The Pharmaceutical Journal 587

Automation

(Vol 285) 20 November 2010www.pjonline.com

Spending cuts and cost-saving are frequently mentioned in the media, and the NHSis not immune to them. Could automation in pharmacies help increase efficiencyand cut costs? Ailsa Colquhoun investigates

Media coverage of the robotic installation atthe Forth Valley Royal Hospital inStirlingshire makes clear the media’sexpectation for the NHS in this post-spending review era of financial austerity.

Headlines such as “Hospital robots cuthospital pharmacy bill” appeal to anincreasing sense of national thrift, sharpenedrecently by the announcement of cuts inpublic spending. They also lend timely weightto the argument for pharmacy automation,said Ron Pate, secondary carepharmaceutical adviser at the department ofmedicines management at Keele University.He said: “In this economic downturn, thespotlight is on systems that do more, do itbetter and do it with less.”

Forth Valley Royal Hospital has risen tothe attention of the national media on theback of the £700,000 worth of hospital drugsbill savings achieved by spending between£500,000 and £600,000 on a dispensingrobot and a bespoke eWard system, as well asthe army of subterranean robot porters that

transport everything from meals to clinicalwaste around the new site.

The robot, an ARX robotic systemdispensing system installed for just under£400,000, features automatic loading andlabelling — the latter of which is a first forScotland.

This supports the use of the eWardsystem, a paperless ward system developedand refined by the NHS Forth Valleypharmacy team using methodology from theUS-based Institute of Health Improvement.It is now available to trusts as a ready-madepackage from Glasgow-based company TheSolution Works.

The hospital uses Ascribe pharmacysoftware and includes the two-way interfacewith the ARX robot that is on site, and theadditional labelling functionality. The Ascribesystem “asks” the robot for an item. If it is instock, it is accurately dispensed by the robotand labelled. If it is not in stock, pharmacystaff will receive a message so that they knowthey will have to look elsewhere.

eWard systemThe eWard system holds patientdemographics, clinical diagnoses andtreatment plan information, and allows therecording of medicines reconciliation onadmission. For the pharmacy, this hasenabled 80–90 per cent of patients cominginto acute care to have their medicationdetails electronically recorded and medicinesreconciliation completed within 24 hours,seven days a week. This compares well withthe previous figure of 10 per cent, five days aweek, and it has contributed to reductions inhospital death rates, says Jann Davison, leadclinical pharmacist at Forth Valley.

For staff, including technicians, the mainbenefit of dispensary and ward automationhas been to increase the amount of wardcontact time, and technicians now workalongside pharmacists to complete medicinesreconciliation on admission. According toMrs Davison, this has improved patient careto levels that, without automation, would haveneeded double the amount of staff to deliver.

Could automation improve efficiencyand help pharmacies with cost saving?

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HOW ROBOTICS FITSINTO QIPPRon Pate, secondary care pharmaceuticaladviser at the department of medicinesmanagement at Keele University, describeshow, in his view, robotics fits into all aspects ofthe NHS Quality, Innovation, Productivity andPrevention programme:

• Quality Reduced patient waiting times foroutpatients and discharge patients; timelyward stock deliveries; and redeployment ofstaff to enhance near-patient services

• Innovation New technology and improvedmedicines security at ward level

• Productivity Reduced dispensing time;space savings and ergonomic benefits;supported skill mix review/staffredeployment; and reduced stock holding

• Prevention Reduced dispensing errors;reduced “lost” prescription income out ofhours; reduced staff absenteeism throughsickness or lack of engagement with routinetasks

LEANLean is an improvement approach to improveflow and eliminate waste that was developed byToyota. Lean is basically about getting the rightthings to the right place, at the right time, in theright quantities, while minimising waste andbeing flexible and open to change.Lean brings into many industries, including

healthcare, new concepts, tools and methodsthat have been effectively used to improveprocess flow. Tools that address workplaceorganisation, standardisation, visual control andelimination of non-value added steps areapplied to improve flow, eliminate waste andexceed customer expectations.(Source: NHS Institute for Innovation andImprovement)

In stock control terms, the eWard systemhas freed staff to address the efficiency ofward-based pharmacy top up and themanagement of ward drug stocks. Byensuring patients’ own drugs are used duringtheir stay and on discharge, staff havedecreased the amount of medicines dispensedby more than 20 per cent. Such are thesavings made that the hospital has introduceda “cost-neutral” weekend clinical pharmacyservice (the costs of introducing the servicewere offset by the savings made byautomation). There has also been a 50 percent reduction in the time taken to dischargea patient, a process that is helped by eWard’sfacility to email patient discharge letterswithin six hours. The hope is to pilot thesharing of this information with localcommunity pharmacies, with a view to roll-out during spring and summer 2011. MrsDavison hopes that, ultimately, this willbecome a two-way process, with communitypharmacies feeding patient information intothe admissions process.

Since its official launch in August 2010,there have been many visitors to Forth Valley,including Scotland’s chief pharmaceuticalofficer Bill Scott, who has described it as“technically the best in Scotland”. MrsDavison is quick to commend theautomation. She says: “We have created aninfrastructure for patients that improvessafety and quality. People tell me they can’tafford it, but I tell them they really can. Theinvestment will more than pay for itself.”

Strategic driversThe NHS has no shortage of national driversthat seek to achieve the goal of improved costefficiencies. In Scotland, there is the NHSScotland Quality Strategy, and, in England,the Quality, Innovation, Productivity andPrevention (QIPP) programme, and theCommissioning for Quality and Innovation(CQUIN) framework. Specifically targetingefficiencies through automation are thevarious national programmes for NHS IT.

Mr Pate thinks that these nationalstrategies present significant opportunities forNHS pharmacy department heads to makethe case for investment in automation.Speaking at a pharmacy robotics conferencein September, Mr Pate told participants thatautomated dispensing systems are “a QIPPand CQUIN opportunity”. He said QIPP isall about re-engineering the care pathway toimprove value. It is his view that robotics fitsinto all aspects of QIPP (see Panel).

values, and make efficiency improvementsthat maximise service delivery without slash-and-burn budget cuts.

At North Staffordshire, Lean principleswere applied to four key processes: goodsreceipt, filling the robot, ward box filling anddispensing processes. Lean thinking resultedin the replacement of the computer system,the integration of store and a separatedispensary, and the installation of aRoboPharma automated dispensing systeminterfaced with an Ascribe pharmacycomputer system. A new system for dischargedispensing was also established.

The result, says Miss Fowler, is that stock-holding values have been reduced and therehave been improvements in dischargemedicine waiting times. Staffing costs (ie,overtime) have also been reduced and theautomation has been used to inform thefuture workforce plan.

However, the process has also flagged up anumber of important lessons learnt. She saysthat trusts considering significant automationneed to ensure they:

• Understand what they are buying, how itworks and how it will fit in with existingdepartment processes and workflows

• Allocate sufficient staff resources to theproject

• Actively seek staff engagement, particularlyduring interface development and futuredevelopments

• Receive in-depth supplier training

Beryl Langfield is the executive leadpharmacist for computers, projects andbusiness services at Imperial CollegeHealthcare NHS Trust. She believes that asuccessful installation must also beaccompanied by adequate support from theIT department. She says: “Once you havedrugs locked in e-cupboards, you needreliable IT support to ensure that the ITdoesn’t just fall over. She also urges trusts totake the long-term view to implementing newpharmacy technologies. She says: “The

Looking at the CQUIN framework, MrPate points out that the current 1.5 per cent“reward” (repayment of contract income) forsuccessfully delivering a CQUIN schemecould be worth about £2m to the averagetrust. Describing discharge medicine waitingtimes in some trusts as horrendous and anembarrassment, he says that trusts shouldseek out CQUIN funding for services thatcould improve this measure. “It is highlylikely that CQUIN budget will rise above itscurrent contract value level,” he forecasts,adding that speculative figures of 10 per centof contract value have been floated. “Trustsshould go for CQUIN funding where theycan. The cash is there to be had,” he said.

Lean towards automationAnother current national driver of trustinvestment in automation is Lean (see Panel),says Heather Fowler, the project managercontracted to deliver four workstreamsinvolving automation at University of NorthStaffordshire NHS Trust. She says:“Although many of us have tried to applyLean thinking in the past, it now has a name-tag, and that is driving its use.”

In the project at North Staffordshire, MissFowler was charged with delivering the trust’svision for electronic medicines management.This includes electronic prescribing,automated ward storage and electronicdischarge. The vision was achieved againstwhat Miss Fowler describes as a “challengingcost improvement plan”.

Lean principles aim to ensure thatattention is focused on understanding what isimportant (the value) and eliminatingeverything that is waste (the non-value). Byapplying lean strategies, organisations areable to identify their key values and non-

“For staff, the main benefit ofautomation has been toincrease the amount of wardcontact time”

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BENEFITS OF INVESTMENT IN AUTOMATIONSuppliers say that the time has never been better to invest in automation. Gill Collins, director of roboticdispensing system manufacturer MACH4 Pharma Systems Limited, says that, since suppliers havemaximised system efficiencies, the cost of automation has decreased. Technological advance has alsoimproved features such as item security and audit, the management of stock rotation and batch recalls,and hourly input rates. These have increased by up to 40 per cent, she says.

Additionally, the key benefits of an investment in a dispensary robot are:

• Time savings Inputs and outputs multiple packs in one movement; decreased patient waiting times;and redeployed staff time

• Space Up to four times as efficient as traditional shelving and capable of holding more than 99 percent of daily dispensing stock

• Accuracy Stock control accuracy and barcode stock identification check

ARX claims an 80 per cent share of the UK and Irish pharmacy automation market. Recentlylaunched in its range is the Rowa Vmax automated dispensing system, with features including:

• Maximum dispensing rate of up to 2,400 packs per hour• Loading rate of 1,200 packs per hour • Multi-pack picking• Integrated camera for servicing and error detection• Touch screen LCD dashboard for ease of use• Optical and audio pack confirmation to ensure the correct packs are input• Integrated box shelf should an emergency order be needed

Other robotic dispensing systems include the RP30 High Density Dispenser and RoboCubestandalone dispenser from RoboPharma and, from Swisslog, the PillPick, DrugNest and BoxPickerunits.

• Capacity Create resource and servicecapacity

Practically, this may involve giving staffthe resources (training and authority) toinform the implementation process and helpengage their colleagues. It may also involvelead staff members in managing expectationsand in maintaining engagement levels overwhat can be a long implementation period,she says.

Bringing staff on boardSuccessfully addressing staffing issues hasalso been instrumental in pharmacyautomation initiatives in three other trusts.

Imperial CollegeImperial College Healthcare NHS Trustrecently installed an automated compoundingunit for hazardous sterile intravenouspreparations. Ann Jacklin, chief of service,pharmacy and therapies, says that the initialreaction of staff to the technology “was as it isalways with any piece of automation: theywere very suspicious about the threat ofredundancies”. Thanks to carefulmanagement of the implementation, staff arenow on board with the idea of using thetechnology and can see its benefits. ProfessorJacklin says: “In fact, they now realise thattechnology brings with it a whole host of newjobs, in particular, managing the technology,and they love it. My advice is engage staff asearly as possible in the implementationproject. Even if you feel you are dealing withrisks rather than benefits, the sooner youengage staff in the process, the better theoutcomes will be.”

The IV compounding equipment installedby the trust is Health Robotics CytoCare,which the trust looked to install for a numberof business-critical reasons: to relieve theworkload pressure of increasing day andoutpatient treatment regimens; save money

highlights the importance of achieving whatshe calls the “five Cs of change”:

• Change Embed in employees a culture ofcontinuous improvement

• Communication Ensure there iscommunication at all stages .

• Challenges Overcome staff resistance andmeet staff expectations

• Cohesion Bring together improvementmethodology

bottom line is if you don’t use IT, you’ll soonfind yourself out of sync, particularly aspatient needs become more complex.”

Getting the culture of changeThe potential for staff cost savings is aconvincing element in the business case forautomation and no more so than currentlybecause trusts recognise that they have tomake investment now to provide patientsafety over the next 10 to 15 years on whatwill be a limited budget, says Chris Wood,healthcare business manager at Panasonic.Panasonic recently supplied the Heart ofEngland NHS Foundation Trust with CF-H1Mobile Clinical Assistant e-prescribingtablets. But what does this do for the moraleof staff, who have to implement and workwith the technology? If staff are not on boardwith the idea of change, the trust is unlikelyto see proper returns on its investment, MrWood suggests. “Staff engagement is critical,”he says.

Looking retrospectively at the NorthStaffordshire project, Miss Fowler says thatkey to the success of her project was engagingthe help and leadership skills of thedispensary manager and senior technicians.“Without their help, the project would havebeen dead in the water,” she says. She alsobelieves it was crucial to give staff a voice inthe process and in highlighting the changesthey wanted to see made. The end result isthat they, as a team, have produced anenvironment that staff want to work in, andmorale has improved.

Likewise, looking back at the Forth ValleyRoyal Hospital changes, Mrs Davison

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through sharing vials; to improve staff healthand safety; and to reduce the hospital’svulnerability to skilled staff shortages.

Health Robotics markets the equipmenton the basis that, in cancer care, there aregrowing pressures to improve patient safetyand decrease operator risk.

According to Gaspar G. DeViedma,Health Robotics executive vice-president,sales and marketing, there is a hard and softfinancial case to be made for the investmentin this kind of equipment. In hard terms, theyreduce the waste of expensive drugs and vialsand, in terms of labour costs, the equipmentcan be operated by non-specialist technicians,who are also protected from the physicalhazards of manually compounding hazardouspreparations. In soft terms, the equipmentoffers greater accuracy and patient safetybenefits.

Health Robotics also markets thei.v.STATION for non-hazardouscompounding, and the TPNstation forcompounding sterile parenteral nutrition.Automated Compounding Devices (ACDs)are also available from Baxa.

Guy’s and St Thomas’Guy’s and St Thomas’ NHS FoundationTrust is currently in the middle of a mass£6.5m-plus automation initiative that has sofar seen 105 Omnicell Smart Storeautomated ward medicines cabinets installedacross 30 wards. Daniel Mandeman, the chiefpharmacy technician automation systemadministrator, says that the installationrepresents one of the biggest changes inworking practice for the trust in over 25years.

Ward cabinets offer the benefits of instant,round-the-clock access to stock medicinescontained in a clinical environment — theaverage transaction time with an automatedward cabinet is 15 seconds — whichincreases clinical contact time. Automatedreordering also reduces the number ofpharmacy top-up visits.

Safety features of the Omnicell SmartStore (Avantec) include barcode checks forhigh-risk medicines, better control ofinventory stock, and reporting functionality,which provides an audit trail for stock anduser work practices.

According to Mr Mandeman, the trust ison target to deliver a 20 per cent saving instockholding, equating to £25,400. He alsosays that discharge medicines turnaroundtime has also improved. But, to achieveefficiencies, a degree of management isrequired, he says, not least to ensure that thedrawers are located in the right placeclinically (eg, proximity to sink andpreparation area, and airflow) but alsopractically to ensure they offer nursing andpharmacy staff the best speed and efficiencygains.

Furthermore, pharmacy departmentsneed to allocate resources to ensure thatstock replenishment levels and deliveryprocesses are optimised and that thereporting functionality delivers business-critical information.

Other near-patient automation optionsinclude the ServeRx range from JACMedicines Management, Mediwell Medi 365cabinets and the Pyxis MedStation range.

King’s CollegeIn an evaluation of an electronic ControlledDrugs cabinet and electronic CD record,King’s College Hospital found that staff ratedelectronic CD cabinets better in terms oftime taken to dispense and ease of use, butworse in terms of accessibility (eg, forgottenpasswords). They concluded that moving toelectronic storage and recording had thepotential to save around 6.25 hours a week,compared with non-automated processing.

King’s used an Omnicell CD cabinet, withfeatures including modular cabinet-basedstorage; Keyless restricted access; automaticdrug location guidance; and reportingfunctionality.

The trust is now looking to link thecabinet to another in the trust to test thesuitability of automatic CD order creation.This aims to relieve pharmacy workloadpressures.

Discharge dilemmasAt the 500-bed Milton Keynes HospitalNHS Trust, the average turnaround time fordispensed items has been halved. Thepharmacy is no longer seen “as thedepartment that is the source of delays todischarge”, says the trust’s chief pharmacistNiall Ferguson about the introduction of anew electronic discharge system that offersthe pharmacy department easier access todischarge prescriptions, and which has thecapability to email discharge letters to GPs.Through the inclusion of mandatoryinformation fields, the system has alsoimproved the quality of dischargeinformation provided by the medical team.

Two pharmacists have been employed toinput data into the system, whereby patientmedication histories on admission are used asbasis of the discharge prescription, which canbe updated during the patient’s stay. It is MrFerguson’s view that the system, which wascustomised from an existing electronicdischarge system at a cost of tens ofthousands of pounds, is functioning as auseful “stop-gap” to improve dischargeprocesses and avoid primary care trustpenalties until fully integrated e-prescribingsystems can be implemented within the trust.

The e-discharge system is supported by anARX dispensing robot, installed to improveefficiencies by reducing stock-holding costsand boost income from prescription chargesgained from accident and emergencypatients. According to Mr Ferguson, therobot, which was purchased on a lease basisand installed for under £180,000, has alreadyreduced the value of held stock in thepharmacy by between £150,000 and£200,000 and it has significantly reducedpicking and dispensing errors. Furthermore,the installation has reduced the trust’svulnerability to vacancies and, following askill mix review, it has enabled staff to bereleased to increase their clinical contact

time. As a result, the pharmacy is no longerseen as just a dispensing service but as apatient-focused service, he says.

In some environments, for example,paediatric wards, the ability to operate in thenear-patient environment is critical, says WillThornhill, principal paediatric pharmacist atGuy’s Hospital, London. Patients may beusing multiple unlicensed medicines andcarers may need help and support inadministering the medicines. To deliver near-patient care, the ward operates mobilepharmacy trolleys, supported by an Episyslabelling system. This offers featuresincluding label preview, header-and-footerverification and batch recording devices.

For the pharmacy staff, Mr Thornhill saysthat benefits include the professionalsatisfaction of delivering quicker, morecomprehensive one-to-one patient care and,due to decreased interruptions, accuracy hasimproved. The hospital is also able to claimCQUIN funding for providing a medicinesinformation service.

Vending the rules!Love them or loathe them, prescriptionvending machines are set to become apresence in pharmacies in both primary andsecondary care, according to installationcompany PharmaTrust. PharmaTrust plansto have six MedCentre installations insecondary care sites by the end of the firstquarter of 2011. The company then hopes tofocus resources on building deployment inthe community, according to managingdirector Peter Ellis.

The machines, which offer visual linkaccess to a remote pharmacist, function asmini-dispensaries. Each MedCentre canaccommodate over 2,000 medicines,

SMART PACKAGINGAccording to research from the US, smartpackaging is currently in development in ahandful of high-profile, high-stake segments.These typically include cardiovascular andneurological drugs, drugs for treating metabolicdiseases, and drugs with a significant riskassociated with overdosing, such as opiatesprescribed for pain management. It is said thatthe key challenge for smart pharmaceuticalpackaging is to deliver the four major markersof compliance with drug protocols:

• Prompts or reminders for patients whoroutinely or systematically forget to take theirmedicines

• Addresses gaps in therapeutic benefitassociated with patient failure to get repeatmedicines in a timely manner (automaticreordering)

• Encourages patients to adhere to medicationschedules (caregiver or support networknotification)

• Reinforces positive behaviour (periodic visualreporting)

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demean the role of pharmacy. It effectivelyputs us in a box that you can switch on andoff.”

Instead, he advocates that pharmacyshould move towards co-operativetechnologies that support the pharmacy teamto develop income streams that are uniquelyprovided by a pharmacy, for example,medicines management. He says: “e-prescribing is here and, with patientnomination, pharmacies can easily see theirfootfall reduce to nothing. Pharmacies needto consider other ways of securing sales, andmaking use of the window of opportunity, orelse they will wake up one morning and findthat their business has gone.”

With this in mind, Protomed is using a£79,000 North West Regional DevelopmentAgency grant to develop a new concept in“intelligent” MDS: Biodose Telepak, which ithopes to have ready for the market by mid-2011. Telepak systems feature a chip withradio frequency identification capability,allowing the packaging to transmit data topatients, carers or GPs, possibly via textmessaging. Metrics, such as heart rate, bloodpressure and blood sugar levels, are used tocorrelate medication compliance withphysiological outcomes.

Mr Niven believes that these patientcompliance reports will become a new fee-for-service income stream for pharmacistswith a specialty in medication management.

suitability of the patient and the prescriptionfor the machine-collection model.

According to Sainsbury’s professionalservices manager David Gilder, the unitsshould appeal to the 95 per cent ofsupermarket pharmacy customers who donot want to wait while their prescription isdispensed.

He says that, in the first eight weeks ofoperation, the two units at Sainsbury’s storesin Haywards Heath and West Green inSussex had attracted 730 users, who weretypically aged over 50 years wanting theirrepeat prescriptions dispensed. AfterChristmas, the chain will be conducting morein-depth user research to assess the potentialfor wider roll-out and development offunctionality, for example, adding a touch-screen advice point.

According to Mr Gilder, the trial will rununtil October 2011. He says: “Pharmacy isbeing looked at to provide additional services,and this frees the time to provide thoseservices. Anything that benefits the patientand the pharmacy should be welcomed. Theprofession needs to move in line withtechnology and embrace it.”

OppositionOpponents of the technology describevending machine technology as ridiculous.Norman Niven, chief executive of MDSsupplier Protomed, says: “Vending machines

including refrigerated items, injectibles andpharmacy medicines. In secondary care, thekiosks offer an alternative source ofdispensary medicines, which reducesworkload pressures and increases timeavailable for counselling. For patients, theyoffer the opportunity for round-the-clockaccess to medicines. According toPharmaTrust research, 78 per cent ofpatients say they are likely to use a kiosk inthe future and, on exit interviews, 97 per centsay they are satisfied with the service they hadreceived.

As for implementation in the community,discussions with the Department of Healthhave begun, and NHS chiefs are said “not tobe against the idea”, according to Mr Ellis. Asthe debate to establish pharmacy supervisionprotocols begins, the task ahead is to “provethe benefits of access and safety, and that itprovides a more cost-effective service,” saysMr Ellis.

ARX is also marketing a similarprescription ATM-type system, although itsversion, VisaVia, is linked to an ARXdispensing robot.

At Sainsbury’s supermarkets, prescriptionvending machines are also being trialled (PJ,7/14 August 2010, p139), although the unitsare intended only to act as a prescriptionreception and collection point for patientsnot wanting to speak to a pharmacist, who isphysically present in-store and checks the