1. technology and computing
2. software

test
Automation in Hospital Pharmacy:
Planning, Selection, Impact on Purchasing
Practice
Sam Colletti, RPh
Director, Clinical Pharmacy
MedAssets
Test
………………………………………………..
CONFIDENTIAL – PROPERTY OF MEDASSETS. MedAssets® is a registered trademark of MedAssets, Inc. Copyright MedAssets, 2009. All rights reserved.
Kelly Froisness, CPhT
Pharmacy Buyer
CHRISTUS Hospital- St Elizabeth
Beaumont, TX
CHRISTUS Health
1999 two historic Catholic nonprofit 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
2
Test………………………
Confidential – Not For Distribution
Introduction
3
 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
Objectives
4
 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
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.
5
History of Automation in Hospital Pharmacy
6
 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 Pharmacy
7
 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
Process
8
 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 Process
Impact on Deployment of Automation
Strategic Planning
 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

10
Strategic Planning
 Define current and future states of both clinical services




and dispensing operations for your facility
Define tools needed to support those services
Project realistic timelines for implementation of services
Evaluate alternate pathways to achieve goals
Five 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)
11
2006 Strategic Pharmacy Plan
Strategic Goal
Initiative
4. Increase the extent to which
Integrate the pharmacy based medication
pharmacy has a significant role in
management safety projects into the overall
improving the safety of medication use. Christus Patient Safety Program.
An annual assessment of all facilities processes
for compounding sterile medications is
completed, consistent with established standards
and best practices.
At lest 95% of routine medication orders are
reviewed for appropriatness by a pharmacist
before administration of the first dose.
Description
Define formulary management within the Christus
enviornment.
Develop a collaborative approach of medication
management to include practicioners and all
relivant members of the healthcare team across
the system.
Create a model to review and communicate
relevant drug information and utilization protocols
to local PNT Committee in consideration of future
impact.
Date
Comments
JCAHO and patient Safety
2006/2007
Data is complied and reviewed and reported
by the pharmacy resource group to ensure
consistent results.
Specific exceptions written for emergency
and physician administration with
retrospecitve review.
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.
All pharmacy technicians will be certified by the Specific guidelines for training, hiring, and
PTCB and/ or the State Board of Pharmacy
development of job descriptions.
5. Create a unified approach to
formulary management within the
Christus System.
Completion
Also see strategic goal #3 initiative.
2007
2008
This is a reportable core measure for each
facility.
2007
2007
2006
2010
2008
Transforming Strategic Plans into Action
Timelines for Bedside Medication Scanning
Facility
Start
Date
Go Live
Date
Carousel
Oral Solid
Packager
Hi-volume
Packager
200 canisters
Liquid
packager
Hospital A
12/10
10/11
Packager/
Carousel
Brand Z
Hospital B
11/10
8/11
Table Top
Packager
NA
Brand Y Table
Top Packager
manual
7/11
Existing
manual
packaging
NA
Outsource/ Manual
manual
Hospital C
9/10
Facility Construction/Plant
Comments
Future Configuration
Scope
Liquid
Packager
Bar Code
labeler
Bar Code
Printer/ X
Software
Bar Code
Printer/ X
Software
Bar Code
Printer/ X
Software
Considering additional space, engineering for a
potential Carousel. Local decisions pending.
Move cabinets and shelving only. No new space
construction.
No construction. Adding new barcode pringter
only.
Create specific plans that give everyone a clear picture.
Allow staff to weight in and take ownership in the project
Give other involved departments a project scope and timeline
Administration, Finance, Plant OPS/Engineering, IM
13
Automation that Directly
Impacts the Buyer
Carousel Technology
Unit Dose and Bar Code Repackaging
Systems
Selection Process
CAROUSELS
15
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 Goals
Increase dispensing accuracy and patient Safety
Simplify workflow and improve productivity
Utilization of barcode process to enhance BMV
Reduce inventory space requirements up to 60%
Reduce inventory on hand and Automate Min
Max
Robust reporting inventory management
Cartfill or non-Cartfill Distribution
Returns
Barcode
Packager/
Labeler
Hub Software
Patient Carts
Pharmacy
Information
System
Carousels
Drug
Wholesaler –
Supplier
Patient Orders
Static
Shelving
&
Refrigerators
Automated
Dispensing
Unit = ADU
Carousel Selection Guidelines
18
Hardware
Large variation in quality and vendors
7,000 to 8,000 pound boxes require
engineering consults
Significant redesign of pharmacy workflow
Software
The large variation among
pharmacy vendors
Interface Costs are significant
Requires hand on
demonstration
Service
Service of hardware and software is a major concern
Significant variation is costs related to service
Recommend doing a 5 year cost cost of ownership when comparing
vendors
Carousel Selection Guidelines
19
 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
Carousel Vendor
5 Year
Capital
Equipment
Hardware, Software, Peripherals
Year 1 Total
$14,000
Vendor Training
$3,000
Pharmacy System Interface
$33,750
HUB Software Installation
$4,000
Carousel Shipping & Handeling
Capital Total:
Year 3
Year 4
Year 5
$5,000
$5,000
$9,225
$18,000
$5,000
$9,225
$18,000
$25,000
$43,675
$90,000
$150,000
Server & OS Agents etc, printer,
workstation
Hub Shipping Costs
5 Year Total
Year 2
$500
$9,000
$214,250
Operating
Pharmacy System Interface Support
*Carousel Annual Support-Hardware
Software Support
$5,000
$8,000
$18,000
$18,000
$5,000
$9,225
$18,000
Operating Total :
$31,000
$31,000
$32,225
$32,225
$32,225
$158,675
$42,850
$47,145
$47,145
$47,145
$227,135
$95,445
$95,445
$70,231
$72,301
$385,810
Total:
$8,000
$245,250
Depreciation over 5 years:
Total Year 1 costs capitalized
$42,850
Yearly Spend with Operating $90,945
20
Example ROI Calculation – Carousel System
Cost Justification (ROI) Calculations
for a Carousel
Inventory Change
* Current Inventory Drug Budget
*
*
*
*
*
Current Dollar Inventory Total
Approximate % to be Controlled by Carousel
Total Dollar Inventory Managed by Carousel
% Inventory Reduction Savings
Total Inventory Reduction
Inventory Carrying Cost
* Total Inventory Reduction
* Cost of Capital
* Annual Interest Savings
Expired Medication Waste
* % Projected Waste Reduction
* Medication Waste Savings
Total Financial Impact
One Time Savings
Recurring Annual Savings
Estimated Initial Capital Inventment
*Excludes monthly service fees
Return on Investment (Years)
350 Bed
Hospital
Current
Inventory Proposed
Turns
Turns
$ 8,200,000
$
$
$
$
737,500
95%
700,625
29.78%
219,628
120 Bed
Hospital
$ 2,541,677
11
16
$ 285,000
95%
$ 270,750
20.50%
$ 58,425
$
$
219,628
5%
10,981
222,578
50%
111,289
$
58,425
5%
2,921
71,455
50%
35,728
$
$
219,628
122,270
$
$
58,425
38,649
$
$
Current
Inventory Proposed
Turns
Turns
$
$
$245,000
$229,000
0.72
2.36
9
11
21
Product Comparison Table
22
Feature/Functionality
Funding Options- Capital Expense, Capital Lease
Hardware Options: Vendor Selected, Client Selected
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.
Safety Features include double scan to confirm correct product and
also operator Safety stops.
Safety- Forced Quality Checks and cycle counts to reduce expired drugs
in carousel
Manages External Shelving and Locations in Sync with Carousel
HUB Software interfaces Pharmacy informations system, Medication
Cabinets, Packagers and Carousel
Wholesaler interface included without additional cost
Dynamic Inventory Optimization functionality based on user parameters.
Setup Wizards for new formulary items, users, security, etc.
User-friendly GUI for viewing and changing product location
assignments
Auto-import of wholesale distributor invoices upon export from wholesale
distributor system
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)
Annual Maintenance Fees per Year
Vendor A
Vendor B
Vendor C
Yes
Yes
Yes
Client
Vendor
Vendor
YES
NO
NO
YES
YES
YES
YES
NO
YES
YES
YES
NO
YES
YES
NO
YES
NO
NO
YES
NO
YES
YES
NO
NO
YES
NO
YES
YES
NO
NO
Minimizes steps to receive Distributor Orders.
YES
NO
NO
Flexible and accurate inventory valuation reporting
display options.
$5,000
$21,000
$38,000
$34,000
$34,000
$34,000
$400,000
800000
$450,000
Pharmacy Informations System Interface Fee
Estimated 5 Year cost of ownership for a hypothetical pharmacy systemSingle carousel
Benefit
Vendor A lease through Company K
There are a number of hardware vendors and significant
variation in quality of cabinets, serviceability.
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.
Minimum Safety Requirements of all vendors
Easily setup new items, users, etc. Wizards that walk you
through the process.
Makes viewing and changing product location
assignments as easy as selecting an airlineseat online.
Wide varietion
HBOC, Meditech, Cerner, etc. Dependant on other IT
contracts.
All prices are negotiable with a high degree of variabllity.
Each contract circumstance is somewhat unique.
Selection Process
UNIT DOSE BAR CODING
SYSTEMS
23
BMV- Bedside Medication Verification
 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
24
Equipment Descriptions
 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
25
Equipment Descriptions
 Manual Packaging –
Disposable low volume
packaging materials
 Over Wrappers/Baggers –
Produce sealed plastic
bags with labeling and bar
coding printed on the bag
26
Packaging Equipment Selection
27
 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
28
 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
29
 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
30
 Oral Solids (Low Volume, Medium Volume, High Volume)
 Oral Liquids
 U/D Injectables & Inhalants ( vials, amps, respiratory meds)
 Multi-Dose Containers (inhalers, topicals, ophthalmics)
 Large Volume IV’s
 Patient Specific Doses ( Admixed IVs, Non-formulary, nonsterile compounded products, home-medications, Insulin,
Investigational Drugs)
Right Sizing Equipment to the Facility
31
 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 Size
32
Small Facility <=50 beds
Dosage Form
Technology
Estimated Capital
Oral Solids
Manual packaging
N/A
Oral Liquids
Manual
N/A
Manually Applied Barcodes
Software, printer, variety of label stock
$4,000 to $6,000
Medium facility 50 to 125 beds
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
Manually Applied Barcodes
Software, printer, variety of label stock
$4,000 to $6,000
Dosage Form
Large facility > 125 beds
Technology
Estimated Capital
Oral Solids
Hi-Volume Repackager (scaled to size)
$150,000 to$350,000
Oral Liquids
Tabletop Repackager or manual
Up to $25,000
Manually Applied Barcodes
Software, printer, variety of label stock
$4,000- $6,000
Conclusion
33
 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 Websites
34
 In addition to your GPO there are a variety of
review sources
Manufacturer
Accuchart (Euclid)
Phacts
McKesson Automation
Pearson Medical Technologies
MPI ( Medical Packaging Inc)
TCG-RX
Pharmacy Automation Supplies
Talyst
Medi-Dose Products
Amerisource Bergen Automation
Health Care Logistics
Klas Research
Pharmacy Purchasing and Products Magazine
Websites
www.accuchart.com
www.phacts.net
www.mckesson.com
www.pearsonmedical.com
www.medpak.com
www.tcgrx.com
www.pharmacyautomationsupplies.com
www.talyst.com
www.medidose.com
www.amerisourcebergendrug.com
www.healthcarelogistics.com
www.klasresearch.com
www.pppmag.com
Disclaimer- The vendor list is not exhaustive and new vendors appear regularly
A Buyer’s Perspective
C A R O U S E L A N D PA C K A G I N G A U T O M AT I O N
K E L LY F R O I S N E S S , C P H T
35
CHRISTUS Hospital – St. Elizabeth
Mission: 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 Environment
37
 Full BMV since 2002
 Currently deployed ADM’s in all patient care, surgical
and clinical areas
 Cartless workflow process for medication distribution
 Two 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 errors
 Automatically 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)
–
–
–
After Automation
•
Manually key in item numbers (30
minutes)
Check for contract items (15 minutes)
Transmit (send)
Buyer will electronically run suggested
order report. (5min daily)
–
–
–
–
•
Medications manually received then
placed on shelves. (2-3 hours daily)
•
Medication electronically received
(medication and quantity)
–
ESTIMATED TIME: 4 -5 HOURS
Upload order to wholesaler (5 minutes)
Check any static shelves(10 minutes)
Check for contract items (15 minutes )
Transmit (send)
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
After Automation
 Technician walks shelves picking
 Medstation polling and first dose
meds for ADM refills and new
Orders
 Technician manually credits returns
and replaces stock to bins.
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

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
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 error
 Cross 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
After Automation
 All Tabs and Caps purchased in
 ADM Fill - Hub Software polls
U/D, batch packaged, or
outsourced
Carousel and Packager and
intelligently sends fill request to all
devices
 Medication electronically received
(medication and quantity)

ESTIMATED TIME: 3 HOURS 45
MINUTES
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
Conclusion
46
 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 !
47