Technology & Automation in Pharmacy Practice Part I & II PHCL 311 Hadeel Al-Kofide M.Sc

Topics to be covered today.. Definitions Why technology & automation Automation & the medication use process Applying technology in inpatient pharmacy Applying technology in outpatient pharmacy Other forms of technology applied all over the pharmacy Safety of automation Cost The impact on pharmacy manpower

Introduction As we entered the 21st century, there are many factors that influence the future practice of pharmacy & delivery of pharmaceutical care Today's health care providers are looking for new ways to improve the quality of patient care & cut costs, while enhancing employee retention & patient satisfaction

Introduction Technological advances have led to automation, which is of particular significance to pharmacists. In pharmacy automation, the machines used to carry out work are controlled by a computer It is very vital that the computer knows & responds to the purpose for which the system is executed Automated systems also promise extra efficiency & accuracy

Definitions Technology Unit-based dispensing cabinets BCMA CPOE Carousel automation

Definitions Technology: For the purpose of this lecture, this refers to anything that is used to replace routine or repetitive tasks previously performed by people, or which extends the capability of people Unit dose dispensing cabinets: Secure storage cabinets of handling most unit-dose & some bulk (multiple dose) medications

Definitions BCMA: Bar code medication administration CPOE: Computerized prescriber order entry Carousel automation: A medication storage cabinet with rotating shelves used to automate medication dispensing

Why we Need To Apply Technology in Healthcare Systems & What are Our Goals?!

Why We Need Technology & Automation Prescriptions Vs. Pharmacists 300,000 4 Billion 200,000 3 Billion 1.5 Billion 100,000 1992 2004 2010

Why We Need Technology & Automation Major Areas for Medication Error 39% 38% 12% 11% Medication Errors Reporting Program US

So The Major Goals From This Technology Decrease rate & percentage of medication errors (in all fields including: prescribing, dispensing & administration errors) Provide pharmacists with more time to apply pharmaceutical care & patient counseling Improve quality of life for your pharmacists & technicians Increase the number of prescriptions filled in a day

Applying this Technology to The Medication Use Process

Strategies for Automation Automation is now used in all phases of medication use process

The Medication Use Process Technologies & automated devices applied throughout the medication use process Prescribing Preparing & Dispensing Administering Monitoring Clinical decision support software CPOE Carousal technology Centralized robotic dispensing technology Centralized narcotic dispensing & inventory tracking Decentralized automated dispensing devices IV & TPN devices Pneumatic tube Unit dose repacking system Bar code medication administration technology Clinical support-based infusion pumps Electronic clinical documentation systems Web-based compliance & disease management tracking systems

Prescribing Clinical decisions support software: interactive computer programs, which are designed to assist physicians & other health professionals with decision making tasks Computerized prescriber order entry (CPOE): is a process of electronic entry of physician instructions for the treatment of patients. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory or radiology) responsible for fulfilling the order

Dispensing 1. Applying technology in hospital inpatient pharmacy: Unit dose packaging: Pyxis Centralization vs. decentralization Robotics Carousel technology Pneumatic tube IV & TPN robotic devices

Dispensing 2. Applying technology in hospital outpatient or community pharmacy: Automation & robotics Automated workflow

Dispensing 3. Other automated systems Telepharmacy & self checkout systems Interactive voice response (IVR) Internet & E-prescribing

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Medication that is dispensed in a package that is ready to administer, directly, to the patient. Medication currently being unit dose packaged & bar coded: 1. Solid dose 2. Liquid unit dose 3. Oral dose syringe fill 4. Sterile Injectable syringe fill

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Unit-dose dispensing was developed in the 1960s to support nurses in medication administration & to reduce waste Today there are numerous companies that will convert your bulk medications & products into unit dose packages

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging There are numerous fast & efficient automated unit dose packaging systems that can be installed & operated in the pharmacy Pyxis system

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Pyxis system Automated dispensing system (ADS) primarily affects nursing, pharmacy & information systems personnel ADS are drug storage devices or cabinets that electronically dispense medications in a controlled fashion track medication use. Their principal advantage lies in permitting nurses to obtain medications for inpatients at the point of use

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Pyxis system Most systems require user identifiers & passwords, & internal electronic devices track nurses accessing the system, track the patients for whom medications are administered, & provide usage data to the hospital’s financial office for the patients’ bills These systems can be stocked by centralized or decentralized pharmacies

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Centralized vs. Decentralized Centralized pharmacies prepare & distribute medications from a central location within the hospital Decentralized pharmacies reside on nursing units or wards, with a single decentralized pharmacy often serving several units or wards Decentralized pharmacies usually receive their medication stock & supplies from the hospital’s central pharmacy

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Centralized vs. Decentralized Decentralized Automated Dispensing System Advantages Disadvantages Ability to allow access to a single dose of medication Nurses may access medications before a pharmacist reviews the order Accommodates multiple dosage forms with flexible drawer configurations Unable to accommodate all medications Faster reach to medications Take large space in word than usual carts Provide detail electronic dispensing & usage report Inspection & removal of expired medications usually must be done manually

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Unit dose packaging Centralized vs. Decentralized Centralized Automated Dispensing System Advantages Disadvantages Reduce pharmacist time Less nurse satisfaction (delay in first dose) Reduce technician labor required to fill carts Require large space & usually needs physical renovation Facilitates pharmacists review of orders before the nurse can use the medication Accuracy depends on accurate computer order entry Automates medication restocking & removal of expired medications Usually does not accommodate refrigerated items

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Robotics & Unit dose systems Now robots can be used to help inpatient pharmacies dispense thousands of medications It uses an electromechanical head coupled with a pneumatic system to capture each dose & deliver it to its either stocked or dispensed location During this process it uses barcode technology to verify its pulling the correct drug

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Carousel Technology Medication storage cabinets with rotating shelves used to automate medication dispensing The carousel uses barcodes & pick-to-light technology It helps reduce error of look-a-like & sound-a-like, HOW?

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Pneumatic Tube System Pneumatic tubes (or capsule pipelines) are systems in which cylindrical containers are propelled through a network of tubes by compressed air or by vacuum. They are used for transporting physical objects, solid objects, compared to the more generic pipelines which transport gases or fluids

Hospital Inpatient Pharmacy Dispensing Hospital Inpatient Pharmacy Robotics in IV Room Now robots can prepare IV & chemotherapy medications Automating the preparation of IV syringes & bags

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Prescription Medication, for patient self administration, that is dispensed in multi dose format, generally in a vial, bottle or unit of use package, with labeling that includes: Patient’s name Physician’s name Drug name, strength, & quantity or volume Usage Instructions & warnings Bar code

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy What do patients want when they come to the pharmacy? The best from their medicines Safe passage Information Flexibility And FAST!

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Automation & technology in outpatient & community pharmacies includes: Automated counting Automated fillers Other automated machines Automated robotics

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Automated counting Different pill counters

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Automated fillers Automed

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Other Automated machines Right now there are lots of different automated machines which can act as either dispensers, counting pills, & fillers Parata

Outpatient & Community Pharmacy Dispensing Outpatient & Community Pharmacy Automated robotics

Other Forms of Technology Telepharmacy Self checkout system Interactive voice records

Other Forms of Technology Telepharmacy Telepharmacy enables pharmacists to provide pharmaceutical services from a remote location Telepharmacy means a central pharmacy, either retail or associated with a hospital, with one or more remote sites in which all sites are connected via computer, audio, & video link

Other Forms of Technology Telepharmacy Prescriptions that are issued at rural hospitals are electronically sent to an urban medical center pharmacy, where they are reviewed, processed, & verified The hospital pharmacist has access to the patient’s electronic medical records, & checks the prescription for proper dosing, allergies, duplications & drug interactions Then the pharmacist electronically authorizes the dispensing through a specialized Automatic Dispensing Device (ADD)

Other Forms of Technology Telepharmacy The prepackaged medication is released electronically via the ADD A nurse (or a technician) in the rural hospital, with password authorization to the ADD work station, double checks the medication & label, prior to administering the medication to the patient

Other Forms of Technology Telepharmacy The pharmacist at the urban medical center is able to electronically monitor the verification process & to oversee the restocking of the ADD via a videoconferencing link The video conferencing system is also used for consultations between the patient, nurse or physician with the urban hospital pharmacist

Other Forms of Technology Telepharmacy Technician/Nurse Patient

Other Forms of Technology Telepharmacy It also has been used recently in preparing chemotherapy preparation In hospital pharmacies, chemotherapy preparation is a high-risk process Critical components of this practice include selecting the correct drug, using the exact medication volume, & injecting the medication into the IV bag for the correct patient

Other Forms of Technology Telepharmacy Pharmacist supervision is vital for the safe preparation of chemotherapy medications. However, limited pharmacist resources & complications of clean room operations hinder the step-by-step verification procedure of the chemotherapy preparation process

Other Forms of Technology Telepharmacy Using the Telepharmacy system, a technician scans the bar code on the drug vial to ensure that the correct medication has been selected The technician captures electronic images of the vial label & the filled syringe in the preparation room before injecting the drug into the IV bag

Other Forms of Technology Telepharmacy Prior to completing the preparation process, the technician presses a button on the Telepharmacy screen to receive verification by a pharmacist From outside the preparation room, a pharmacist reviews the images of the vial, the pullback on the syringe, the IV bag, & the patient's medication order The images & confirmation of these steps are documented & available for future reference

Other Forms of Technology Telepharmacy

Other Forms of Technology Self Check-out System In about a minute, customers can pickup & pay for their prescriptions. It gets them out of line & lets the pharmacy staff spend extra time with customers who really need it Consumers can shop on their own schedule & conveniently pickup their prescriptions even after the pharmacy has closed It comes with barcode technology to ensure each consumer receives the prescription they ordered

Other Forms of Technology Self Check-out System When installing the machine, consumers sign up to have their prescriptions placed in the self checkout system if they want Consumers enroll using a touch screen.  After this one-time enrollment, its like using an ATM Consumers log in, confirm their prescriptions, then sign & pay As soon as the payment is approved, it delivers the pharmacist-prepared prescriptions. It takes about a minute from start to finish

Other Forms of Technology Self Check-out System

Other Forms of Technology Interactive Voice Response Automated telephone answering system giving customers the option of calling for refills while allowing the pharmacist to continue other services A touch-tone telephone to interact with a database to acquire information from or enter data into the database IVR technology does not require human interaction over the telephone as the user’s interaction & access with the database is predetermined by what the IVR system will allow

Other Forms of Technology Internet

Other Forms of Technology Internet

Other Forms of Technology Electronic prescribing

Other Forms of Technology Electronic health record An individual patient's medical record in digital format Electronic health record systems coordinate the storage & retrieval of individual records & they are accessed on a computer, often over a network A variety of types of healthcare-related information may be stored and accessed in this way Linked directly to e-prescribing

Other Forms of Technology Electronic health record

Other Forms of Technology Barcode or BCMA One of the high risk areas for medication error is drug administration Bar coding identifies medications for preparation, dispensing & administration By taking action to ensure all medications used in the hospital include a bar code, pharmacists can set a strong foundation for patient safety

Other Forms of Technology Barcode or BCMA The FDA investigated bar code medication administration processes and concluded they would reduce medication errors by 50% if fully implemented This study led the agency to require pharmaceutical manufacturers to apply bar codes at the unit-of-use packaging level & to all drugs April 2006

Benefits of Automation Necessity is the mother of invention The demand for reliable & flexible prescription dispensing services has brought about many improvements in the area of pharmacy automation Robotic prescription dispensing systems are breathing new life into an industry where time is a luxury & space is at a premium

Benefits of Automation Automation plays a role in saving time Automation can improve patient safety Although in other industries automation had led to losses in jobs but in pharmacy, automation has not involved replacing people. Instead it has enabled the profession to focus on pharmaceutical care

Safety Issues Regarding Automation Very little data is available on their appropriate use & safety Technology can introduce a new source of error But if properly integrated all these systems show promise in reducing medication error

Safety Issues Regarding Automation Automation reduces medication error by: Reducing complexity Simplifying & standardizing processes Avoiding overreliance on human memory Improving efficiency

Safety Issues Regarding Automation Technology by it self will rarely reduce medication error, rather it needs to be effectively integrated into the medication use process & appropriately managed to insure patient safety If not used properly it can produce more dangerous errors Implementing this technology takes years to accomplish with the need of dedicated employees

Safety Issues Regarding Automation Automation can instill a false sense of security leading to carelessness by health care professionals All health care professionals & patients must understand that the technology can not completely substitute for human checking

Safety Issues Regarding Automation Desired safety features for incorporating automation in the medication use process: The system must have a bar code technology for drug restocking, retrieval & administration A system must force the user to specify a reason whenever medications are accessed or administered outside of the scheduled administration time or dosage range

Safety Issues Regarding Automation Desired safety features for incorporating automation in the medication use process: Identification bar codes or passwords must be assigned for each user Bar code administration systems must be able to identify & document the patient, the medication, & the person administering using the scanning technology function

Safety Issues Regarding Automation Desired safety features for incorporating automation in the medication use process: Devices are interfaced with the pharmacy computer system only allowing the nurse to view & access those medications that are ordered for a specific patient Devices need electronic reminders to nurses when a medication dose is due

Safety Issues Regarding Automation Desired safety features for incorporating automation in the medication use process: CPOE are interfaced with automation devices to provide warnings about allergies, interactions, duplication & inappropriate dose at the point of dispensing & administration Real time integration or interfaces must exist for all steps in the medication use-process starting at prescribing, to order entry & dispensing, & through administration

Which Automated Technology Should be Selected? There is no right or wrong answer It depends on how they are carefully integrated into the system Characteristics for an ideal system you need: patient care & safety benefits, responsiveness to costumer or patients needs, & cost effectiveness

Which Automated Technology Should be Selected? Before implementing a technology in your hospital check the advantages & disadvantages, check safety issues regarding the automation you are about to implement Must always remember the importance of pharmacist role in overseeing & coordinating the use of such system

Cost Issues in Automation Adding New Fixtures/Shelving - $5,000 to $100,000 Automated Workflow - $5,000 to $200,000 Automated Dispensing - $6,000 to $70,000 Robotics - $100,000 to 225,000 Self Checkout - $80,000 IVR - $5,000 to $20,000

Cost Issues in Automation Must know the area in your pharmacy which requires automation Funding issues There is no doubt that automation is costly but when it comes to patient care & safety the quality of services comes first

Impact of Automation on Manpower Pharmacists fear that automation will decrease the number of pharmacist positions & consequently the demand for pharmacists It MAY decrease the number of positions for pharmacists & technicians in which their only job was preparing & dispensing They will probably cause less jobs for pharmacy technicians

Impact of Automation on Manpower It actually depends in the pharmacists & pharmacy directors to show the value of having pharmacists If they were able to demonstrate & market the quality & economic value of pharmacist patient care services to physicians & administrators, there will be rather an increase of job opportunities for pharmacists

Impact of Automation on Manpower We should look how automation opened a new role for pharmacists rather than deleting their role They provided the pharmacists with opportunity to work more closely with patients & physicians to assure appropriate drug therapy & outcomes There will always be need for pharmacist to identify, solve & prevent drug related problems

In Summary We are entering a new era in pharmacy technology There is no perfect technology & all systems must be well managed to provide best outcomes To be successful in the future pharmacists must view automation-induced productivity & efficiency as desired goals not threats to their work Every change must be implemented with an understating that even good changes can create unexpected hazards

Thank you