technology currently in use, Key safety, security, and efficiency data and processes surrounding the use of automation (e.g., the percentage of medications in automated dispensing cabinets and associated numbers of refills per day, standard user templates, dose-error reduction software compliance, dollar value of waste per month), and Vendors currently in use both across and within IDNs. Once a current-state variation analysis has been conducted, a mapping tool such as the sample enterprise deployment matrix depicted in Figure 1 can be constructed to summarize findings. For example, each hospital within the IDN identified in Figure 1 should be mapped relative to its technology systems: the electronic health record (EHR), infusion systems for large-volume parenteral (LVP) injections, automated dispensing cabinets, and so on. Vendors for each technology system across the IDN should also be mapped to identify similarities and differences, system ages and current contracts, clinical workflow needs, and other characteristics. Current-state results can then be used to identify and prioritize harmonization efforts that are consistent with the IDN’s strategic business objectives. Figure 1 View largeDownload slide Example of results of current-state analysis using an enterprise deployment matrix. A red X denotes that a medication administration or management task is not performed or a technology is not in use at a facility. IDN = integrated delivery network, EHR = electronic health record, HIT = health information technology, LVP = large-volume parenteral, PCA = patient-controlled analgesia, ADC = automated dispensing cabinet, OR = operating room. Reprinted with permission of Becton, Dickinson and Company, Franklin Lakes, NJ. Figure 1 View largeDownload slide Example of results of current-state analysis using an enterprise deployment matrix. A red X denotes that a medication administration or management task is not performed or a technology is not in use at a facility. IDN = integrated delivery network, EHR = electronic health record, HIT = health information technology, LVP = large-volume parenteral, PCA = patient-controlled analgesia, ADC = automated dispensing cabinet, OR = operating room. Reprinted with permission of Becton, Dickinson and Company, Franklin Lakes, NJ. Large-scale harmonization initiatives require significant planning and coordination involving all affected parties. An executive steering committee comprising stakeholders from key departments should be established to support the project team and serve as the final approval body. The executive steering committee should also provide guidance when faced with roadblocks such as financial issues or when final decisions cannot be agreed upon. The primary charges of the executive steering committee should be to develop a harmonization strategy that standardizes design and development across the IDN to the highest extent tolerable, to solicit clarification when decision points are ambiguous, and to provide guidance for IDN-specific workflows or exceptions (which should be minimized). Organizations can then use project teams or project work groups that report to the executive steering committee and then incorporate the knowledge and expertise of stakeholders to execute harmonization of technologies and processes as well as vendor-platform harmonization and optimization. Project team members should be able to articulate any issue at hand, the current state of practice across all IDN member institutions, and the risks and benefits associated with each decision point. In addition, frontline super users should be identified in order to provide feedback on issues and help during harmonization of processes. Project planning. A successful project implementation meets key stakeholder expectations when carried out in a timely fashion and within budget while maintaining patient safety. A detailed project plan that includes human resource costs, equipment costs, ongoing service costs associated with harmonization, and program schedules for multiple concurrent projects provides a foundational framework for harmonization planning and coordination. Investing time in upfront planning pays significant dividends down the road, and its importance should not be underestimated. Planning for successful harmonization across an enterprise requires coordinated “plan within a plan” project plans. When harmonizing technology systems, the first step is to identify what will be within and outside the scope of harmonization. Which parts of processes, medications, order sets, and policies make sense to harmonize? Results of the current-state analysis (Figure 1) can be used to identify similar processes and to better understand the reasons for deviations. Financial, safety, regulatory, workflow, or system barriers that could limit the ability to harmonize also need to be considered. After careful consideration, the harmonization team should create clear “dissonance guidelines” to establish criteria that, when met, allow for nonharmonization. Dissonance guidelines might include criteria that allow for dissonance in addressing issues such as Differing patient populations and associated needs, The need to maintain an operational ability to compound due to factors related to equipment, facilities, or expertise, and Limitations of automation, including automated technologies related to infusion devices and interfaces. The issue of who will have the authority to make dissonance approval decisions should also be addressed. Documentation tools such as impact–effort grids can be used to map timelines and tasks for smaller projects, because the implications of any change for other systems, including formulary, inventory, interfaces, and other automation systems, need to be tracked. For example, harmonizing LVP concentrations and order-set builds between institutions or across the IDN requires coordinating a change in the medication build with inventory changes, smart-pump updates, provider and nurse education related to guidelines and policies, and other activities; those changes would then be considered in addition to updating of active orders and delivery of new medications. Decisions whether to harmonize can also be based on system impact versus the amount of effort required to achieve harmonization (e.g., staffing and support needs for both rollout and maintenance phases of implementation). Regardless, a proper change control process should be in place to predict and subsequently address present and future harmonization barriers to ensure that critical steps are not overlooked. With use of the map of the smaller project plan timelines, a realistic rollout plan for “how to harmonize” can be constructed. Once project planning mapping is completed, examination of individual contracts for existing automation and technology can begin. Contracts, vendor reviews, and requests for proposals. Most practitioners are aware of their institution’s contracting and vendor selection processes, but suggestions for streamlining harmonization steps include conducting a thorough evaluation of (1) current obligations and contracts (Is current equipment owned or leased? Is it supplied by a single vendor or multiple vendors?), (2) current leases (What are the terms and end dates? What are the lease extension requirements? Is renegotiation of terms with same vendor an option?), and (3) currently owned items (What is their resale value? What are the disposal and/or removal costs?). The current-state analysis should include these aspects, and an automation team consisting of anyone from a department affected by harmonization changes can be put together to develop specific automation and technology selection criteria when changes are desired. Vendor reviews and selection processes often begin with an informal scan of the market in order to gather information on potential vendors and how their products and services compare in terms of a list of key questions. There may be “must-have” functionality or a preference for architecture such as a Web-based application, nonproprietary hardware or servers, or a preferred interface technology in different service areas of the IDN (Figure 1). Once vendor reviews have been completed, request for proposal (RFP) and boilerplate language that conform to local contracting requirements within the IDN can be used to complete the process. As part of the RFP process, specific contract milestones should be scheduled, and decision criteria should be established. For larger projects, vendor clarification and information requests, as well as written RFP responses and in-person presentations, should be expected. Milestones should also include vendor demonstrations, presentations, and references to site visit expectations. After the RFP process has been completed, review of proposals should be completed to determine which vendors come closest to meeting the needs of the IDN on the basis of the selection criteria defined at the beginning of the process. Implementation of harmonization plans. Part of the planning process for harmonization efforts should include extensive evaluation of implementation plans. Any design and testing decisions should aim for a mix of vendor recommendations, best practices, and accommodation of current practices that results in the lowest complexity in the redesign of existing systems. If an extensive build-out is required for harmonization efforts, minimum maintenance requirements and maximum compatibility with future workflows and expansions must be considered. Testing and validation of a newly designed or redesigned system should occur “in-step,” or concurrently, in order to minimize rework. For each automation and technology system identified in the current-state analysis (Figure 1), there should be an identical test system, and testing should rarely have to occur in the production system. Functionality that is not working as intended should be discussed with the vendor. The harmonization team should work closely with the vendor to determine how to best approach testing. Also, system administrators should work closely with IDN teams to coordinate efforts to ensure proper flow of data between interoperating systems, authentication of devices and users on the network, and the physical connectivity of the enterprise solution (if any) in terms of power, networking, and location; often this will require collaborative efforts with teams responsible for servers, databases, interfaces, information security, and networks and, potentially, with other facilities. Identification of these resources and their early inclusion in decision-making are vital to meeting projected timelines and deadlines. Special consideration should be given to servers and databases, and someone knowledgeable of the IDN’s server and database teams should be present to initially review and vet all requirements, provide guidance, and solicit clarification when necessary. For institutions with large data warehouses, an early understanding of database schema is important to allow functional data abstraction. Ultimately, a sign-off acknowledging general compatibility must be obtained prior to initializing harmonization projects. “Scalability” of harmonization efforts to current IDN size and future growth should also be assessed, as it might entail the purchase of additional servers. Complexities associated with multiple servers should be weighed against the complexity of a single server, particularly if settings must be maintained across all servers. Downtime associated with a single server will affect the IDN as a whole, whereas downtime issues associated with multiple servers may be isolated. Finally, interfaces, security, and user access all require well-developed and well-tested interfaces between the harmonization technology and the EHR. The use of a single EHR across the IDN may be ideal, and harmonization efforts should follow EHR convergence efforts when feasible. Harmonization across the IDN that is driven by EHR convergence should pave the way for automated harmonization. Issues with divergent formulary configurations, interface specifications, and/or preparation and dispensing workflows can be mitigated by achieving a single EHR. If a single EHR cannot be achieved, efforts to assess functionality and feature gaps associated with each IDN’s EHR must be made. Identification of a future state in which practices are harmonized, whether under a single or multiple EHRs, is also important. Security and user authentication are becoming increasingly important in the healthcare setting as more institutions become targets of exploits and attacks. Understanding IDN security standards for vendor products, including local privileges, password requirements, and remote access and support restrictions, is essential to project success. An initial review and vetting of security requirements for harmonization should include the system or IDN data security officer or a like representative and be conducted prior to or along with any project charter. Likewise, due diligence should be conducted to determine the compatibility of all services associated with an application relative to IDN policies; if they are incompatible, the vendor and/or IDN member should provide a workable technical solution before proceeding with further build and design efforts. Implementation of harmonization plans. When harmonizing existing technologies, IDN leaders must also plan for the impact of the change on the organization as a whole and on any individual users. This planning is accomplished through 2 means: (1) a stabilization phase planned prior to any changes and (2) an optimization and evaluation phase in which optimization of technology and measurement of the results of harmonization are achieved. As previously described, IDN leaders should determine goals or milestones for the stabilization period as a step toward setting the foundation for the optimization phase. Stabilization goals could include defining what “stable” looks like relative to the integration of key applications, team cohesiveness in patient care, or the right connections between components of new and existing systems. Performance levels of any new technology should be ascertained; in addition, a decision as to whether it is necessary to achieve stabilization for a single IDN member or all members involved in a technology change must be made. Technology training needs should be reidentified, and processes necessary to deal with user dissatisfaction should be identified. Finally, routine progress reports should be sent to users and/or relevant IDN members. As previously described, an established governance structure for clear and effective problem resolution during stabilization helps align decisions collaboratively and efficiently. Stabilization work groups that address day-to-day build fixes, workflow, and training issues can be created to focus on specific applications or practice areas. Work groups should provide a mechanism for ongoing feedback and a method to uncover, document, and address workarounds that are discovered. During the stabilization phase, users should try to maximize the efficiency of new workflows and look for opportunities to address issues at the individual IDN member level and across multiple entities that may be involved in harmonization efforts. Users should be encouraged to capture important ideas and suggestions from the stabilization phase work groups for potential inclusion in the optimization phase. Once the organization has achieved the predetermined goals of a stable harmonization effort, energy should be directed toward optimization. Use of reporting and analytics tools should be maximized, and the capabilities of all automation and related technology should be fully leveraged. A defined process for receiving and evaluating project requests from groups of end users should be established and clearly communicated to user groups and department leaders. Members of clinical applications or automation support teams should consider spending time online working as end users to look for opportunities to improve automation and technology harmonization. Surveillance for workarounds should also be performed to address unreported problems. Individuals or groups responsible for ongoing maintenance tasks should develop or refine responsibilities for software or hardware updates, regulatory or compliance changes, and changes to third-party databases (if applicable). Clinical applications or automation support leaders should have a process in place to ensure accountability for ongoing quality assurance and performance improvement. Finally, an important part of optimization is conducting postrollout and poststabilization status evaluations. A comparison of current-state metrics with preharmonization metrics demonstrates the benefits of automation and technology harmonization. A gap analysis of preimplementation projections relative to current-state metrics is also a beneficial exercise to determine whether technology has met expectations. If postimplementation measures are not where they were projected to be, the harmonization leadership team should determine the cause and work to bridge the gap. Finally, leaders should share their findings through publications, presentations, and professional networks. Other organizations will benefit from lessons learned and from understanding preharmonization expectations versus actual postharmonization findings. Conclusion Harmonization is an evaluative process whereby process variation due to automation and technology variability can be reduced and organizational interoperability to meet patient-specific needs can be promoted. Disclosures The authors have declared no potential conflicts of interest. References 1 Knoer S . Stewardship of the pharmacy enterprise . Am J Health-Syst Pharm. 2014 ; 71 : 1204 – 9 . Google Scholar Crossref Search ADS PubMed 2 Woller TW Knoer S Daniels R . Strategic considerations for centralization of services across the pharmacy enterprise . Am J Health-Syst Pharm. 2015 ; 72 : 74 – 7 . Google Scholar Crossref Search ADS PubMed 3 Aguero D Cooley T de la Torre C et al. Optimizing automation and technology across a pharmacy enterprise . Am J Health-Syst Pharm. 2016 ; 73 : 1347 – 50 . Google Scholar Crossref Search ADS PubMed 4 Brown TC Werling KA Walker BC et al. Current trends in hospital mergers and acquisitions . Healthc Financ Manage. 2012 ; 66 : 114 – 8,120 . Google Scholar PubMed Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Harmonization of technology across an integrated delivery network
JO - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp170301
DA - 2018-07-15
UR - https://www.deepdyve.com/lp/oxford-university-press/harmonization-of-technology-across-an-integrated-delivery-network-0dEAam42b3
SP - 1073
VL - 75
IS - 14
DP - DeepDyve
ER -