0. NEW AUTOMATION PRODUCTS
Pharmacy Informatics Conference
June 20, 2012
Marian Daum, Pharm D
Coatesville VA Medical Center
Coatesville, PA
Hello and welcome to the 5th Annual Pharmacy Informatics Conference, the virtual edition. Today we will be reviewing new automation products, and some old ones, how to go through the selection process, some of the deal breakers and finally, some advice for navigating the acquisition process.
June 2012

1. NEW AUTOMATION PRODUCTS OBJECTIVES
1. Name one new type of automation available for use within VA Pharmacies.
2. Construct a needs grid and use the grid for product evaluation
3. Name one feature that may make installation of a technology impossible within a VA Pharmacy.
At the conclusion of this presentation, the listener will be able to name at least one new type of automation available for use within VA pharmacies. To construct a needs grid and use the grid when conducting product evaluations when considering a major equipment purchase and finally, the listener will be able to spot processes or equipment that would make installation of the technology impossible within a VA Pharmacy. We will also be reviewing the results of the most recent Automation Survey. I would like to thank all who participated and would also make a plea to participate in the annual survey this year. It does not take long to fill out and the information is very valuable. That being said, I will start with the machines primarily used in the inpatient areas of the pharmacy.

2. NEW AUTOMATION PRODUCTS UNIT DOSE
Machine
Overall Score
Help Desk
Repair & PM
Timeliness of Service
Choose Again?
Fastpak/Exp (40)
3.55
3.53
3.51
3.47
67.5%
Talyst Autopak (27)
3.42
3.16
2.95
52.6%
TCGRx (6)
4.5
3.83 4
83.3%
PacMed (4) 3
50%
Safetypak (1)
100%
Auto-print (1) 0%
There are a number of unit dose repackaging machines currently in use within the system. As you can see from the results of the most recent automation survey, the two most popular machines are the Fastpak/EXP and the Talyst Autopak, but neither would be repurchased by almost half of the users. The machines were rated in four categories, the help desk, repair and maintenance, timeliness of service and an overall score. A few other choices were rated and they are listed on the slide, but is difficult to draw too many conclusions as there was such a small sample and the numbers may be skewed. The rating scale was from one (negative) to five (positive). Three was neither positive nor negative. While those site that would not repurchase the machine had a more negative score in each of the rated areas, the scores were not that significantly different, so the reason for the dissatisfaction is not immediately clear.

3. NEW AUTOMATION PRODUCTS UNIT DOSE
Fastpak/Exp
Talyst Autopak
TCGRx
PacMed
Safetypak
Speed
63/min
60/min
Interface
Ease of Use
Canisters
20 free/yr
Additional Cost
Make your own
Service Contract
Cost
Other VA
This is an example of a needs grid which is partially filled out. If you are interested in purchasing a new unit dose machine, you should review the information available from the vendors of the different machines and fill in the information. You will want to touch base with IRM for the interface information and Biomedical Engineering for the Service Contract requirements. Once you have all of the information on the grid, I would suggest that you contact other facilities using the machine(s) you are considering for feedback especially with unit dose repackaging units as the rate of buyer’s remorse if very high. If you have a very small inpatient unit, that is, less than 75 beds, you may want to consider a manual pick with purchased unit dose tablets.

4. NEW AUTOMATION PRODUCTS AUTOMATED DISPENSING CABINETS
Machine
Overall Score
Help Desk
Repair & PM
Timeliness of Service
Choose Again?
Pyxis Profile (35)
4.35
4.18
4.15
4.21
97.14%
Omnicell (31)
4.23
3.93 4
3.86
100%
Accu-Dose (10)
3.2
3.5
40%
Med-Select (2)
Reviewing the automated dispensing cabinet data, while most of the machines were rated on the positive side in all of the categories and most sites would repurchase the machine they chose, there was one machine that clearly has some issues that lead to dissatisfaction among users. Pyxis Profile and Omnicell both had very positive scores and almost all of the sites would choose the same machine if they had to repurchase it. However, the Accu-Dose machines were rated as average, neither positive, nor negative and less than half of the sites that now have the machine would repurchase it. Since none of the categories we rated were negative, and the scores were not that different from the ratings of the Med Select which had a high repurchase rate, there must be another factor or factors which we did not pick up on the survey that is the cause of this dissatisfaction. If your site is considering the Accu-Dose, you need to contact several Accu-Dose sites and find out exactly what the cause of their dissatisfaction. It may be something that is not a big deal to you and would not be a problem, but you will need this information prior to making a decision.

5. NEW AUTOMATION PRODUCTS CONTROLLED SUBSTANCE STORAGE
Machine
Overall Score
Help Desk
Repair & PM
Timeliness of Service
Choose Again?
Pyxis C-II Safe (7)
4.58
4.14
4.29
4.26
100%
Omnicell Secure Vault (7) 4
3.6
Only two of the Automated Dispensing Cabinets have a storage option for controlled substances within the pharmacy. These cabinets offer an added layer of security to the storage of controlled substances within the narcotic vault and oversight software that allows management to match removals to restocking episodes in the cabinets. The machines are pretty evenly matched with Pyxis receiving more positive grades on the individual factors, but all sites would repurchase the equipment again. A site that has a busy narcotic vault that requires use across several shifts by a lot of different personnel would be the ideal one for this type of machine.
As an aside, the use of this machine does not absolve you of having to do the VistA/Automated Dispensing Cabinet reconciliation as part of the narcotic inspection program. If you are a pharmacy manager, you would probably want to randomly review the Inventory by Station for Pyxis against the Daily Activity Log or NAOU Usage Report. If you have a Pyxis 3500, you want to scan the report for anything that was removed from the C-II safe that is still in “pending status. If you have a Secure Vault, you want to look the De-Stock/Re-Stock matching report to make sure that everything was removed from the secure vault made it to a cabinet. There was recently an incident in a VA facility using the Accu-Dose Dispensing Cabinets. The pharmacy vault technician was creating false entries and diverting narcotics from the VistA inventory. The site’s 72 hour vault count was always correct and all cabinets were stocked correctly and all stocking episodes were recorded correctly. The only way that the diversion could be detected was to review the VistA reports against the dispensing cabinet activity. The extra entries and hence, the diversion would then be apparent. We have sent guidance to the Controlled Substance Coordinators regarding proper reconciliation.

6. NEW AUTOMATION PRODUCTS INVENTORY MANAGEMENT SYSTEMS
Machine
Overall Score
Help Desk
Repair & PM
Timeliness of Service
Choose Again?
McKesson MedCarousel (3)
4.3
3.67 4
100%
Omnicell Pharmacy Central (2)
3.5
50%
Talyst Med Carousel (1) 5 3
Med Carousels are a major investment. They will manage inventory down to the tablet or capsule which is a great thing from a management perspective, but they require a high level of commitment from the pharmacy staff for an accurate inventory in that all stock must be scanned into the system and scanned upon removal from the pharmacy for either a cart fill or an automated dispense cabinet restock. That being said, they do have a major advantage for sites with a large number of inpatient beds. I am probably showing my age here, but I have memories of doing cart fills manually in a facility that had 15 wards. It took 3 technicians and a pharmacist at least 6 hours to get the fill done. The carousel adds up the number of each tablet/capsule that is required for the fill and the technician picks them all at once. Five of the six sites that reported using a carousel had at least inpatient beds and with the use of one of these carousels, the fill for a facility with that many beds can be done in about 1-2 hours which is a significant time savings. It also can store medication in a very tight footprint as it stored medication using space vertically. It might also be considered by a site that is expanding services and has become tight for space. Satisfaction scores may not be predictive as the number of sites evaluation sample is very small.

7. NEW AUTOMATION PRODUCTS OUTPATIENT DISPENSING ROBOTS
Machine
Overall Score
Help Desk
Repair & PM
Timeliness of Service
Choose Again?
ScriptPro (65)
4.3
4.29
4.22
98.5%
Optifill (10) 4
3.9
90%
Parata/McKesson (10)
2.5
2.2
2.4
2.3
10%
Fast Fill (1)
100%
A-Frame (1)
Now we will change gear and go through the survey results for the equipment used in the outpatient pharmacy. These fill robots are probably the most commonly used type of automation within the system and there were some real differences between the robots. The most commonly used robots are the ScriptPro SP50,100 and The level of satisfaction was extremely high and all but one site would repurchase their robot. That being said, this machine should be used in a facility that does less than 60,000 local fills per month or about 375 fills/8 hour day. That is about the maximum capacity of the robot and gives you no room to grow. Sites with this amount of work may find the Scriptpro too slow to keep up with their work even with the installation of a multiplexor and high capacity/high speed canisters. In that case, your site should consider an Optiflll machine which has a much higher daily fill capacity. Sites that use it also report a high level of satisfaction with its performance however, it needs a dedicated technician to run it. The Parata/McKesson robot has a capacity similar to the ScriptPro, but was rated negatively in all categories. It had the highest rate of dissatisfaction for any device in the survey with 10% of those sites that have it saying they would purchase it again. I have never personally worked with this robot, so I can’t really speak to why it is so universally panned.
Finally we had one site report the use of a Fastfill which is a good choice for a very small site with a small number of fills and one CMOP report that they are happy with their A-Frame which fills 1.4 million prescriptions per month. That’s a bit more capacity than most sites need.

8. NEW AUTOMATION PRODUCTS OUTPATIENT DISPENSING ROBOTS
Machine
Vial Conversion Cost
Comments
ScriptPro
SP50,100 = $7965/machine
SP200 = $11,800/machine
Parata/McKesson
Mini, Max, Rexam or RC to Kerr = $15,000/machine
Mini, Max, Tristate to Kerr = $3,000/machine
The RDS cannot support Kerr vials and cannot be converted.
Optifill (Automed)
Currently does not have a recalibration option
Recently there has been a push for contract compliance that does not give us any wiggle room for exceptions. Berry received an exclusive contract to supply Kerr vials. This caused heartburn at many sites when the vial contract was announced last October because their machines were calibrated to use other vials and some machines, the RDS and Optifill could not be calibrated to use Kerr vials. To add to the problems, prescription vials are a petroleum based product and contracts are not made for longer than a year due to the oil market’s volatility. Even if a site was willing to spend the money to convert their robot to the currently contracted vial, there is no guarantee that the vial would be on contract the next year and the site would have spent a lot of money for nothing.
Sites may apply for a waiver to contract compliance. Contact Joe Canzolino at Joe.

9. Machine Overall Score Help Desk Repair & PM Timeliness of Service
Choose Again?
ADDS (11)
3.27
2.9
45.5%
Pickpoint LXS (4)
3.5
3.75 3
50%
SPUD (1) 4
100%
I have included telepharmacy in the outpatient portion of this session, because all sites that reported using it reported using it in the outpatient area. There are some inpatient applications including it use in an IV clean room to allow the pharmacist to check the technician’s work without having to gown up and enter the clean room and it has been used in the private sector in that manner, but here, it is mostly used to service off-site dispensing mainly in CBOCs. This ratings of these machines showed the most variation in the survey. Sites either loved or hated them and rated them with a 4 or 5 or a 1 or 2 Which is why the ratings average out to around 3. If you are considering one of these machines, I would suggest that you contact a site that is happy with it and a site that is very unhappy with it to get a better assessment of its performance and whether it will meet your needs. If you are using it to provider service to a CBOC, you may want to explore an emergency prescription contract service such as Heritage to see if that will meet your needs. If you want to store clinic stock securely, then an automated dispensing cabinet may be a better option. We have 2 CBOCs that are 50 miles away from the main facility and we have successfully installed these cabinets in them for that purpose.

10. NEW AUTOMATION PRODUCTS QUEUING SYSTEMS
MACHINE
OVERALL
REPAIR
TIMLINESS OF SERVICE
REPURCHASE?
Q-Matic (21)
3.86
3.46
3.25
85.7%
Nemo-Q (1) 4 3
100%
Q-Flow (1) 2 0%
Turn-O-Matic
Take a Number-Matic
This year we asked about queuing devices which are used to control patient flow at the outpatient windows in busier facilities that have multiple drop off or pick up windows. Some of these systems have reporting capability and may be used to track peak traffic times to better manage workload. The most commonly used system is
Q-Matic which almost anyone who has visited a state DMV facility is familiar with. Almost all of the reporting sites had Q-matic, but I have included the other systems for completeness, though the rating numbers are all based on one site and are less reliable.

11. NEW AUTOMATION PRODUCTS MARKET RESEARCH
1. Market Research : GSA Advantage Section 65 IIA
- Automation Friday Presentations
- Automation Survey Results.
Ex. Unit Dose Repackager
- Wanted a high speed machine (60-65 packets/min)
- Wanted to keep setting trays to a minimum
- Wanted a Class 1 interface
Now that we’ve reviewed the survey results, I’d like to switch gears and talk a little bit about the acquisition process. You need to do a little market research to see what is available to you. The best place to start is on the GSA Advantage website. All pharmacy robotics and automation is listed in Section 65 IIA. The GSA listing has a link to the vendor’s website and also lists the contact for government sales. Also, you may want to take the time to listen to the Automation Friday presentations which are on the 4th Friday of the month except November when it’s the 3rd Friday due to the Thanksgiving Holiday and December when there is no presentation due to the Christmas and New Year Holidays. So, for example, if you are interested in replacing a Unit Dose repackaging machine as we did at this site last year, you will see that there are choices available from Automed, Talyst, Omnicell and TCGRx. . We also had heard the Automation Friday presentations and had access to the survey results. We were doing a fill for about 450 beds, which would be the lower limit for a carousel to be an advantage, we did not have the physical plant for one. We had used machines from Talyst and Automed previously. We had switched from Talyst to Automed due to interface issues and that was great, but we were still having problems with double filled or empty packets with no way to go back and try to drill down into the problem. We also had a fine collection of old canisters due to frequent contract changes and spot shortages. We did get 20 free canister changes with our service contract, but they were usually used up in no time and we ended up having to use the universal tray for the routine fills. Our largest fill averages 4500 packets which would take 75 minutes to run if there were no tray drugs, but was frequently taking close to 3 hours to run out because we had so many trays that had to be pulled and checked and then placed into the fill by our technicians. The techs felt pressure to rush through checks to get the fill done one time and we attributed that to our problem with double packet/empty packet making it to the units.

12. NEW AUTOMATION PRODUCTS MAKING YOUR CHOICE
Machine
Speed
Interface
Canister Change
Production Trail
Talyst Autopak
63/min
Class 3 No
Automed Fastpak/EXP
65/min
Class 1
20/yr
Omnicell Safetypak
60/min
TCGRx ATP
63/mn
Make as needed
Yes
We had an Automed Fastpak/Exp, so that was our baseline. We elimintated the Talyst and Omnicell products due to their interface as we had had issues previously at this site. We that the choice of repurchasing a Fastpack or changing to the TCGRx ATP. We liked the fact that tray fills and checks were documented allowing us to drill down on fill problems, but what really sealed the deal for us was the ability to make our own canisters. This allowed us to keep the number of trays on the fill to a minimum to speed the fill which was our most important requirement. We settled on the TCGRx which would also be a savings for us our current Fastpak could be converted to an ATP with a software and a few minor hardware upgrades. We also purchased the canister replacement kit and the tablet splitter which would allow us to make half tablet canisters, again, minimizing the dreaded tray fills.

13. NEW AUTOMATION PRODUCTS ACQUISITION
Sole Source Justification
APPROPRIATE
Product cannot be supplied
by another vendor
Vendor’s product has an
advantage to the facility
NOT APPROPRIATE
Product/Service can be supplied by more than one
GSA vendor
Selection based on personal preference with no distinct advantage to the facilty.
We went through the process and made our decision and we got the go ahead to replace the machine from our local equipment committee, now it was time to make the purchase. We contracted our contracting service and presented our market research to the contracting officer. She looked it over and asked that we generate a sole source justification letter. Without it, she would have to ask for our requirements on a statement of work and then place our requirements out for a bid. Our market research had showed that we could get the ability to make our canister changes in house and save money or the purchase as we didn’t have to repurchase hardware as we could use what we had which was a cost savings to the facility. We generated the sole source justification letter outlining these advantages and attached it to our market research which allowed the contracting officer to purchase the equipment without having to bid it out. If none of the repackagers had the ability to modify canisters and we had to replace the machine outright, we would have had to make a statement of requirements and placed the request out for bid as several GSA vendors could supply unit dose repackaging machines. Asking contracting to purchase the machine from vendor A over vendor B or C because I found that vendor easier to work with would not be appropriate. The advantage has to be for the facility, not for you.

14. NEW AUTOMATION PRODUCTS SERVICE CONTRACT
Statement of Work
How long does the warranty last?
How many preventative maintenance sessions are you entitled to?
Is there a “first responder discount” if your local Biomedical Engineering
is trained to service the machine?
Do you get software upgrades included?
How long does service personnel have to respond to your service call?
Do you get other items such as free canister changes,?
Can you upgrade computers/other ancillary hardware or must these items be repurchased?
Does the vendor support older versions of their machines?
Estimating contract cost
Most machines come with a warranty and during the warranty period, all service issues will be covered. It is important to find out how long that warranty period lasts. It can be as long as one year and a little as 90 days. You should have a service contract in place to pick up when the warrant period expires so that you don’t have down time because a 2237 has to be cut to cover your service or worse yet, a member of your service creates an unauthorized commitment and we all know what a headache that can create. You may also want to find out if training is available for your Biomedical Engineering personnel. In some cases, vendors will give a “first responder” discount on the service contract as the facility’s personnel can handle routine issues. In one instance, we were entitled to 2 preventative maintenance service calls from the vendor, but our Biomedical Engineering personnel also performed 2 PMs so that our machine was being cleaned, oiled and services 4 times per year instead of 2. Also, in-house personnel can respond a lot faster that the vendor or a contractor which may be attractive to a rural or remote site. Make sure to find out if software upgrades are included. If so, you may have to set up VPN or other type of access for these upgrades. Also find out if the standard service contract entitles you to extras such as so many canister changes per year. The last 2 items should be spelled out in the service contract, but depending on the type of equipment, they should be included in market research as well because they may cause your site to have to repurchase equipment such as servers or automated dispending cabinets because older versions of the equipment are no longer supported. If you have to estimate the cost of a service contract during your purchase process, a good rule of thumb (as per our Biomedical Engineering Service) is that the service contract will cost approximately 8-10% of the acquisition cost of the equipment.

15. NEW AUTOMATION PRODUCTS SERVICE CONTRACT
What if the terms and conditions of a service contract are set as part of the vendor’s FSS contract?
Sole source justification letter should be generated.
Most of the equipment in use in VA Pharmacies have the terms of a service contract spelled out as part of their FSS contract. In that case, a statement of work does not need to be generated as only one vendor will be able to meet the terms and conditions of the contract. I have attached a copy of a sole source justification form in use at this facility that will make sure that contracting gets the information it needs to be able to do their job and meet their regulations. If you do need to generate a sole source contract, I would recommend that you work with your Biomedical Engineering and Contracting Services to make sure that the contract numbers are correct and that the service requirements are what they need to be.

16. NEW AUTOMATION PRODUCTS NEW PRODUCTS
Some Considerations:
Does the system under consideration use a portable device?
Doe the portable device store patient information
Does system store VA patient information on the vendor’s server?
Does the system transfer patient information using a wireless network.
All that is great if you are purchasing equipment that has been in use in other VA facilities, but what if you are considering an item that has never been used within VA before? We have done this twice at our facility. One project was unsuccessful and one is on-going. I will talk about the unsuccessful project first. We looked at a ScriptPro mobile checkpoint and we thought it would have many applications at this site. The mobile checkpoint is a hand held device that would allow pharmacy to deliver prescriptions anywhere in the facility and capture the signature and counseling information at the point of delivery. The information could then be downloaded in the ScriptPro archives back in the pharmacy. We contacted our IRM service and started the evaluate the feasibility of using this product in the facility. The mobile checkpoint downloaded the information into the ScriptPro server wirelessly. We asked if there was a way to dock the device to do the transfer so that we would not have to worry about the wireless encryption which needs to be FIPS compliant, but the device was designed so that it could only be downloaded wirelessly. While this was a problem, it was still not a deal breaker. Scriptpro could install an encryption routine that met the VA current specifications and upgrades could be written into the contract as part of the purchase. The deal breaker for us was the storage of information on the device itself. The device did not encrypt the stored information and if it was ever lost, a lot of patient information would be there on the device leading to a major HIPPA security breach. As a result, we had to abandon this purchase. Some of these issues may be solved at a later date and, if so, it would go back into consideration.

17. NEW AUTOMATION PRODUCTS NEW PRODUCTS
But what if you REALLY WANT a new device? Where to you start?
How do you work with the vendor to see if the device can be installed within VA
Will the vendor be willing to modify some parts of the system to make it work?
While we were not successful with that project, we didn’t give up on trying new systems that we thought could enhance our program. One of the software programs we are currently evaluating will allow us to track unit dose medication. Currently, the order processing can be tracked through provider order to finishing pharmacist, but then the next time anything is documented is when nursing is getting ready to administer the dose. All of the processes in between are opaque. The vendor already has devices in use in the VA, but this is a new program. We went to a civilian facility and saw the system and it worked well there, but the VA is in a category by itself. The system uses an i-pod to scan the fill, check an delivery processes and Apple products, while great, do not meet the FIPs encryption certification. The device was only to be used as a scanner, so the vendor was willing to set the program up on a microsoft device that could meet the VA’s requirements.

18. NEW AUTOMATION PRODUCTS NEW PRODUCTS
New device/software evaluation
Go through the assessment with the vendor and your IRM and Biomedical Engineering Services so that you don’t have to explain to your facility’s Director late on a Friday how a virus got downloaded onto your network and apologize for the overtime clear up the problem.
I have attached a copy of the VISN 4 Network Medical Device Assessment Policy. I got this from our ISO and I would imagine that the ISO at your facility has something similar in his or her files. Attachment A has a nice check sheet that will help you evaluate a new piece of equipment and to make sure that the device I installed with safeguards from the start. I know of a facility that did have a virus downloaded through their repackaging machine’s VPN access which did not have anti-virus software. The clean up was not pleasant as you can imagine, so even if this looks daunting, it is less daunting than cleaning up a preventable problem.

19. NEW AUTOMATION PRODUCTS ON THE HORIZON
IV Preparation Machine
A self contained IV preparation robot that can be set up to prepare syringes, IV admixtures or chemotherapy
Meets all USP 797, NIOSH and OSHA requirements
There are several new machines for IV preparation on the market. We have featured some in our Automation Friday series, but we have not seen any site report using one. The IV robot will prepare IV medication using barcode technology to prevent error and create an audit trail to document the compounding process. This machine would be most helpful in a large facility that compounds many IV solutions or a multi-center site that would like to designate one site to prepare the routine IV piggyback solutions. Items could be frozen after preparation to allow the other sites to maintain an inventory. While this machine can be set up to prepare chemotherapy, there is also a specialized machine for the its preparation.

20. NEW AUTOMATION PRODUCTS ON THE HORIZON
Chemotherapy Preparation Machinery
Prepares Chemotherapy in an ISO 5 Environment with barcode technology to prevent error
Prevents Operator Exposure to Hazardous Chemotherapeutic Material
Seals waste in containers for proper disposal of hazardous material
The chemotherapy preparation machine is a fairly new entry into the field. There are a few, the one in the picture is available from Devon Robotics. It prepares the chemotherapy in an ISO 5 environment and in a manner that protects the operator from exposure to the chemotherapeutic medications. There are reports in the literature of nursing personnel who prepared and administered chemotherapy in the 1970s developing cancer later in life. However, it should be noted that chemotherapy was prepared bare handed on counter tops in those days and the exposure to the hazardous material was much greater. This machine differs from the Riva in that all chemotherapeutic waste is dropped into a container within the machine which is sealed prior to removal to prevent exposure to this material as well. It can then be collected by your GEMS program for proper disposal. If your facility might benefit from using either of these machines, than I urge you to pursue it. Bring in your IRM, Biomedical Engineering and other departments and work through the check sheet. Don’t be afraid of the process. It might not always work out, but if you don’t try, it will never work out.

21. NEW AUTOMATION PRODUCTS
Thank you for your attention. Are there any questions?
Any Questions?