Current Concepts in Pharmacy Current Concepts in Pharmacy Current Concepts in Pharmacy Current Concepts in Pharmacy

AutomationAutomationAutomationAutomation

Mike Sanborn, MS, RPh, FASHP

Corporate Director of Pharmacy

Baylor Health Care System

Dallas, TX

Objectives

• Review automation options available for unit dose dispensing in acute care pharmacies

• Assess automation options for IV admixture compounding

• Discuss pros and cons of various automation choices

• Review a variety of other considerations and system issues

Typical Automation Goals

• Expand pharmacy services

• Redeploy pharmacy staff

• Improve medication turnaround time and pharmacy efficiency

• Reduce medication errors

• Improve charging/billing

• Increase formulary compliance

• Reduce cost of drug therapy for patients

• Improve Adverse Drug Reaction reporting

• Improve pharmacy image, morale, and pharmacist job satisfaction

• Take responsibility for medication use in all patients

Key Technology Drivers

• Profits and entrepreneurial spirit

• Cost Effectiveness

• Patient Safety

• Fewer pharmacists allured by dispensing,

compounding, and other manual tasks

• Workforce shortages

• Inherent need for continuity of care

Incorporation of Technology

0%

10%

20%

30%

40%

50%

60%

70%

80%

SmartPumps

BCMA CPOE Robots Cabinets

Am J Health-Syst Pharm. 2006; 63:327-45

KLAS, CPOE Digest 2007

Technology and Automation are

Major Issues

Unit Dose Automation for Unit Dose Automation for Unit Dose Automation for Unit Dose Automation for

Acute Care HospitalsAcute Care HospitalsAcute Care HospitalsAcute Care Hospitals

Automation Options

• Decentralized

• Automated Dispensing Cabinets (ADC)

• Centralized

• Inline Packagers

• Carousels

• Robots

Technology Changes Over Time

Robots vs. ADMs

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40

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60

70

80

Robots ADMs

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Robot Growth

ADM Growth

Pedersen CA et al. Am J Health-Syst Pharm 2006; 63: 327-345.

What is the Future of Automated

Dispensing?

• Currently 73.9% of hospitals have a centralized

system versus 26.1% decentralized ¥

• In the future, 50.1% envision a centralized

system versus 50% decentralized ¥

• The truth is likely dependent upon a variety of

factors

¥ Pedersen CA et al. Am J Health-Syst Pharm 2006; 63: 327-345.

Factors Affecting the Dispensing

Model

• Philosophy (Rx and RN)

• Resources

• Logistics

• Patient Flow/Turnover

• Bed size

Distribution Model by BedsizeDistribution Model by BedsizeDistribution Model by BedsizeDistribution Model by Bedsize

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50-99

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50-99

100-199

100-199

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100-199

200-299

200-299

200-299

200-299

300-399

300-399

300-399

300-399

>400

>400

>400

>400

CentralizedCentralizedCentralizedCentralized DecentralizedDecentralizedDecentralizedDecentralized

¥ Pedersen CA et al. Am J Health-Syst Pharm 2006; 63: 327-345.

¥

Major Players in Decentralized

Automation

Omnicell Pyxis AcuDose

Nursing Battles(Trying to fill cabinets while nurses are vending meds)

Withdrawals by Time of Day(Average and Avg + 1 S.D.)

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Maximize Restock Activities

Restock Activity for the Top 15 Units

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Centralized Systems

• Inline Packagers

• Multiple vendors of JVMedi

• Carousels

• Multiple vendors

• Software is key

• Robots

• Swisslog

• McKesson

Inline Packagers

• Essentially an oral solid packager

• Similar concept to the original ATC-212

• Both canister and on demand

• Utilizes bar-codes

• Can include 100-500 line items

• Can fill patient-specific strips

• Allows for bulk drug utilization

• Canister calibration, returns, and incompatibilities

Carousels

• Great for inventory control• 2000-3000 line items

• Easily integrated to fill ADMs

• Can be used for first doses

• Integrated barcode capabilities

• Minimal training required• Lighted prompts are very helpful

• Handles virtually unlimited package sizes

• Returns and restocking a challenge

Centralized Dispensing Robotics

• Picks patient-specific meds to envelope, ring, or bin

• Bar-coded individual doses

• Very good inventory control

• Generally error free

• Simple crediting and restock process

• Limited pharmacist check

• Will likely reduce technician labor

• Space considerations and packaging

The Trade Off

Pharmacy

ConvenienceNursing

ConvenienceRobots ADMs

Hybrid

The Hybrid Option

PROS• Can take advantage of different

technologies

• Synergies do exist

• Especially effective for larger hospitals (>200beds) and IDN’s

• Flexibility of dispensing methodology, based on the drug

• Can maximize the benefits of each type of automation

CONS• More equipment to justify

• More equipment to manage

• Interfaces

• Integration can initially be time consuming

Patient Safety Concerns

• Decentralized Automation• Misfills

• LASA

• Stockout delays

• Matrix drawers

• Overrides (errors have been reported as high as 11.7%, with 1.7% resulting in actual patient errors¥)

• Centralized Automation• LASA

• Bar-coding errors

• Return/Discontinue accuracy

• Bin restocking with Carousels

¥ Kester Ket al. Hosp Pharm. 2006;41:535-537.

Anesthesia Workstations

• Automated medication

documentation

• Some incorporate bar-code

scanning

• Can improve documentation

and charge capture

• Mixed provider feedback, but

generally positive

• Can be configured with most

stereo systems and iPods

Additional Considerations

• Automation integration with • CPOE

• “Smart” Infusion Devices

• BCMA

• Bedside scanning and ADMs may not be the best mix• Nurse servers are somewhat attractive again

• Inventory space requirements (due to barcoded meds) may increase

• Company’s have experienced consolidation, and this will likely continue• Multiple solutions from one vendor

• Still opportunities for price negotiation

IV Admixture Robotics for IV Admixture Robotics for IV Admixture Robotics for IV Admixture Robotics for

Acute Care HospitalsAcute Care HospitalsAcute Care HospitalsAcute Care Hospitals

Robotic Systems

• Historically limited to TPN compounders

• Intellifill was first to market with syringe filling robotics

• Cytocare available in the US in November for chemotherapy compounding

• Currently functioning in Italy and the UK

• Riva is soon to be available for standard admixtures or chemotherapy

Major Players for IV Robotics

IntelliFill Cytocare Riva

Pharmacy AutomationChemotherapy Robot Video

Robotic Admixture Systems

PROS

• Can automate very complex

tasks and manipulations

• Precision is significantly greater

than human capabilities

• Very high throughput

• Employee exposure reduction

• Reduced opportunities for

contamination

• Enhanced 797 compliance

CONS• IntelliFill requires adoption

of syringe program

• Can be costly, although ROIs are generally good

• Space considerations and potential construction

• More equipment to manage (downtime, interfaces, etc.)

• Riva and Cytocare are not tested in the U.S.

Additional Automation Additional Automation Additional Automation Additional Automation

ConsiderationsConsiderationsConsiderationsConsiderations

Single Vendor Advantage?

• Many vendors are leveraging their multiple

technologies to improve integration

• Omnilink to Omnicell ADM Example

• McKesson Robot, Carousel, and Cabinet Example

• Some have argued that best of breed is a better

solution

• Advantages and Disadvantages

Vendor Selection Considerations

• Functionality

• Is an ADM an ADM?

• Total Product Offering

• Ongoing Product Development

• Service and Support

• Market Penetration and Growth

• Facility and System Considerations

• Cost and Value

Return on Investment

• Vendors can assist with calculations, but they should always be validated internally

• Business plans are helpful

• Many installations will have a reasonable ROI• Personnel

• Tangible

• Intangible

• Mixed results in the literature• Depends on implementation effectiveness

Pharmacy Automation

• Continued automation of manual tasks

performed by pharmacists and/or technicians.

• Refinement of existing technologies

• Automation outsourcing

• Packaging facilities, compounding facilities, etc.

• Health-system initiatives and co-ops

Conclusion

• Important to understand advantages and disadvantages

of each type of automation

• Health-systems should develop an overall automation

plan based on current and future automation needs

• Optimization is critical to the success of the department

and improvement of the medication use process.

• A positive experience is dependent upon lots of work

and lots of data analysis (and lots of time)

DiscussionDiscussionDiscussionDiscussion