High-speed unit dose packagers for pharmacy

There are a lot of pharmacies out there that utilize high-speed packagers for one reason or another. Sometimes medications aren’t available in unit-dose packages from the manufacturer, or in one case that I came across recently, a pharmacy may elect to package from bulk bottles for efficiency and/or cost savings.

I haven’t given much thought to high-speed packagers in a while because they seem to be a low priority in many pharmacies these days. But I had reason recently to give them some thought. Someone sent me an email asking me about the various high-speed packagers on the market, who sells them, who they’re made by, etc. So I put together the table below. It covers the basics.
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#1 thing to consider when buying pharmacy automation and/or technology…

There are a ton of things to consider when you’re thinking about putting new technology in the pharmacy. You have to consider the cost, the impact on your operations, the reputation of the company that you’re buying from, what type of technology you’re going to buy, and so on and so forth ad infinitum.

However, the number one thing you must consider before taking the plunge is whether or not the technology fits your dispensing model. Do you still do a cart fill? Are you completely decentralized? Are you using a just-in-time dispensing model? Will the technology that I’m looking at fit what I hope to accomplish? You need to think about that long and hard before making a decision.

It’s like buying a new vehicle. You certainly don’t buy a Toyota Prius if you need to pull a 24 foot Centurion Enzo SV244 – a really nice boat – to the lake on weekends. No, instead you buy a new Ford Super Duty truck. I know that makes perfect sense to you, yet I hear people frequently say “it doesn’t fit the way we work” when talking about pharmacy automation and technology. When they say that, the first thing that pops into my mind is “then why did you buy it?”. It’s a question that needs serious consideration because some of this stuff is expensive.

I experienced this firsthand in my previous role as an IT pharmacist. We installed new technology that didn’t really fit our distribution model all that well. We tried to cram the technology into an manual process. Didn’t work. I fought it for a few months until the light bulb finally went off. Once we got out act together we redesigned the process around the technology. We took advantage of the automation and filled in the gaps where necessary. It fundamentally changed the way we did things, and in the process improved the overall distribution process.

So before you go and buy a robot, or a carousel, or a high-speed packager, or a compounding machine, make sure you ask yourself how you’re going to use it.  This stuff isn’t top secret. Do a quick Google search. Watch some videos. Talk with hospitals that do the same things as you.

In a nutshell do your homework before taking the plunge because once you take the plunge and decide you’ve made a mistake you can only do one of two things: 1) change automation, or 2) change the way you work.

Automating the oral pediatric syringe filling process [idea]

oral syringeThe distribution process in pediatric acute care can be quite a bit different than its adult counterpart. The basics are the same on the surface: 1) receive medication orders, 2) fill medication orders, 3) dispense medications. The big difference however is how those medication orders are filled. Pediatric patients require a lot medications in liquid form pulled into oral syringes with patient specific dosages. The bummer is that a vast majority of these syringes are not manufactured in unit of use syringes. In other words you have to do most of the work yourself. It’s a bit of a hassle, but it has to be done. The process of pulling liquid doses into oral syringes has more in common with work done in the IV room than it does with traditional oral solid distribution.

Recently I was visited a pediatric hospital and watched this process in action. Based on what I witnessed I started to wonder if it was possible to automate the process. And if you could automate it, would it offer any benefit? I suppose it could increase the safety of the process as well as potentially eliminate the need for a pharmacist, freeing them to do something else. Maybe. Maybe not. Regardless, it was worth more thought.

I started breaking down the process and realizes that it’s more complex than it appears on the surface; it always is. Automating the process would be difficult. Several pieces of the puzzle are already available today, but as completely disparate systems.

Just thinking out loud, or in writing as the case may be, the process would look a little like this:
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Robots better than human surgeons? Maybe…maybe not.

MedPage Today: “Robotic prostatectomy has spread all over the U.S., despite the fact that we don’t have clinical trial data to show that it’s better than traditional open surgery. 

The company marketing the robotic surgery systems boasts on its website about news coverage from ABC’s “Good Morning America” and from CNN’s Dr. Sanjay Gupta.  And, under a picture of a couple dancing, the manufacturer claims:

“Studies show patients who undergo a da Vinci Prostatectomy may experience a faster return of urinary continence following surgery … Several studies also show that patients who are potent prior to surgery have experienced a high level of recovery of sexual function (defined as an erection for intercourse) within a year following da Vinci Surgery.”

But a paper published by the Journal of Clinical Oncology concludes that:

Risks of problems with continence and sexual function are high after both (robotic and open prostatectomy). Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.”

The article gives examples of complications following open (“normal”) surgery versus robotic surgery using Medicare claims data from 406 men that had robotic surgery and 220 that had open surgery. The data from the two groups looks surprisingly similar. In fact, the open surgery group had a larger percentage of respondents reporting no complications than did the robotic surgery group; although the difference may not be significant.

Ultimately the authors of the Journal of Clinical Oncology suggest that the reason for the popularity of robotic surgery may be “gizmo idolatry” is at play. The authors go one step further by calling out Medicare’s reimbursement for robotic prostatectomy, “The apparent lack of better outcomes associated with (robotic prostatectomy) also calls into question whether Medicare should pay more for this procedure until prospective large-scale outcome studies from the typical sites performing these procedures demonstrate better results in terms of side effects and cancer control.”

It makes one wonder where the line for reimbursement should be drawn. Should reimbursement be tied to evidence based outcomes? It’s a good question when you think about all the treatments we use everyday that may not have sufficient data to back them up. Does that mean we should only use evidence based treatment? No, that would limit our ability to try new therapies when others fail. Interesting debate nonetheless.

Technology in the IV room – its time has come

The cleanroom environment, a.k.a. the IV room, is one of my favorite areas inside an acute care pharmacy. It is often alive with activity, and can often be the busiest area of the pharmacy. It is also a unique place since the use of intravenous (IV) medications is vital to the successful outcomes of patients, but at the same time can result in some of the most egregious errors in healthcare. While the IV compounding process is under tight control as demanded by USP guidelines, the method of preparation and distribution is decidedly more conventional, i.e. IV rooms often rely heavily on humans. It’s an interesting dichotomy found nowhere else in the pharmacy. It is for these reasons that I find it interesting that pharmacy IV rooms have lagged behind other areas of pharmacy operations in automation and technology. However, that’s beginning to change.

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Cleanrooms – the forgotten realm of acute care pharmacy

Cleanroom environments, a.k.a. IV rooms, inside acute care pharmacies compound some of the most complex and dangerous medications used inside a hospital. Unfortunately this area is often overlooked when implementing safety features such as bar-code verification, identification of high-alert medications, advanced training and competency and so on. I was reminded of the dangers of intravenous products by a recent story coming out of Alabama where the death of 9 patients was linked to TPN (total parenteral nutrition) contaminated with Serratia marcenscens.

While IV rooms remain a high risk area they tend to fall off the radar of many hospital administrators when it comes to implementing technology capable of reducing risk. USP <797> tends to get all the glory even though much of the guidelines proposed in this USP chapter have yet to be shown any more effective than diligent hand washing and impeccable technique.
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Where will automation and technology make the biggest impact in pharmacy?

I was planning on writing a rant this morning about lack of motivation, leadership and dumbasses – hey, I was in a fould mood when I got up – but then I opened an email from a friend. He asked me “How can retail pharmacists get involved in this [pharmacy informatics] industry?”. My first thought was to say that retail pharmacy would be the death of our profession and that they have no business getting involved in pharmacy informatics. Harsh I know, but I told you I was in a foul mood.

Then I did something I rarely do, I thought about the question a bit more before answering. After some time I came to the conclusion that retail, or more generally outpatient, pharmacy is exactly where more automation and technology is needed. I follow a few retail pharmacists on Twitter and one generalization I can make from reading their Tweets is that they all pretty much hate their jobs. Why? Because they spend precious little time working as pharmacists, instead spending most of their time physically filling prescriptions, chasing insurance claims, etc.

What retail pharmacy needs is a super-sized dose of pharmacy automation, technology and greater pharmacy technician involvement. Nowhere in pharmacy is there a greater need for automation and technology than outpatient services. Much of what’s done in the outpatient pharmacy setting does not require a pharmacist. This echoes the words by Chad Hardy last week on the RxInformatics website. Chad states “The longer we rely on pharmacists to run the entire supply chain, the higher our risk of obsolescence.” He’s absolutely right, although the article he references insinuates that pharmacists will become obsolete secondary to technology. Nay, I say. Technology in the outpatient arena can offer pharmacists the opportunity to break away from the mundane and do a little more hands on patient care. In addition, the drive to implement automation and technology in the retail setting creates the perfect job opportunity for pharmacists interested in informatics.

Of course we’ll have to prove to the retail boys upstairs that they can save money by using pharmacists in a more clinical role, but that’s what business cases are for. Unfortunately I couldn’t write a business case to save my life. In fact, a colleague of mine told me that pharmacists are terrible at creating business cases. I suppose that’s true as most of us didn’t become pharmacists to practice business. Instead we became pharmacists to provide patient care. Go figure.

How not to design an application for pharmacy

I’ve used Pyxis PARx before, but only in combination with a carousel storage system. I recently had the opportunity to play with the standalone version of PARx and all I have to say is yikes!

The system utilizes an older version of Windows Mobile on a clunky Motorola handheld. To get from log-in to a useful place in the application required me to go through no less than four screens. The touch screen was unresponsive and difficult to use, the device was painfully slow and the connectivity was lacking.

So, to sum up my experience with PARx – used with carousel technology it’s great, but try to use the standalone product and you might find yourself spewing profanity.


Cool pharmacy technology – UCSF Robotics

UCSF: “Although it won’t be obvious to UCSF Medical Center patients, behind the scenes a family of giant robots now counts and processes their medications. With a new automated hospital pharmacy, believed to be the nation’s most comprehensive, UCSF is using robotic technology and electronics to prepare and track medications with the goal of improving patient safety.

Not a single error has occurred in the 350,000 doses of medication prepared during the system’s recent phase in.

Robotics is nothing new, but it seems like everyone is taking notice of the new robotics in the pharmacy at UCSF. I suppose all the people pointing it out to me has something to do with the fact that UCSF School of Pharmacy is my alma mater, but you never know. Anyway, I’m pleasantly surprised to see UCSF taking such an active role in advancing pharmacy practice. When I spoke with some colleagues sill working for UCSF a little over a year ago they were still practicing pharmacy invented in the dark ages. Not any more.

Now I’m trying to get a hold of someone at UCSF that will let me stop by for a tour, and all of a sudden no one knows me. Poetic justice I suppose.