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Automation in Hospital Pharmacy:Planning, Selection, Impact on Purchasing Practice
Kelly Froisness, CPhTPharmacy BuyerCHRISTUS Hospital- St ElizabethBeaumont, TX
Sam Colletti, RPhDirector, Clinical PharmacyMedAssets
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Confidential – Not For Distribution2
1999 two historic Catholic non-profit charities formed CHRISTUS Health:• Sisters of Charity Health Care System• Incarnate Word Health System
Mission: To extend the healing ministry of Jesus Christ• Top 10 Catholic health system in U.S.• 43 hospitals / 16 long-term acute care
facilities across 8 states and Mexico• Net patient revenues exceeding $2.6
billion• Assets totaling more than $4.3 billion• Supplies, Purchased Services, and
Energy $957million
CHRISTUS Health
Test………………………
Introduction3
Automation and the acquisition of capital equipment have become essential to the hospital pharmacy in recent years
Greater than 95% of all hospital pharmacies have some level of automation and 60% to 70% of facilities currently expect significant increases in their automation budgets over the next few years
Objectives4
Outline the progression of automation in hospital pharmacy
Describe the strategic planning process for incorporating automation into current and future practice
Define the selection process for automation that incorporates the clinical, dispensing, and purchasing functions of the pharmacy department Carousels Packagers
Discuss the impact of automation on purchasing practices A Buyer’s Perspective
History of Automation in Hospital Pharmacy
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Most texts refer to the early efforts in the 1960s as the beginning of Automation.
1970s- almost entirely manual processes. The largest facilities utilized main frames or mini-computers solely for billing. There were initial attempts at unit dose packaging. The most advanced technology was the memory typewriter.
History of Automation in Hospital Pharmacy6
1980’s The progress of automation in general is tied to the
emergence of PC’s in the pharmacy workplace Initially focused on IV labeling to replace the typewriters Beginning of simple programs that could balance TPN ions or
do simple statistics Much of the software was written by pharmacists for use
locally then passed on to others The beginnings of ADT/Order Entry/Profiles emerged as the
storage capacity and speed increased The seeds of much of today’s pharmacy automation come
from this decade
History of Automation in Hospital Pharmacy7
1990’s – Explosion of Integrated Hospital Systems which included pharmacy Elimination of manual patient profiles for almost everyone Introduction of ADMs, Computerized Clinical Information
Sources, Controlled substance inventory management, and Carousel, BMV , bar coding technology
All of these efforts needed years of experimentation and improvement to get to the current levels
Technology Applied in the Medication Use Process8
Prescribing Clinical decision support software Computerized prescriber order management(CPOM)
Dispensing Carousel technology Centralized robotic dispensing technology Centralized narcotic dispensing technology Decentralized automated dispensing cabinets IV and TPN compounding devices Pneumatic tubes systems Unit Dose repackaging systems
Administration Bar Code medication administration technology Clinical decision support infusion pumps
Monitoring Electronic clinical documentation systems Web based compliance and disease management tracking systems
The Strategic Planning ProcessImpact on Deployment of Automation
Strategic Planning
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Successful Planning and Implementation Integration with Facility/System Capital Plans
It is necessary to establish a long range vision of pharmacy services that can be consistently expressed to the C Suite
A formal plan provides long term continuity despite staff changes A formal plan provides specific objectives to develop and the ability
to present a single vision of pharmacy services over time Solicitation of support for other disciplines that can benefit from
changes in pharmacy Long term outlook for pharmacy services
Equipment can tie you to specific dispensing methods for years Pharmacy is not perceived as requiring capital funding Obtaining capital or operations funding for a large project can
take several years to get approval
Strategic Planning
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Define current and future states of both clinical services and dispensing operations for your facility
Define tools needed to support those servicesProject realistic timelines for implementation of
servicesEvaluate alternate pathways to achieve goalsFive and ten year goals are realistic approaches
the best chance for approval and successful implementation know your limits and make proposals fit Present proposals to fit your audience (CFO talk not Pharmacy
talk)
2006 Strategic Pharmacy Plan
Strategic Goal Initiative DescriptionCompletion
DateComments
4. Increase the extent to which pharmacy has a significant role in improving the safety of medication use.
Integrate the pharmacy based medication management safety projects into the overall Christus Patient Safety Program.
JCAHO and patient Safety
2006/2007
An annual assessment of all facilities processes for compounding sterile medications is completed, consistent with established standards and best practices.
Data is complied and reviewed and reported by the pharmacy resource group to ensure consistent results. 2007
Also see strategic goal #3 initiative.
At lest 95% of routine medication orders are reviewed for appropriatness by a pharmacist before administration of the first dose.
Specific exceptions written for emergency and physician administration with retrospecitve review. 2008
Each pharmacy will participate in ensuring that patients receiving antibiotics as surgical prophylaxis will have their prophylactic antibiotic therapy discontinued within 24 hours after the surgery end time.
2007
This is a reportable core measure for each facility.
All pharmacy technicians will be certified by the PTCB and/ or the State Board of Pharmacy
Specific guidelines for training, hiring, and development of job descriptions. 2007
5. Create a unified approach to formulary management within the Christus System.
Define formulary management within the Christus enviornment. 2006
Develop a collaborative approach of medication management to include practicioners and all relivant members of the healthcare team across the system.
2010
Create a model to review and communicate relevant drug information and utilization protocols to local PNT Committee in consideration of future impact.
2008
Transforming Strategic Plans into Action
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FacilityStart Date
Go Live Date
ScopeFacility Construction/Plant
Comments
CarouselOral Solid Packager
Liquid packager
Bar Code labeler
Hospital A 12/10 10/11Packager/ Carousel
Brand ZHi-volume Packager
200 canisters
Liquid Packager
Bar Code Printer/ X Software
Considering additional space, engineering for a potential Carousel. Local decisions pending.
Hospital B 11/10 8/11Table Top Packager
NABrand Y Table Top Packager
manualBar Code Printer/ X Software
Move cabinets and shelving only. No new space construction.
Hospital C 9/10 7/11Existing manual
packagingNA Outsource/ Manual manual
Bar Code Printer/ X Software
No construction. Adding new barcode pringter only.
Future Configuration
Timelines for Bedside Medication Scanning
Create specific plans that give everyone a clear picture.Allow staff to weight in and take ownership in the projectGive other involved departments a project scope and timeline
Administration, Finance, Plant OPS/Engineering, IM
Automation that Directly Impacts the Buyer
Carousel TechnologyUnit Dose and Bar Code Repackaging
Systems
CAROUSELS
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Selection Process
What is a Carousel?16
Carousel Storage Systems are industrial grade hi-density shelving systems with software that meets the specific requirements of hospital pharmacy.
Functional GoalsIncrease dispensing accuracy and patient Safety
Simplify workflow and improve productivityUtilization of barcode process to enhance BMVReduce inventory space requirements up to
60% Reduce inventory on hand and Automate Min Max Robust reporting inventory management
Cartfill or non-Cartfill Distribution
Pharmacy Information
System
Barcode Packager/
Labeler
Static Shelving
& RefrigeratorsDrug
Wholesaler – Supplier
Patient Carts
Returns
Patient Orders
Carousels
Hub Software
Automated Dispensing Unit = ADU
Carousel Selection Guidelines18
HardwareLarge variation in quality and vendors
7,000 to 8,000 pound boxes require engineering consults
Significant redesign of pharmacy workflow
SoftwareThe large variation among pharmacy vendorsInterface Costs are significantRequires hand on demonstration
ServiceService of hardware and software is a major concernSignificant variation is costs related to serviceRecommend doing a 5 year cost cost of ownership when comparing vendors
Carousel Selection Guidelines19
Innovation All vendors do the basic functions, but style and user
interface varies Evaluate each vendor’s product for your unique
requirements and their ability to adapt to your current and future needs.
Equipment Integration Currently for most vendors the Carousel and Hi-volume
packager interface is proprietary
Example 5 Year Total Cost of Ownership Model
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5 Year TotalCapital Year 1 Total Year 2 Year 3 Year 4 Year 5
EquipmentHardware, Software, Peripherals $150,000
Server & OS Agents etc, printer, workstation $14,000
Vendor Training $3,000
Pharmacy System Interface $33,750
HUB Software Installation $4,000
Hub Shipping Costs $500
Carousel Shipping & Handeling $9,000
Capital Total: $214,250
Operating
Pharmacy System Interface Support $5,000 $5,000 $5,000 $5,000 $5,000 $25,000*Carousel Annual Support-Hardware $8,000 $8,000 $9,225 $9,225 $9,225 $43,675Software Support $18,000 $18,000 $18,000 $18,000 $18,000 $90,000
Operating Total : $31,000 $31,000 $32,225 $32,225 $32,225 $158,675
Total: $245,250Depreciation over 5 years:
Total Year 1 costs capitalized $42,850 $42,850 $47,145 $47,145 $47,145 $227,135
Yearly Spend with Operating $90,945 $95,445 $95,445 $70,231 $72,301 $385,810
Carousel Vendor 5 Year
Example ROI Calculation – Carousel System
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Cost Justification (ROI) Calculations for a Carousel
350 Bed Hospital
Current Inventory
TurnsProposed
Turns
120 Bed Hospital
Current Inventory
TurnsProposed
TurnsInventory Change
* Current Inventory Drug Budget 8,200,000$ 2,541,677$
* Current Dollar Inventory Total 737,500$ 11 285,000$ 9* Approximate % to be Controlled by Carousel 95% 95%* Total Dollar Inventory Managed by Carousel 700,625$ 270,750$ * % Inventory Reduction Savings 29.78% 20.50%* Total Inventory Reduction 219,628$ 16 58,425$ 11
Inventory Carrying Cost* Total Inventory Reduction 219,628$ 58,425$ * Cost of Capital 5% 5%* Annual Interest Savings 10,981$ 2,921$
Expired Medication Waste 222,578$ 71,455$ * % Projected Waste Reduction 50% 50%* Medication Waste Savings 111,289$ 35,728$
Total Financial ImpactOne Time Savings 219,628$ 58,425$
Recurring Annual Savings 122,270$ 38,649$ Estimated Initial Capital Inventment
*Excludes monthly service fees$245,000 $229,000
Return on Investment (Years) 0.72 2.36
Product Comparison Table
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Feature/Functionality Vendor A Vendor B Vendor C BenefitFunding Options- Capital Expense, Capital Lease Yes Yes Yes Vendor A lease through Company KHardware Options: Vendor Selected, Client Selected
Client Vendor Vendor There are a number of hardware vendors and significant variation in quality of cabinets, serviceability.
Mobile PC - ability to pick and bar code scan items “off-line” during a carousel network connectivity failure and auto-sync/upload the transactions when network connectivity restored. YES NO NO
System operational redundancy. Can pick items from carousels, print labels to a mobile printer and store the transaction data which auto-syncs with the transaction history database and adjusts the item's QOH when it senses the hospital network connectivity is restored.
Safety Features include double scan to confirm correct product and also operator Safety stops.
YES YES YESMinimum Safety Requirements of all vendors
Safety- Forced Quality Checks and cycle counts to reduce expired drugs in carousel
YES NO YES
Manages External Shelving and Locations in Sync with CarouselYES YES NO
HUB Software interfaces Pharmacy informations system, Medication Cabinets, Packagers and Carousel YES YES NO
Wholesaler interface included without additional costYES NO NO
Dynamic Inventory Optimization functionality based on user parameters. YES NO YES
Setup Wizards for new formulary items, users, security, etc.YES NO NO
Easily setup new items, users, etc. Wizards that walk you through the process.
User-friendly GUI for viewing and changing product location assignments
YES NO YESMakes viewing and changing product location assignments as easy as selecting an airlineseat online.
Auto-import of wholesale distributor invoices upon export from wholesale distributor system
YES NO NO Minimizes steps to receive Distributor Orders.Reporting - Physical Inventory Value: Summary, individual item detail and subtotaled by Inventory Storage Area (Total Value of Inventory), Detail (Descending by Line Item Based on Dollar Investment)
YES NO NO Flexible and accurate inventory valuation reporting display options.
Annual Maintenance Fees per Year$5,000 $21,000 $38,000 Wide varietion
Pharmacy Informations System Interface Fee
$34,000 $34,000 $34,000HBOC, Meditech, Cerner, etc. Dependant on other IT contracts.
Estimated 5 Year cost of ownership for a hypothetical pharmacy system- Single carousel $400,000 800000 $450,000
All prices are negotiable with a high degree of variabllity. Each contract circumstance is somewhat unique.
UNIT DOSE BAR CODING SYSTEMS
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Selection Process
BMV- Bedside Medication Verification
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Barcode Medication Verification- is a check system utilizing bar code technology to ensure each dose of medication given to a patient is correctly matched to a physician’s order including right drug, dose, time, and patient
A number of tools are required for the pharmacy portion of BMV Unit Dose Packaging Equipment – oral solids Liquid packagers Over-Wrappers Bar Code Labeling Equipment
Equipment Descriptions
25
High Volume Packagers – Canister packagers integrated into the pharmacy distribution process through Hub software to package in real time
Table Top Packagers – Traditional unit dose packagers producing batches of product for future dispensing
Equipment Descriptions
26
Manual Packaging – Disposable low volume packaging materials
Over Wrappers/Baggers – Produce sealed plastic bags with labeling and bar coding printed on the bag
Packaging Equipment Selection
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BMV is an all or none system. Avoiding gaps or workarounds is a primary goal
A “readable” barcode must be on every dose at the bedside
A variety of equipment is needed to resolve all the different product situations encountered
The decision process is complex due to the variety of packaging and bar coding solutions required in pharmacy
Initial decisions about operations determine equipment selection
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Questions: All packaging in house (90-100%)? Outsourced Packager ( 50-90%)? Manufacturer U/D bar coded Product with minimal in-house
packaging ( 30-80%)? What is the cost break point for each option? Which bar codes are actually readable by your bedside scan
system?
Decision Trees
Medication Dosage Forms and related Bar Code Technology Solutions
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A bar code solution is needed for every type of product dispensed. Selection depends on facility size(dispensing volume), labor,
and available capital A total cost of ownership should be calculated for each piece
of equipment with an estimated cost per unit dispensed
Medication Dosage forms and related bar code technology solutions
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Oral Solids (Low Volume, Medium Volume, High Volume)
Oral LiquidsU/D Injectables & Inhalants ( vials, amps, respiratory meds)
Multi-Dose Containers (inhalers, topicals, ophthalmics)
Large Volume IV’sPatient Specific Doses ( Admixed IVs, Non-formulary, non-
sterile compounded products, home-medications, Insulin, Investigational Drugs)
Right Sizing Equipment to the Facility31
Selection Determination Availability of Capital Funding Labor Costs
Undersized Equipment Choices Reduced life cycle of equipment High Labor Costs / unit dispensed
Oversized Equipment Choices Poor return on investment Unnecessary labor to maintain system
5 Year cost of ownership model for Leases and Capital Purchases is essential
Workflow and labor utilization analysis is essential
Equipment Choices by Facility Size32
Dosage Form Technology Estimated Capital
Oral Solids Manual packaging N/A
Oral Liquids Manual N/A
Small Facility <=50 beds
Manually Applied Barcodes Software, printer, variety of label stock $4,000 to $6,000
Dosage Form Technology Estimated Capital
Oral Solids Table Top Repackager $16,000 to $25,000
Oral Liquids Tabletop Repackager or Manual Up to $25,000
Medium facility 50 to 125 beds
Manually Applied Barcodes Software, printer, variety of label stock $4,000 to $6,000
Dosage Form Technology Estimated Capital
Oral Liquids Tabletop Repackager or manual Up to $25,000
Oral Solids $150,000 to$350,000
Manually Applied Barcodes Software, printer, variety of label stock $4,000- $6,000
Large facility > 125 beds
Hi-Volume Repackager (scaled to size)
Conclusion33
Planning Vision of future pharmacy practice Discussions with team and facility to form a compatible idea Form ideas into a strategic plan time lines and priorities Create specific plans with actionable detail Search for products and vendors that can make it happen Don’t be afraid to modify plans along the way
Planning and Strategy first– then exhibit halls and vendors
Manufacturer and Review Websites34
In addition to your GPO there are a variety of review sources
Manufacturer WebsitesAccuchart (Euclid) www.accuchart.comPhacts www.phacts.netMcKesson Automation www.mckesson.comPearson Medical Technologies www.pearsonmedical.comMPI ( Medical Packaging Inc) www.medpak.comTCG-RX www.tcgrx.comPharmacy Automation Supplies www.pharmacyautomationsupplies.comTalyst www.talyst.comMedi-Dose Products www.medidose.comAmerisource Bergen Automation www.amerisourcebergendrug.comHealth Care Logistics www.healthcarelogistics.comKlas Research www.klasresearch.comPharmacy Purchasing and Products Magazine www.pppmag.com
Disclaimer- The vendor list is not exhaustive and new vendors appear regularly
CAROUSEL AND PACKAGING AUTOMATION
KELLY FROISNESS, CPHT
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A Buyer’s Perspective
CHRISTUS Hospital – St. ElizabethMission: To extend the healing ministry of Jesus Christ
Established in 1962 in Beaumont TX 434 Licensed beds All acute care services 1,700 associates 554 combined medical staff 133 Allied health practitioners
Current Pharmacy Environment37
Full BMV since 2002Currently deployed ADM’s in all patient care, surgical
and clinical areasCartless workflow process for medication distributionTwo carousels and one high speed packager in the
central pharmacy Manual barcode labeling systems
Pharmacy Carousels - Pro’s and Con’s
Pro’s Accurate inventory control Quick & accurate order and
restock Ability to electronically upload
current inventory level during yearly inventory
Electronic polling for ADM refill Decrease in quantity of
medication errorsAutomatically interrupts
work flow for STAT/NEW orders Programming priority levels
allow creation of Queue's and Over-rides
Con’s Unexpected stock outs,
typically user error
Carousel - Work Flow Changes for Buyer
Before Automation:Buyer walks shelves (1 hour daily)– Manually key in item numbers (30
minutes)– Check for contract items (15
minutes)– Transmit (send)
• Medications manually received then placed on shelves. (2-3 hours daily)
ESTIMATED TIME: 4 -5 HOURS
After Automation• Buyer will electronically run suggested
order report. (5min daily)– Upload order to wholesaler (5
minutes)– Check any static shelves(10 minutes)– Check for contract items (15 minutes )– Transmit (send)
• Medication electronically received (medication and quantity)– The carousel rotates to the proper shelf
allowing user to scan barcode to assure proper placement of medication. (30 minutes daily)
ESTIMATED TIME: 50 MINUTES
Carousel/Packager - Work Flow Changes for Technicians
Before Automation Technician walks shelves picking
meds for ADM refills and new Orders
Technician manually credits returns and replaces stock to bins.
Technician must add low stock items to want list for buyer to review
Technician assists buyer with stocking new orders on shelves
ESTIMATED TIME: 12- 25 hours
After Automation Medstation polling and first dose
interface trigger automated response (carousel to roll) to correct shelf for proper medication dispensing
“Scan feature” allows a medication that is to be returned to be placed into queue for quick and accurate stock replacement
Established par levels make it unnecessary to have a “short list” for items stored in the Carousel
ESTIMATED TIME: 8-15 hours
Carousel Install Process - Technician
• Formulary imported (by vendor) from hospital computer system
• Set pars (min vs max)• Add wholesaler id• Program barcodes• Placement and arrangement
medication on shelves• Assign users• Label bins• Work time required
Approximately 80+ hours
Packager-Pro’s
Electronic Pharmacist verification during refill of canister Purchase bulk bottles for additional savings Consistent labeling and bar code scan quality Accurate inventory control Quick/accurate order and restock Longer expiration on pre-packed meds
Medication not packaged until time of use Electronic polling for ADM refill
Decrease in quantity of medication errors Medication is polled from ADM machine by pneumonic minimizing user error(s)
Multi-tasking Packages medication while tech is completing other tasks
Packager – Con’s
• Unexpected stock outs, typically user errorCross contamination possible in packager, typically
user error (Caused by poor cleaning and improper canister placement)
Mechanical device requiring consistent cleaning and preventative maintenance If packager malfunctions it will take time to receive parts and a technician
from company on site to make repairs. Backup packaging system recommended
Canisters are custom made for each NDC# making brand changes expensive If canister malfunctions it may take up to 8 weeks for replacement
Packagers - Work Flow Changes - Buyer
Before Automation All Tabs and Caps purchased in
U/D, batch packaged, or outsourced
ESTIMATED TIME: 3 HOURS 45 MINUTES
After Automation ADM Fill - Hub Software polls
Carousel and Packager and intelligently sends fill request to all devices
Medication electronically received (medication and quantity) the carousel rotates to the proper
shelf allowing user to scan barcode to assure proper placement of medication. (30 minutes)
ESTIMATED TIME: 50 MINUTES
Install Process Packager- Technician
• Formulary imported from hospital computer system
• Set pars (min vs max)• Assign locations (separation of
look alike sound alike)• Load canisters• Assign users
(Technician/Pharmacist)• Pharmacist verification of
medication • Work time required
– Approximately 30 manhours
Conclusion46
In conclusion although automated dispensing has made the work load of both the pharmacy buyer and the pharmacy technician quicker and more streamlined it requires daily upkeep maintenance
Both inventory control and Safety are greatly improved making the switch from manual medication storage to automated storage a great advantage
Thank You !
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