I’ve mentioned before the importance of attending healthcare conferences, and while this wasn’t nearly as good as being there in person, it was certainly better than not being involved at all. User groups offer the chance to hear about new company products long before the information is released to the general public and give you the opportunity to commune with people in the same situation as you.

The main focus of this particular user group meeting was to discuss the Talyst Software Only Workstation (SOW) pilot that I’ve blogged about here, and here; introduce and review the new AutoPharm3 patient safety release; and discuss the new barcode scanning hardware that Talyst is planning on rolling out in the near future. In addition there were discussions on various issues ranging from customer best practices to utilizing the Talyst customer portal.

The SOW pilot presentation and discussion was led by Brian Peters, Pharm.D., Director of pharmacy, Community Hospital North in Indianapolis, IN. He described the use of the SOW system in a cardiovascular specialty hospital using CPOE, eMAR and digital imaging technology. His experiences with SOW were mostly positive and similar in many ways to what I’ve experienced with the system myself. He too felt that a solution that offered visual feedback when scanning items while out of sight of the AutoPharm workstation would be beneficial. Overall, the presentation went well and provided some good information.

The show stopper, however, was the presentation on the upcoming AutoPharm3 release. Talyst has been talking about this “patient safety release” for quite some time and based on what I saw today there are some great new features. In a nutshell the AutoPharm3 will offer:

• Lot number and expiration tracking. For many facilities this won’t make much of an impact because they already utilize the expiration tracking function in their automated dispensing cabinets (ADC). On the other hand, the ability to track lot numbers is becoming increasingly important as recalls are giving everyone a giant headache. One could easily skip the expiration tracking in their ADCs in favor of using the lot and expiration tracking in AutoPharm. The benefit of using the AutoPharm system would be the reporting capabilities and the in-your-face way the system presents the information on the main dispensing screen.
• High alert medications. AutoPharm will now allow facilities to control messages for high alert medications at the formulary level. The functionality forces additional steps prior to dispensing a high-alert item and provides the end user with informational text on the label in the form of a watermark.
• Pediatric auxiliary labels for pediatric syringes. This is an interesting addition and one that I have discussed with various Talyst representatives in the past. I’m not sure where it fits in, but like many adult facilities pediatric medications can be challenging. Wait and see on this one.
• New role based permissions. This feature will be a welcome addition as it is a glaring hole in the current AutoPharm release. The current permissions structure in the AutoPharm system offers little flexibility and creates some workflow issues. This new feature will offer additional flexibility to users of the system. Looking forward to this.
• New reporting. This is something that I’ve been waiting on for a while. Quite frankly it has been a weakness of the system until very recently. New reports include high alert medication tracking, expired drug reports, lot number tracking, inventory adjustment report, i.e. discrepencies, and improper scan reports. That last one is the one I’ve been after for a while. I call them bad scans, but it’s the same idea. The report basically tells you how many times the system intercepted someone pulling the wrong drug. It’s a basic concept, but one that you can drill into to find out quite a bit about workflow.
• The new Code 3500 scanner. Tony North from Talyst spent quite a bit of time going over the new Code Corp 3500 scanner. He presented the advantages that the 3500 offers over the older CR3. In addition, he dissected the technology and presented some of the new features offered by the scanner. I’ve talked about the Code Corp 3500 scanner before. It is significantly better than the current CR3 scanner used by most Talyst customers. I’m fortunate that I’ve been using the 3500 for several months. End users will appreciate the upgrade.

Overall I picked up quite a bit by “attending” the 2010 Talyst user group meeting at the ASHP summer session. It was a little weird watching everyone on the monitor and I had trouble hearing at times, but as I said before it was better than missing the whole thing. There were a couple of times when the screen was filled with a slide and I continued to hear everyone, but couldn’t see them. It actually felt strange not being able to see everyone during those periods. I felt like I was more engaged when I could see what was going on at the table. Anyone else ever experience anything like that?

Below are several screen shots I took during the user group. There isn’t anything spectacular about them, but I thought I would include them for anyone that was interested. Enjoy.

We currently utilize software and hardware from Talyst to manage a sizable chunk of our inventory by running it through two automated carousels. If you’re interested you can see photos of the installation back in 2008 here. As we use a decentralized pharmacy model and dispense a majority of medications directly from automated dispensing cabinets, i.e. Pyxis, our entire pharmacy workflow revolves around these two carousels. However, there are still some areas of the pharmacy inventory that are not easily managed with the carousels, including the refrigerators, the freezers, items in the IV room and some of our large volume products that require a significant storage area. Talyst offers a solution for the refrigerated areas called AutoCool that we chose not to use, but the other areas remain a challenge. With the availability of the AutoPharm software only solution we’re able to place a workstation strategically in the pharmacy to cover some of these areas by creating static “carousel” shelving where there are no physical carousels; same idea as the carousels, they just don’t move.

Two areas that were of particular interest to me were an area in the main pharmacy affectionately called “the wall“, and our two offsite satellite locations, especially the sub-acute facility which is just down the road from the main campus. The pharmacy on the main campus and the sub-acute pharmacy couldn’t be more different. The pharmacy at the main campus is a busy acute care pharmacy that processes over a thousand orders and dispenses several thousand unit-doses each day for a census of nearly 400, while the sub-acute pharmacy processes less than 50 orders per day for a census of less than 30. The main campus pharmacy is open 24/7, while the sub-acute pharmacy is open Monday through Friday 8:00am-12:30pm. The main campus pharmacy is responsible for nearly 100 Pyxis med stations throughout the hospital, while the sub-acute pharmacy maintains only a handful. And so on.

The installation at the main campus was a breeze as we were simply adding to the existing system. Once installed, the technicians quickly integrated the new area into their workflow. There was no confusion and it took less than a day for the technicians to become comfortable with the location of the new workstation. With the addition of the workstation we’ve been able to shave about 30 minutes off our a.m. Pyxis fill, which is our largest fill of the day. In addition the number of items that are pulled from the wall on a daily basis without going through the AutoPharm system has decreased. I attribute this to the new workstation being in line-of-sight of the pick area. In addition, during the installation of the new AutoPharm workstation we uncovered an interface problem that may have never been discovered; can you say serendipitous. The HL7 message for several of our  premixed piggyback medications was arriving at the AutoPharm system with a quantity of zero. It had something to with custom programming in the HL7 within Siemens Pharmacy that was erased when we upgraded in late 2009. I wonder how something like that could have gone on for several months without being noticed. Since discovery, the item has been added to the test plan for future upgrades. I’ve found no appreciable difference in Pyxis fill errors, although there were very few to begin with. I’ll probably have to collect 6-12 months worth of data just to make a realistic comparison.

The sub-acute facility has been a different story altogether as the installation completely changed their workflow. The sub-acute pharmacy consists of a single pharmacist and a single technician that had their workflow ironed out prior to installing the AutoPharm system. Over the past several weeks, and with a little bit of hand-holding, they’ve integrated the new system into their operations pretty well. It took a little getting used to, but they’ve adapted. The ordering appears to be slightly smoother than before secondary to the tight inventory control offered by the combination of limited personal, AutoPharm’s inventory tracking and integration with the wholesaler. In addition I’ve turned on the Pyxis PARx feature at the sub-acute facility to close the loop between the pharmacy and the Pyxis. No problems so far. In my opinion the PARx system works quite nicely when combined with liberal use of Cubies in the Pyxis med drawers.

The only thing that appears to be less efficient for the sub-acute pharmacy is the re-stocking process. At the main campus the orders arrive in various totes that are separated on to carts and taken to their prospective areas to be put away. The system works well as the AutoPharm workstations are in close proximity to the storage areas so the technicians can see the computer screen while putting the order away. However, the sub-acute facility is slightly different as the screen on the AutoPharm workstation is either too far away or obscured as the technician moves around the pharmacy while restocking.

I’ve had several calls with Talyst since the pilot project started and one of the possible solutions to the line-of-sight issue at the sub-acute facility is to use a handheld computer with a small screen that the technician can view in place of the larger monitor while putting the order away. There are no immediate plans for testing, but the idea seems plausible. The technology appears to favor this solution as I’ve found a few scanners that might fit our needs. Examples of scanners with this functionality include the Motorola MC3100 series mobile computer and the Intermec CK31ex. The other option would be to mount the AutoPharm workstation on a mobile cart, a.k.a. COW. The workstation already has a small enough footprint we would just have to ensure wireless connectivity for it to work.

Other than that things have been going quite smoothly. The AutoPharm software has several potential uses throughout the facility. In addition to implementing in several other areas of the main pharmacy, I see the system being beneficial in a satellite setting. Considering the addition of our new tower and the probable addition of at least one pharmacy satellite in the next 12 months, that’s a good thing.

Results. The estimated labor savings comparing the preimplementation and postimplementation time studies for automated dispensing cabinet (ADC) refills, first-dose requests, supplemental cart fill, and medication procurement totaled 2.6 full-time equivalents (FTEs). After departmental reorganization, a net reduction of 2.0 technician FTEs was achieved. The average turnaround time for stat medication requests using CDT was 7.19 minutes, and the percentage of doses filled in less than 20 minutes was 95.1%. After implementing CDT, the average accuracy rate for all dispense requests increased from 99.02% to 99.48%. The inventory carrying cost was reduced by $25,059.

Conclusion. CDT improved the overall efficiency and accuracy of medication dispensing in a university medical center pharmacy. Workflow efficiencies achieved in ADC refill, first-dose dispensing, supplemental cart fill, and the medication procurement process allowed the department to reduce the amount of technician labor required to support the medication distribution process, as well as reallocate technician labor to other areas in need. ”

The article comes from Jack Temple and Brad Ludwig in the department of pharmacy at the University of Wisconsin Hospital and Clinics, Madison (UWHC). According to the article UWHC is a 471-bed tertiary facility with all the normal medical services you’d expect to see in a medium to large facility. They are similar in size to my facility at 581-beds. Unlike my facility however, they use a hybrid distribution model consisting of a centralized robotic cart fill as well as automated dispensing cabinets (ADCs). We, on the other hand, do not use a cart fill model and chose to dispense greater than 95% of our medications directly from ADCs. I am not a fan of the cart fill model as it is cumbersome, wasteful and time consuming. In addition the medications stored in patient carts can potentially be hours behind changes to the patients medication regimen resulting in missing medications and extra medications lying around, i.e potential medication errors.

For the article UWHC evaluated turnaround time for stat medications, technician accuracy, the medication procurement process, labor requirements and inventory management before and after implementation of the carousel dispensing technology (CDT). I can relate to much of the information in the article as our experiences with CDT were similar. There is a lot of good information in the article for any facility thinking about implementing CDT so make sure you check it out.

The images below represent the carousels from UWHS from the article (top) and our carousel set-up (bottom) Scary similarity.

The day started with me giving a brief presentation at their quarterly meeting about Kaweah Delta’s experience installing Talyst equipment, and ended with a tour of their warehouse facility in Preston that included a peak at their process for managing and testing canisters for their AutoPack Oral Solid Packaging System; very interesting stuff.

Talyst was a wonderful host and I had a great time visiting their facilities and speaking with a bunch of very intelligent and interesting people. I learned a lot and had fun at the same time. You can’t ask for more than that.

Once you get past the name, the technology is impressive. The most interesting thing about the Swisslog BoxPicker however, is that it is available in dual-temperature and refrigerated models. The “dual-temperature ™ option for BoxPicker allows automated storage and picking of temperature-sensitive drugs requiring refrigeration and room temperature storage within one automated compact unit.” And the “BoxPicker refrigerated option eliminates the need for pharmacy refrigerators and increases security with automated storage and dispensing of refrigerated medications.”

In addition, the BoxPicker is clean room compatible with positive pressure. The pass-through capability is a very nice feature for an automated storage unit featuring refrigeration. It prevents staff from moving in and out of the clean room environment to retrieve equipment or medications necessary for compounding.

According to Swisslog:

BoxPicker, Swisslog’s pharmacy storage and retrieval system, is a cost-effective alternative to vertical carousel storage and retrieval in the hospital pharmacy. BoxPicker provides higher speeds than vertical carousels, averaging 5 picks per minute and up to 200 transactions an hour. A two-workstation configuration allows for simultaneous production. Drug access is secured in the BoxPicker by limiting user access to one medication bin at a time with a single-box access port. The software adds security by tracking inventory and user access. View our BoxPicker Component document for further information and specifications.

A unique single-opening loading feature provides added security by limiting access to the specific items requested using controlled access drawers. Medication and supplies are stored in individual bins on an internal racking system. To load or dispense, an authorized user enters the order using the keypad or barcode; or via interface messages with wholesalers, health information systems, or cabinet replenishment systems.

Features and Benefits
1. Secure and limited access to medications
2. Limits access to one medicine at a time
3. Picks more than 3 bins to 1 when compared to carousels
4. Software tracks inventory, access and interfaces directly with hospital information systems
5. Unique single-opening loading feature reduces wrong location placement

That’s some cool technology for pharmacy.

About 60% of our medication inventory is stored in the AutoCarousel system. Not unlike most acute care pharmacies the remaining inventory is scattered throughout various areas in the pharmacy: refrigerators, freezers, large shelving areas, etc. Items not stored in the carousels aren’t necessarily routed through the AutoPharm system, and thus don’t benefit from the software’s functionality.

Talyst is currently piloting a system that makes use of their AutoPharm software without the need for their AutoCarousel system. The pilot is designed to take advantage of the AutoPharm software in an area with static shelving. I prefer using the automated carousels for storage, but this new idea is ideal for smaller facilities with limited capital resources that might not be able to afford the AutoCarousel system. They get the benefits of AutoPharm at a greatly reduced cost.

Our facility is fortunate enough to be involved in the pilot. For the last several days I’ve been installing AutoPharm workstations at both our sub-acute facility and an additional AutoPharm workstation in our main pharmacy. The installation was quite painless and went amazingly smooth. The process consisted of getting the hardware peripherals connected to the PC, configuring the network connections and entering the inventory into the system; piece of cake.

The stand alone AutoPharm system consists of a POS-X PC117 workstation, a Code CR3 scanner and a Zebra ZM400 printer, and of course Talyst’s AutoPharm software.

According to the Talyst website:

AutoPharm

Inventory and Workflow Manager
The Talyst connected pharmacy uses powerful AutoPharm® software and a suite of hardware components to enable greater patient safety, improved efficiency, and control of your inventory. The unique AutoPharm software platform allows you to manage your complete pharmacy inventory from arrival to delivery. It works throughout your facility, even with multiple locations and multiple hospitals.

Patient Safety
• AutoPharm allows multiple bar code checks to receive, restock, and dispense medications Works with your current bedside verification system and unit-based equipment.
• Supports automated packaging and labeling to bar code virtually 100% of your doses
• Supports Automatic Canister Recognition Systems for accurate pharmacy packaging

Inventory Control
• Enables the creation of a real-time, perpetual inventory system
• Supports your current hospital information system and wholesale relationships
• Enables password-protected security to limit access to medication and data
• Enables centralized ordering and management
• Supports multiple pharmacy inventory locations

Workflow Efficiency
• Automates receiving, stocking, picking, and returns
• Synchronizes user tasks and system components
• Automates wholesale orders driven by actual usage
• Works with centralized or decentralized pharmacy distribution models
• Supports web-based ordering from remote departments or hospitals

However, the ATP-71 (PDF) from Swisslog is a bulk packager that can hold up to 71 canisters in a relatively small footprint: 31.5 inches wide x 29.6 inches deep x 30.6 inches high. For comparison, a Pyxis MedStation 4000 2-drawer main unit is 22.8 inches wide x 26.7 inches deep x 27.7 inches high. I would say that makes the two units comparable in terms of size, and I can tell you from personal experience that a 2-drawer main isn’t very big up close.

According to Swisslog: “Swisslog’s high-speed packaging and barcoding solutions are not only fast and efcient, they provide many levels of patient safety. Color coded fll-to-light trays, locking canisters, and accurate labeling with barcode capabilities enable pharmacies in any size hospital to make patient safety the highest priority. Many additional accessories and interfacing capabilities complement the packager and provide gains in workfow effciency.”

For those of you that aren’t familiar with bulk packagers you should take a look at the technology; it’s very interesting. Loose tablets/capsules are placed in a medication canister that is fitted with a computerized chip that uniquely identifies the medication contained inside. Once started the packager drops tablets/capsules one at a time from the canister, down a shoot and into a hopper where they are packaged and labeled with the medication name, strength, dosage form, lot, expiration, barcode, etc. We’ve found it to be a very efficient way to unit-dose and barcode large numbers of bulk tablets/capsules.

I still like the idea of having a small unit like this on the nursing units. Maybe I could talk Carefusion into adding something like this to their line of Pyxis products.

The portal is well designed, relatively easy to navigate and was well received by the user group meeting at ASHP Midyear. Areas of the portal include access to technical support, general product information, ordering consumable products, a blog from the company’s CEO, and probable one of the more useful things, a customer community where users can get together and bounce ideas off each other and talk about how to best use Talyst automation.

Communities of similar minded people are always helpful; look no further than the explosion of social media use among healthcare professionals as testimony to the fact. I’ve found the Siemens Listserv to be much more beneficial than the actual documentation for our Siemens Pharmacy System so I’m looking forward to diving into the Talyst Customer Portal as a way to get ideas on how to improve the use of our systems. Remember, there’s always someone smarter, more experienced and better prepared than you, and those are the people you want to hang around with.

Today I attended a webinar from Baxa titled “Improving Sterile Compounding Quality Through Automation” given by Eric Kastango RPh, MBA, FASHP. The presentation was very interesting. I thought it was going to focus more on technology, but it was heavy on the human component of contamination in the clean room environment with only minor mention of automated IV devices. Anyway, during the presentation Kastago talked a bit about robotic automation for clean rooms and mentioned the CytoCare Robot.

The CytoCare Robot is a chemotherapy compounding robot in an ISO class 5 environment. According to the website CytoCare is “the world’s first and only automated robotic system for the safe compounding of hazardous, life-critical cancer therapy medications.”

The company website lists the CytoCare Robot’s workflow process as:

1. Pharmacists plan the preparation cycle at the managing station. CytoCare’s software integrates with hospital pharmacy systems’ software (e.g. HL7,XML).

2. CytoCare is loaded with proper drugs and final containers (IV bags, vials, and syringes).

3. A 6-axis robotic arm removes excess solutions, weighs IV solutions for accuracy, and compounds the drugs. Powdered drugs are reconstituted and drugs are mixed by single-use syringes to prevent cross-contamination. Toxic waste is safely discarded, and air curtains with 5 HEPA filters prevent accidental exposure and environmental contamination.

4. Dose accuracy is checked by three independent systems: Digital indexers control the syringe-driving mechanism, position encoders double-check the accuracy of the syringe movement, and fluid measurements are then verified using pre- and post-weight checks.

5. Final syringes, IV bags, or drug vials are unloaded and ready to administer to patients. An automatic hazardous waste management system eliminates exposure to toxic wastes. Unused drugs are also unloaded and available for reuse.

Technical specifications:

SIZE: Approximates a standard chemotherapy hood (7’6″h x 6’6″w x 3’6″d)
WEIGHT: Approximately 3,300 lbs.
INTERFACE: HL7, XML, Custom
ENVIRONMENT: Self-contained, negative pressure; ISO 5 airflow engineering with 5 HEPA filters
WASTE MANAGEMENT: Automated
ACCURACY CHECKPOINTS: 3 Independent Systems independent systems: Digital indexers control the syringe-driving mechanism, position encoders double-check the accuracy of the syringe movement, and fluid measurements are then verified using pre- and post-weight checks.

The CytoCare Robot can be acquired and installed with no upfront cost by the user. The website lists the acquisition cost of the system as $20 per dose. Looks like hardware vendors are taking note of many software vendors by offering their product as a service; Hardware-as-a-Service (HaaS) if you will. This could be important to healthcare systems as capital dollars continue to shrink.

If you would have asked me a year ago if I had any interest in IV automation or robotics I would have said no. Since coming back from the ASHP Midyear however, I’ve found these systems to be quite compelling. I definitely think there is room for this type of automation in the pharmacy of the future. The key will be how to integrate them not only into one’s workflow, but into all the other pharmacy systems.

The system is designed to flow something like this:

- IV medication orders entered by the pharmacist, or other healthcare professional, are sent to the DoseEdge system where they appear on the DoseEdge touchscreen.
- When the technician, or pharmacist in some cases, accesses the order via the touchscreen instructions for preparation of the product are displayed.
- The product label is generated.
- The barcode on each injectable ingredient used for the preparation of the IV product is scanned to ensure the correct medications have been selected. Items identified as incorrect result in an audible message of “product not allowed for this dose.”
- The barcode on the IV product label generated by the pharmacy is scanned to ensure that ingredients are appropriately matched.
- Each ingredient is drawn into a syringe.
- An image of the syringe with appropriately drawn medication is taken for review by the pharmacist, or technician, whichever the case may be. This is a nice feature as it allows one to see the actual amount of drug drawn into the syringe prior to shooting it into the fluid bag.
- Ingredients are injected into the fluid bag and an image of the final product is taken.
- A final scan of the product barcode is done to complete the fill.

While not as advanced as a system like Robotic IV Automatoin (RIVA) DoseEdge offers some nice features. When followed as designed, the chances of making a mistake are limited by the barcode scanning and the photo image of the medications drawn to the appropriate dose. A syringe drawn to the inappropriate dose could easily get rejected during review of the image taken during compounding.

An additional benefit of a system like this would be the possibility to perform remote checking, via tele-pharmacy, for hospitals with limited pharmacy presence such as critical access hospitals. In addition a system such as this could potentially be used when pharmacists are unable to reach a location for unforeseen circumstances such as inclement weather or natural disaster.

Overall I like the idea behind the process and look forward to seeing the system in person sometime.

The DoseEdge website offers an interesting video of system and information on a DoseEdge road show and webinar can be found here.

Update:

The following is a comment regarding DoseEdge left at RxInformatics where this blog was cross posted:

There’s more…

Submitted by DATdoc on Fri, 02/12/2010 – 05:26.

I must first disclose that I work for the company that makes Dose Edge and am credited with being its inventor. The following is offered solely to round out the description of the product (in no particular order):

1) Transactions within the system are logged in detail making it practical to assess performance metrics on an ongoing basis, as well as to log actual fluctuations in work flow.

2) The software offers a feature called “scan events” that allow a site to create markers for events of interest in the life cycle of a dose and then track the progress of doses through those events using bar code scanning. While the value here is most obvious for the tracking of delivery of doses to patient care areas, consider other applications such as tracking returns, or creating destruction manifests (required in some states for hazardous materials).

3) Since bar code scanning is required to verify the ingredients in each dose, the NDC code of the actual drug used for each dose is recorded and available for reporting and billing.

4) The software automatically performs volume calculations based on the product scanned in by the user.

5) If the volume needed is below a site-defined threshold, and a more dilute product is available, the software prompts the user to use the more dilute product.

6) The software supports a function called “kitting” that permits a pharmacy that keeps everything outside of the clean room to assemble everything needed for a group of doses (including all the labels) into a kit (with bar code scanning of the component drug containers) that can then be passed into the clean room (or into a barrier isolator).

7) The product is offered on an SaaS model at a per-dose price; the data are ultimately kept at a hosting site that is SAS70 compliant, but are stored locally on a database cache as well to ensure continued operation even if internet connectivity is lost or bandwidth drops.

8) The procedures associated with preparation of specific drug products as well as the dose preparation procedures can be customized per drug.

9) Pharmacist checking is performed on-line using the pictures taken during preparation.

10) Doses reach the system through a print capture process that is field configurable.

11) Data are stored perpetually; pictures and original label capture images are purged after 90 days, but additional retention can be arranged at an additional per-dose price.

12) The formulary comes with information not ordinarily found in a commercial database, including the amount of diluent required for reconstitution (where applicable) and the concentration of the product, the permitted diluents, and a table of known stabilities at various concentrations, various storage conditions, and in various diluents.

13) There is a formulary update process that permits a user to download changes, select the changes to implement in their system, and then implement them at their leisure.