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

2. 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

3. 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

4. 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

5. Definitions Technology Unit-based dispensing cabinets BCMA CPOE
Carousel automation

6. 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

7. 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

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

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

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

11. 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

12. Applying this Technology to The Medication Use Process

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

14. 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

15. 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

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

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

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

19. 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 Liquid unit dose
3. Oral dose syringe fill Sterile Injectable syringe fill

20. 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

21. 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

22. 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

23. 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

24. 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

25. Hospital Inpatient Pharmacy
Dispensing
Hospital Inpatient Pharmacy
Unit dose packaging

26. 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

27. 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

28. 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

29. 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?

30. 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

31. 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

32. 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

33. 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!

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

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

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

37. 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

38. Outpatient & Community Pharmacy
Dispensing
Outpatient & Community Pharmacy
Automated robotics

39. Other Forms of Technology
Telepharmacy
Self checkout system
Interactive voice records

40. 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

41. 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)

42. 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

43. 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

44. Other Forms of Technology
Telepharmacy
Technician/Nurse
Patient

45. 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

46. 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

47. 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

48. 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

49. Other Forms of Technology
Telepharmacy

50. 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

51. 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

52. Other Forms of Technology
Self Check-out System

53. 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

54. Other Forms of Technology
Internet

55. Other Forms of Technology
Internet

56. Other Forms of Technology
Electronic prescribing

57. 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

58. Other Forms of Technology
Electronic health record

59. 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

60. 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

61. 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

62. 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

63. 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

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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. Thank you