PHARMACY INFORMATICS

SPECIAL FEATURES

Pharmacy informatics in multihospital health systems:

Opportunities and challenges

Jeffrey Chalmers, Pharm.D.,

Cleveland Clinic Health System,
Cleveland, OH.
Mark Siska, B.S.Pharm., M.B.A., Mayo
Clinic, Rochester, MN.
Trinh Le, M.S., B.S.Pharm., University
of North Carolina, Chapel Hill, NC.
Scott Knoer, M.S., Pharm.D.,
Cleveland Clinic Health System,
Cleveland, OH.
Purpose. Challenges and opportunities in managing pharmacy-related
technology in a multihospital health system are reviewed.
Summary. With electronic medical record (EMR) implementations, phar-
macy technology deployments, and increased numbers of hospitals merg-
ing into single health systems, opportunities and challenges for pharmacy
informatics (PI) teams have grown. Pharmacy leaders must consider the
implications of using technology in a multihospital health-system environ-
ment, as well as the impact of the health system’s organizational structures
on technology implementations and dedicated support teams. Common
challenges in achieving EMR and other technology implementation and
standardization initiatives in multihospital health systems include harmoni-
zation of practices across hospitals of various sizes and types and issues
of platform compatibility and interoperability. PI teams must collaborate
with information technology teams at the system level to identify prac-
tical strategies for making the best use of available resources to imple-
ment pharmacy automation and software to help pharmacists continue to
provide safe and effective patient care. The organizational structures that
affect informatics teams, pharmacy integration and standardization initia-
tives, formulary management practices, data management and analytics,
and clinical decision support systems all must be areas of focus.

Conclusion. An integrated pharmacy enterprise can be well positioned to

leverage operational efficiencies gained from appropriate use of technol-
ogy to enhance patient care. Careful attention must be paid to the manner
in which these systems are designed, implemented, and managed in order
to make the best use of the technological resources used by the health
system.

Keywords: automation, electronic health record, health system, informat-

ics, technology

Am J Health-Syst Pharm. 2018; 75:457-64

Address correspondence to Dr. Chalmers

(chalmej@ccf.org).
This article is part of a special AJHP
theme issue on pharmacy practice
in multihospital health systems.
Contributions to this issue were
coordinated by AJHP Editorial Advisory
Board member Scott Knoer, M.S.,
Pharm.D., FASHP; and Senior Director,
ASHP Section of Pharmacy Practice
Managers, David F. Chen, B.S.Pharm.,
M.B.A.
Copyright © 2018, American Society of
Health-System Pharmacists, Inc. All rights
reserved. 1079-2082/18/0401-0457.
DOI 10.2146/ajhp170580
S
everal factors have resulted in an
increase in hospital mergers and
acquisitions and business partner-
ships across the United States over the
past 15 years. Healthcare reform and
a desire to increase market share and
negotiating power with payers and
suppliers are both contributing fac-
tors that have fueled this trend.1 The
mergers and acquisitions trend has
overlapped with the introduction of
more robust and comprehensive elec-
tronic medical record (EMR) systems
that have the ability to support mul-
tiple hospitals’ clinical and financial
systems on a single platform. Within
pharmacy departments, there has also
been a significant increase in the de-
ployment of technology to support the
medication-use process.
With EMR implementations, phar-
macy technology deployments, and
more hospitals merging into single
health systems come more opportu-
nities and challenges for pharmacy
informatics (PI) teams.2 Technology
can be leveraged as a driver of practice
standardization across organizations;

AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018  457

 SPECIAL FEATURES PHARMACY INFORMATICS
however, commonly there are chal-
lenges with harmonization of prac-
tices in a system of hospitals of differ-
ing sizes and with differing levels of
patient acuity. Pharmacy technologies
have increasing compatibility across
platforms, but challenges with in-
teroperability still exist, and platforms
often require labor-intensive main-
tenance and support. Centralized
technology systems engender a vast
amount of data to be explored, mined,
summarized, and acted upon. Report-
ing, analytics, and data management
require employees with unique skill
sets and in greater numbers than were
previously required.
This article reviews the implica-
tions of using technology in a multi-
hospital system environment and the
impact of the system on the use of
technology and the teams dedicated
to supporting it. We will examine the
different types of challenges that are
present in multihospital systems as
well as practical strategies used to
make the best use of available re-
sources to allow pharmacy automa-
tion and software to help pharmacists
continue to provide safe and effective
patient care.
Organizational structure
As pharmacy and information
technology (IT) departments con-
tinue to modify their organizational
structures to meet the growing de-
mands of an integrated healthcare
delivery system, PI teams must also
consider moving away from tradi-
tional departmental models to those
that provide a cross-system perspec-
tive.3 Leveraging PI at an enterprise
level comes with many challenges yet
creates opportunities to reduce inef-
ficiencies and variability while allow-
ing for shared experiences, skills, and
expertise across technology, practice,
and informatics domains. A number
of approaches for architecting an en-
terprisewide PI team exist; however,
the most common design initiatives
should include defining structures
with clear roles and responsibilities
and mapping process accountabilities
458    AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018
KEY POINTS
• To effectively support the organ-
ization, the pharmacy informat-
ics team must maintain positive
collaborative working relation-
ships with both the pharmacy
and informational technology
departments.
• The pharmacy informatics (PI)
team plays a key role in health-
system integration and change
management.
• Key broad roles of PI teams
within the organization include
formulary management (across
multiple applications), clini-
cal decision support, and data
management and analytics.
to specific roles. Other design aspects
to consider include ensuring that the
team and/or team structure
• Enables a central approach capable
of delivering sustained value and
increased efficiencies through
economies of scale,
• Is nimble and responsive with local
and regional support so that the
right skills and resources can be
allocated to the highest-priority
initiatives,
• Promotes adoption of strategically
aligned technologies,
• Allows for collaboration and sharing
of experiences, skills, and expertise
across various areas of practice and
technologies,
• Enables and fosters collaborative
and transparent healthcare technol-
ogy industry relationships,
• Extends medication management
informatics beyond the sphere of
traditional pharmacy responsibili-
ties and allows for continued align-
ment with the practice of pharmacy,
• Participates in and exerts influence
at all levels of the organization,
including the C-suite,
• Reflects a centralized and best-
practice approach to data, infor-
mation, knowledge delivery, and
change management
• Fosters, performs, and applies
research involving the core issues of
clinical informatics, and
• Monitors, measures, and evaluates
systems effectiveness while assisting
in optimizing assets.
Roles and responsibilities
A PI team with a high-functioning
organizational structure will deliver a
coordinated approach to driving ap-
plied IT forward—not only in terms
of infrastructure but in terms of us-
ability and integration across the care
continuum.4 Team members’ broad
knowledge of pharmacy practice and
the health system’s culture enables
them to augment care team resources
with advanced technologies that im-
prove patient care and access and an
organization’s reach. Their primary
role must support 5 broadly defined
categories of functions:
1. Data, information, and knowl-
edge management—Managing
medication-related information
while promoting integration,
interoperability, and information
exchange
2. Information and knowledge
delivery—Delivering medication-
related knowledge throughout the
clinical knowledge lifecycle (from
the point of knowledge generation
to cataloging data and embedding
knowledge into workflows) and
measuring the usage and effective-
ness of that knowledge
3. Practice analytics—Developing
point-of-business analytic solutions
for improved decision-making
4. Applied clinical informatics—
Applying user experiences, research,
and principles of theoretical infor-
matics to improve clinical practice
and usability
5. Leadership and management of
change—Ensuring alignment with
existing practice, technology, and in-
formatics organizational structures
 PHARMACY INFORMATICS SPECIAL FEATURES
and participation in the procure-
ment, customization, development,
implementation, management, eval-
uation, and continuous improve-
ment of clinical information systems
Essential job responsibilities nec-
essary to support the primary roles of
pharmacy informatics teams should
center on functional and shared ser-
vices and should include
• Application support and
maintenance,
• Application optimization and
development,
• Service and solution manage-
ment (e.g., training, downtime
contingencies),
• Monitoring and evaluation of sys-
tem effectiveness,
• Project management,
• Business intelligence and analytics
development, maintenance, and
support, and
• Data and informational governance.
Determining if the PI team is or-
ganizationally aligned primarily with
the pharmacy department or with the
IT department is another important
factor to consider. Prior to the health-
care technology integration era, phar-
macy IT teams were traditionally
positioned within regional or local
pharmacy departments. The grow-
ing need to implement EMR systems
at the turn of the century prompted
healthcare organizations and their
supporting IT departments to broad-
en their perspective and reach across
the enterprise. PI teams that may not
have been effectively organized at a
system level were often moved stra-
tegically to IT departments to sup-
port the medication management
aspects of patient care at the system
level. As pharmacy departments be-
gin to organize across the broader
health system, PI teams may con-
sider remaining in their professional
home while maintaining an enter-
prise medication management view
and collaborating effectively with the
system’s IT department. There is not a
clear consensus on the most effective
approach, as there are benefits and
challenges with each. It is critical that
the PI team maintain an effective col-
laborative relationship with both de-
partments. The team is uniquely posi-
tioned to work with pharmacy leaders
to problem solve and optimize tech-
nology related to the medication-use
process. Without knowledge of the
IT department’s vision, processes,
strategies, and timelines, the PI team
will struggle with misperceptions,
miscommunication, and overlapping
work between the 2 groups; this can
only be remedied by consistent inter-
action and positive relationships with
leaders and teams in both the IT and
pharmacy departments.
Regardless of how an integrated
healthcare system defines direct re-
porting relationships, PI will be most
effective when designed and posi-
tioned to support not only pharmacy
practice but also collaborative work
at all levels of the organization where
decisions are made involving health-
care IT and medication management
(Figure 1).
Pharmacy systems
standardization
Standardization is inevitable as
health systems evolve under tremen-
dous pressure to reduce resource use.
Health systems comprising multiple
community, critical access, and teach-
ing hospitals have varying pharmacy
practices and resources. There are a
number of reasons to start the cul-
ture change of standardization. A
common catalyst is the selection of a
new enterprisewide EMR. Implemen-
tation of a new EMR may start with a
discussion with the vendor about the
recommended standard configuration
for key workflows. There will often still
be specific practice design􀀆decisions
to be made, as the standard configura-
tions are typically basic and not inclu-
sive of optional customizations.
There are 3 key steps that may de-
termine a health system’s success in
developing the standardization cul-
ture: (1) enlisting champions from
AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018  459
the highest leadership ranks (chief
executive, pharmacy, medical, and
operating officers) to support clinical,
quality, and operational standardiza-
tion, (2) leveraging a strong gover-
nance structure, and (3) developing
key guiding principles and a decision-
and-escalation pathway
Several areas of standardization
can be accomplished throughout the
health system. Standardization is la-
bor and time intensive and will re-
quire a strong organizational commit-
ment to be successful. Some examples
of successful IT standardization proj-
ects are
• System portfolio simplification,
which allows reduction of IT costs
and contracts and negotiation with
a preferred vendor,
• Pharmacy operational initiatives—
from i.v. room processes to supply
chain5 and formulary processes—
leading to centralized shared ser-
vices models, and
• Pharmacy clinical system practice
initiatives such as antimicrobial
stewardship requirements.
Whether the health system tackles
small or large standardization proj-
ects, it will gain benefits and encoun-
ter challenges. Practice redesign will
happen at both small and large hos-
pitals. Health-system standardization
at the IT and pharmacy operational
levels can be viewed as a classic varia-
tion of the Kübler-Ross model.6 The 4
stages of the change curve for system
standardization are denial, resistance,
exploration, and commitment. Most
clinical end users in the denial stage of
change do not believe that the change
is happening and try to ignore think-
ing about it. Resistance to change be-
gins as these clinical users realize that
the change is actually taking place and
there is no way to avoid it. During this
stage of the change curve, feelings like
fear and anxiety can build up, which
can create substantial barriers to im-
plementation. The next stage of the
change curve is the exploration phase,
in which team members discuss the
 SPECIAL FEATURES PHARMACY INFORMATICS

Figure 1. Typical organizational structure and flow of technology integration and standardization initiatives for a multihos-
pital health system with several operational regions.

Chief pharmacy Chief medical

officer and information
director of officer and chief
pharmacy information officer

Chief pharmacy
informatics officer
and director
of pharmacy
informatics

Strategic and functional direction and implementation

Ambulatory Medication Outpatient Reporting, Hematology,

and acute care management pharmacy analytics, oncology,
medication automation and clinical population and research
management departmental systems and health, and systems
clinical systems systems automation individualized
medicine

Pharmacy
informatics
resident

Regional support and maintenance teams

Region 1 Region 2 Region 3 Region 4

standardization and work toward so-
lutions or influencing the operational
impact. At this stage, people start act-
ing in and learning new ways to con-
tribute to the change. Commitment is
the final stage of the change curve and
is achievable through strong leaders
and processes.
Systems that can identify and re-
duce unwarranted variation will ben-
efit in several ways. However, there are
some operational and clinical initia-
tives that cannot be standardized due
to variations in hospital structures,
sizes, and types of practice. Common
challenges include resource varia-
tion and constraint in areas such as
staffing (i.e., enlisting staff champi-
ons), hours of pharmacy operations,
and financial risk tolerance. Another
challenge, one specific to multistate
health systems, is variation in indi-
vidual state requirements or regula-
tions. Differences in state or federal
interpretation of pharmacy practice
can be a hindrance to standardization;
examples may include laws or rules
requiring 2-factor authentication for
medication verification and differ-
ences in controlled medication clas-
sifications among states. Variation in
patient acuity or patient care service
offerings can be another standardiza-
tion challenge. Some hospitals may
have specialty services such as stroke
prevention, pediatrics, level 3 neona-
tal intensive care units, and special-
ized cardiology services, while others
do not offer these patient services or
primarily serve a less complex patient
population; these variations influence
the discussion around order sets and
other EMR functionalities.
Integration efforts can be increas-
ingly frustrating for end users and
managers because the process feels
time-consuming, bureaucratic, and
less “agile” than when those efforts
were autonomous and indepen-
dent; this may be particularly true
for smaller hospitals accustomed to
implementing changes quickly. It is
important to identify the key stan-
dardization processes that provide the
most value and to allow each hospital
within the system to maintain cus-
tomized processes and its own pace

460    AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018

 PHARMACY INFORMATICS SPECIAL FEATURES
of change with regard to processes
and workflows for which standard-
ization is not necessary or beneficial.
Challenging the status quo and pursu-
ing the question “Can this change be
considered so that our practice can be
more standardized?” are imperative to
continuous quality improvement and
the process of standardization.
Efficiency
Efficiencies are gained with a
standardized process, especially in
the IT arena and with regard to man-
aging the complexities of pharmacy
services. Standardized IT systems
typically require fewer resources for
maintenance tasks and allow infor-
matics teams to devote more time to
optimization projects. With a mostly
standardized workflow and formu-
lary, a centralized model of analyst
support is possible.
There are a number of advantages
to having a centralized service and
support model aside from avoidance
of duplicative resource use. One of
the key advantages pertains to service
delivery. With a centralized model,
cross-training can be conducted to
ensure that support personnel are
not specialized in only 1 area and can
consistently support pharmacy infor-
mation systems. With a centralized
support team, it is possible to respond
to a variety of needs with just the right
amount of support. The team can con-
sist of specialists with much more ex-
perience than generalists and deliver
higher-quality support as needed.
Centralized teams can also more
easily leverage knowledge sharing and
collaboration to support end users.
Cross-trained and redundant teams
also allow for coverage when person-
nel are out of the office.
In a local support model, support
resources are often duplicated in each
hospital within a health system; this
may be required in order to fill many
ad hoc roles in each pharmacy depart-
ment. This model often is compart-
mentalized and may not be a key topic
of discussion in strategy meetings
within the IT department on topics
such as change control management
and auditing or security requirements.
The local-support model is seen to be
more “personalized”; however, in this
model, support analysts often cannot
be crossed-trained to support mul-
tiple systems.
Local support, provided in col-
laboration with the centralized team,
will likely be required for some spe-
cific maintenance activities requiring
an onsite presence. Automation and
device-related maintenance often re-
quire that work be performed within
the local pharmacy. Local team mem-
bers can serve as liaisons to the cen-
tralized team and make it aware of
problems occurring locally that may
not otherwise be visible.
Formulary management
It is common for an individual
hospital to maintain a specific formu-
lary, or list of medications, that the
pharmacy is committed to acquiring,
preparing, and dispensing for patient-
specific use. In an integrated multi-
hospital system, there is often a desire
to maintain a single common formu-
lary across the health system. Even
when this scenario is in place, there
are typically many medication lists or
databases to maintain.
EMRs, automated dispensing cabi-
nets (ADCs), carousel inventory man-
agement systems, robotic dispensing
systems, smart infusion pump soft-
ware, i.v. room workflow management
software, and robotic compounding
systems are all examples of devices
and applications that likely contain
a database of medications. Within a
health system, these devices and ap-
plications can become very complex
and challenging to maintain when
each institution has a different hos-
pital formulary. It is less complex but
still challenging to maintain separate
formularies when there is an agreed-
upon standard across the organi-
zation. In either case, there are best
practices that may be considered to
allow for the most efficient and accu-
rate maintenance of medication lists
across the enterprise.
AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018  461
Common medication identifiers.
Although hospitals may need to stock
different medications, the use of com-
mon medication identifiers should be
strongly considered to avoid the use
of crosswalk tables or other interface
logic to relate like medications in dif-
ferent formularies.
Use of a medication build
guide. Frontline clinicians will likely
view medications on a variety of plat-
forms (e.g., ADCs, EMRs, medication
labels). It is important that medication
orders are built to the same standards
regardless of the system by which they
are configured. A systemwide medi-
cation build guide, which may be a
simple document or a more complex
electronic guide, can be useful in stan-
dardizing medication configurations
across systems. Considerations during
development of a medication guide
may include but are likely not limited
to
• Consistent use of capital and lower-
case letters,
• Standard representations of brand
names,
• Dose rounding (e.g., rules on the
number of decimal places for denot-
ing the strength of liquid prepara-
tions or how many times a tablet can
be split),
• Use of extended-release modifiers
(e.g., XR, SR, XL),
• Use of abbreviations to denote dos-
age forms (e.g., “INJ” for injectable)
and container types (e.g., syringe,
vial, ampule),
• Text formatting (e.g., consistent use
of bold or italic lettering), and
• Terminology for storage instructions
(e.g., refrigerate, protect from light,
do not crush).
Change management. Certain
fields within a formulary entry should
be considered high-risk fields for
changes; these may include round-
ing considerations, billing units, and
costs. Consider putting a double-
check process or notification system
in place so that only appropriately au-
thorized staff members make updates
 SPECIAL FEATURES PHARMACY INFORMATICS
to these fields in order to assure trans-
parency in the event of changes.
Postimplementation commu-
nication. There are typically stake-
holders who need to be informed as
changes are made to the formulary.
Stakeholders may include buyers, fi-
nancial analysts, department manag-
ers, local pharmacy automation man-
agers, and nursing staff leaders, all of
whom should be made aware as medi-
cations are added to or removed from
hospital-system formularies. Systems
to communicate relevant information
to the correct personnel at the right
time should be in place.
Centralized formulary man-
agement. Depending on the size of
the organization, it is often advisable
that formulary maintenance be per-
formed by a central team dedicated
to maintaining system formulary
standards; this is especially true with
regard to the EMR due to the large
number of clinician users who can be
affected by variances in the standards.
Some inventory management systems
(ADCs and carousels) may need to be
maintained locally due to the need to
physically stock the devices, associate
barcodes with products, and trouble-
shoot problems.
Data management and
analytics
As a healthcare system aims to be
more performance driven, it will have
a number of medication management-
related informational needs, including
needs related to formulary use, cost
of care, expenses, forecasting, op-
erational performance, safety, patient
treatment and adherence, and drug
utilization.7 Meeting these needs will
require an organizational structure
that can effectively leverage informa-
tion to monitor and provide insight
into performance.
To address these challenges,
healthcare organizations must have a
culture and organizational structure
that recognize medication manage-
ment data and information as foun-
dational assets in patient care, quality
improvement, research, and educa-
462    AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018
tion. The structure must extend to the
enterprise level, allowing more con-
sistent and comprehensive historical,
concurrent, and prospective insight
into medication use within the health
system. This structure must include
and/or reflect
• Data architecture and design
strategy,
• Data quality oversight,
• Governance,
• Cross-functional collaboration and
coordination across all disciplines,
• The corporate vision of analytics,
• Flexibility and alignment with indi-
vidual business units, and
• A team or program anchored by the
PI team.
Clinical decision support
Effective clinical decision support
(CDS) interventions have the potential
to provide great value in terms of safe-
ty and efficiency within electronic sys-
tems used in health systems. However,
many of the unintended consequenc-
es associated with the implementa-
tion of EMR systems have happened
because of suboptimally conceived
and implemented CDS strategies.8,9 A
complete review of key CDS concepts
is beyond the scope of this article;
these concepts are described in great
detail in well-recognized publications
supported by organizations such as
the Agency for Healthcare Research
and Quality, the Office of the National
Coordinator for Health Information
Technology, and the Healthcare In-
formation and Management Systems
Society.10-12 Here we examine the key
components that consistently con-
tribute to successful CDS teams with-
in multihospital systems.
The CDS team. Within an inte-
grated delivery network, medication-
related CDS initiatives can originate
from key organizational strategic
goals or from specific departmental
requests and needs; this results in a
long list of varied potential stakehold-
ers associated with a given CDS ob-
jective. The CDS team therefore must
also encompass different areas of pro-
fessional practice if it is to effectively
assess potential interventions and the
associated implementation strategies.
Successful CDS teams should include,
at minimum, the chief medical infor-
mation officer; the chief nursing in-
formatics officer; the chief pharmacy
informatics officer; EMR technical
experts from nursing, pharmacy, and
IT; EMR vendor support; and other
specialists to be engaged on an ad hoc
basis, such as emergency department,
obstetrics, oncology, and anesthesia.
Project intake. Ideally, a signifi-
cant portion of the CDS team’s efforts
will be devoted to interventions to ad-
dress the most strategic goals of the
health system. These projects are typi-
cally time and labor intensive due to
their broad scope, large stakeholder
base, and extensive training, commu-
nication, and implementation plans.
Examples of these projects may in-
clude high-risk patient prioritization
systems, venous thromboembolism
prophylaxis screening and treatment
programs, and hospital readmission
reduction projects. In most cases,
these projects are balanced with
smaller, more targeted projects origi-
nating from specific areas or depart-
ments. These smaller projects need
to be reviewed and assessed for their
overall value to the organization, as
they likely cannot all be taken on by
the team due to resource constraints.
Some organizations have used quan-
titative prioritization techniques that
consider factors such as the number
of users potentially affected by the in-
tervention, the risk and severity of pa-
tient adverse events if the issue is not
addressed, the potential cost savings
for the organization, and the resource
requirements for the functionality
to be implemented. Project intake
challenges are not exclusive to CDS-
related projects and are found across
all domains of informatics project
management.
Implementation. Implementation
of specific interventions also has impli-
cations for health systems. It is typical
for health systems to be composed of
hospitals of a variety of sizes and types.
 PHARMACY INFORMATICS SPECIAL FEATURES
Due to differences in the delivery of care
at these facilities, it becomes critical to
understand the impact of a proposed
CDS intervention across the organi-
zation. This understanding will often
result in the need to engage stakehold-
ers from the different sites who will
eventually use the tools deployed so
that they can assist in the assessment
of the potential solutions. Availability
can be an issue for these ad hoc team
members due to their patient care
responsibilities. The dedicated CDS
team may need to arrange meetings
with these individuals locally (at their
practice sites) or via Web conferences
to get their feedback; regardless, their
participation in projects is often a crit-
ical factor in the overall success of the
intervention.
Once the intervention has been
evaluated, designed, configured, and
tested, the CDS team will need to de-
termine the timing of training, com-
munication, and rollout. Again, this
can be more complex in larger orga-
nizations due to competing project
implementations. Organizations typi-
cally want to minimize the number of
changes affecting their clinical staffs
in a given time frame, and, therefore,
the CDS team will want to interface
with other project teams to determine
the best time for the full implementa-
tion of the project.
Monitoring and optimization.
The last—and most often overlooked—
aspect of a CDS project in a multihos-
pital system is the monitoring and opti-
mization phase of the implementation.
The reasons that this phase is often not
conducted can often be traced to the
amount of resources dedicated to it.
There is often pressure to get the next
problem solved or the next project
underway. The implementation team
may be the most knowledgeable of the
details of the intervention, but a sepa-
rate team dedicated to monitoring the
effectiveness of the intervention may
be necessary to combat the inclina-
tion to “move on.” Consideration can
also be given to leveraging the pri-
mary stakeholders benefiting from the
intervention to assist with analysis of
data to demonstrate the ongoing ef-
fectiveness of the project as a condi-
tion of participation in the process.
The methods used to monitor an
implementation will vary accord-
ing to the tools or technology used
to solve the problem addressed. If an
interruptive alert was implemented,
understanding the frequency of alert
firing and knowing the actions staff
members are taking in response to the
alert are clear starting points for mon-
itoring. Surveying staff members who
have encountered the alert regard-
ing its usability and the clarity of the
message conveyed is also important.
Other tools, such as order sets and
dashboards, may be monitored for ac-
cess and usage to ensure that the clini-
cal staff is aware of the tools and what
they are intended to be used for. The
monitoring and optimization plan is
developed as the solution is being im-
plemented and configured, since the
methods for monitoring will depend
on knowledge of how the intervention
is built within the system in which the
intervention is deployed.
Knowledge management. Suc-
cessful organizations will quickly find
the quantity of CDS content avail-
able to their clinical staff in their EMR
growing. There is a need for a coordi-
nated knowledge management effort
to accompany this growth. Knowledge
management is defined as “a com-
prehensive approach for acquiring,
adapting, and monitoring information
for use in clinical decision support
that keeps it up to date with current
clinical evidence, expert consensus
and location conditions including
pertinent health information system
implementation(s).”8 Care paths, or-
der sets, dashboards, and alerts con-
tain logic and clinical content that can
quickly become dated or inaccurate if
left unattended.
The first step of knowledge man-
agement is the knowledge of what
content is deployed within a system.
Maintaining a database or catalog of
the different types of CDS tools an or-
ganization has in place, in addition to
the rationale or business process they
AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018  463
are intended to support along with
basic information regarding the con-
figuration or build techniques used
and the last date on which the content
was reviewed, is the starting point for
being able to manage the data con-
tained in CDS tools. This is another
area where frontline clinical experts
can and should be engaged to assist
with content review. Many organiza-
tions use a rolling schedule of reviews
to ensure that each piece of content is
reviewed in a reasonable time frame in
an effort to keep the content as accu-
rate as possible.
Managing PI initiatives across a
multihospital system requires a com-
prehensive, knowledgeable team that
is tightly integrated with the pharma-
cy and IT leadership teams and other
stakeholders of the medication-use
process. Adoption of medication-use
technologies is often a driver of opera-
tional standardization within a multi-
hospital system. Resources should be
applied in a manner that allows ad-
equate maintenance of systems, with
focus and priority given to optimiza-
tion projects. Challenges with stan-
dardization efforts and system optimi-
zation persist, but a well-designed and
tightly integrated PI team will assist
the pharmacy department in having
a positive impact on organizational
priorities as well as pharmacy-specific
initiatives.
Conclusion
An integrated pharmacy enter-
prise can be well positioned to lever-
age operational efficiencies gained
from appropriate use of technology
to enhance patient care. Careful at-
tention must be paid to the manner in
which these systems are designed, im-
plemented, and managed in order to
make the best use of the technological
resources used by the health system.
Disclosures
The authors have declared no potential
conflicts of interest.
References
1. American Hospital Association.
Trendwatch chartbook 2014. www.
 SPECIAL FEATURES PHARMACY INFORMATICS

aha.org/research/reports/tw/
chartbook/2014/14chartbook.pdf
(accessed 2017 Oct 28).
2. Siska MH, Tribble DA. Opportunities
and challenges related to technol-
ogy in supporting optimal pharmacy
practice models in hospitals and
health systems. Am J Health-Syst
Pharm. 2011; 68:1116-26.
3. Garbarz DM, Reichard JS. A system
approach to pharmacy leadership
(March 2016). www.pharmacytimes.
com/publications/health-system-
edition/2016/march2016/a-
system-approach-to-pharmacy-
leadership?p=2 (accessed 2017 Mar
25).
4. Siska M. ASHP statement on the
pharmacist’s role in clinical informat-
ics. Am J Health-Syst Pharm. 2016;
73:410-3.
5. Moore D. Optimizing medication
inventory through consolidation
(May 2014). www.pppmag.com/
article/1508 (accessed 2017 Mar 25).
6. Mind Tools Ltd. The change curve: ac-
celerating change, and increasing its
likelihood of success. www.mindtools.
com/pages/article/newPPM_96.htm
(accessed 2017 Oct 15).
7. Dudas J, Siska MH et al. Medication
management analytics white paper
(unpublished internal document).
Rochester, MN: Mayo Clinic; 2016.
8. Oscheroff JA, Pifer EA, Teich JM et
al. Improving outcomes with clinical
decision support: an implementers
guide. Arlington, VA: Health Infor-
mation Management and Systems
Society; 2005:110.
9. Campbell EM, Sittig DM, Ash JS et al.
Types of unintended consequences
related to computerized provider
order entry. J Am Med Inform Assoc.
2006; 13:547-56.
10. Berner ES. Clinical decision support
systems: state of the art (June 2009).
https://healthit.ahrq.gov/sites/de-
fault/files/docs/page/09-0069-EF_1.
pdf (accessed 2017 Dec 22).
11. Karsh BT. Clinical practice improve-
ment and redesign: how change in
workflow can be supported by clinical
decision support (June 2009). https://
healthit.ahrq.gov/sites/default/files/
docs/page/09-0054-EF-Updated_0.
pdf (accessed 2017 Dec 22).
12. Healthit.gov. Clinical decision sup-
port (CDS) (January 13, 2015). www.
healthit.gov/policy-researchers-
implementers/cds-implementation
(accessed 2017 Mar 15).

464    AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 7 | APRIL 1, 2018