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.

Pharmacy IV rooms are no longer overlooked when implementing innovative technologies. As pharmacy operations continue to evolve it is becoming clear that IV rooms are starting to receive their due respect. A certain percentage of healthcare systems already utilize some form of technology in the IV room, however the numbers are small. A 2007 ASHP national survey on informatics found that, depending on number of beds, between 9% and 27% of facilities were utilizing some form of device in sterile product preparation¹ (small-volume and large-volume parenterals). It is unknown what technologies these facilities were utilizing at the time of the survey.

Based on information from the 2011 Pharmacy Purchasing & Products survey on the State of Pharmacy Automation, adoption of automation and technology in the IV room remains low. Only 4% of those pharmacies surveyed were using a robotic IV device.² Of those 4% most implementations were in large hospitals. Furthermore, the survey shows that the overall use of robotics in acute care pharmacies is declining. However, that same survey showed increased interest in IV room automation, specifically “workflow management” systems. Approximately 20% of all survey respondents indicated interest in implementing one of these systems, 10% within the next two years.

This was the focus of another recent Pharmacy Purchasing & Products article.³ The article discusses the implementation of IV workflow management tools at two sites within Indiana University Health: Riley Hospital for Children and Bloomington Hospital. According to the article “Prior to adopting IV management tools, [they] employed [a] rather unsophisticated method for processing IV orders common in many hospitals. Labels were printed for individual IV doses or batches three or four times a day and a pharmacist would hand off the labels at the cleanroom pass-through window for a technician to sort by time.” This is common practice in many acute care pharmacy operations.

Indiana University Health determined that their system was outdated and basically unsafe, which led them to search for a viable alternative. Their review resulted in the selection of an IV workflow management system because “such technology could provide the solution [they] needed to bridge the gap between [their] overall bar code scanning protocol and [their]IV dose preparation process.”

Implementation provided Indiana University Health with several advantages over their previously utilized system for IV preparation. Items specifically mentioned in the article include:

• Improved safety through the use of bar code scanning
• Reduced waste
• Expiration tracking for compounded medications
• Standardized method of training and preparation
• ncreased accountability
• Improved data and reporting for medications compounded in the IV room

Overall the technology has been well received and successful at Indiana University Health. The article concludes with “this type of scanning should become the standard of care for all facilities with compounding processes in place.” I agree.

References:
1. Am J Health-Syst Pharm. 2008; 65:2244-64
2. State of Pharmacy Automation, Pharm Purch Prod. 2011
3. Pharm Purch Prod. Nov. 2011, Vol. 8, No. 11

Afterthought: DoseEdge is dominating the workflow management category inside the IV room at the moment. I’ve talked with a lot of pharmacy directors over the past 6 months and they’re either using DoseEdge or evaluating it as an option. I wrote about DoseEdge nearly two years ago here.

Baxa Corporation webinar on “DoseEdge®: Changing Pharmacy Practice Through Workflow Management.” Presented by Dennis Tribble, PharmD, FASHP. Original air date: March 25, 2010

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.

Improving patient safety inside the cleanroom environment

Bar-code verification – BCMA continues to provide a simple solution to enhance patient safety at the beside. What’s often overlooked is the benefits of utilizing bar-code scanning inside the acute care pharmacy, especially in the IV room. Not only does bar-code scanning provide a secondary layer of safety, it can help pharmacies manage and track inventory as well as create audit trails for later use.

Systems that utilize bar-code technology in the IV room include DoseEdge from Baxa and i.v.SOFT from Health Robotics. I’ve talked about DoseEdge before, but only recently discovered i.v.SOFT. Both solutions offer several excellent features to assist in making the IV room a safer place.

Robotics – The pharmacy world has been quietly making robotic advances in the IV room. While robotics appears to be more popular in the non-IV areas of a pharmacy, my favorite area of pharmacy robotics has to be in the preparation of intravenous medications. It’s a hot topic of discussion and appears to be advancing faster than most other areas in pharmacy automation and technology at the moment.

Health Robotics has been quite prominent in the area of IV room automation with i.v.STATION for non-hazardous compounding and CytoCare for hazardous compounding. The company recently released the results of their i.v.STATION beta-test. The results appear promising.

RIVA by Intelligent Hospital Systems is another fully contained automated IV preparation system. Secondary to i.v.STATION, RIVA is probably the most often cited IV room robot.

IntelliFill I.V by ForHealth Technologies, Inc is another automated IV solution that’s slightly different than i.v.STATION and RIVA as it specializes in preparation of small-volume IV medications. It’s hard to tell where IntelliFill I.V. fits because I rarely hear the system mentioned when talking about IV room automation. According to Baxa “the IntelliFill i.v. from Baxa is the market leader for pharmacy automation — with more than 29 million safe doses processed to date. Recently named as one of the 12 Advances in Medical Robotics by Information Week IntelliFill i.v. has more active user sites than all of its competitors combined.”

Carousel dispensing technology (CDT) – I’ve talked briefly about CDT before, but was unaware that the technology can be used inside a cleanroom environment as well as in the general pharmacy.

CleanRoom Connect from SencorpWhite “is an advanced AS/RS system for moving and securely storing inventory as it goes into and out of a clean room environment. CleanRoom Connect provides an ideal clean room gateway in a wide range of applications from pharmaceutical compounding in hospitals to clean rooms in medical device manufacturing.” I have to admit that I think it’s a pretty slick piece of hardware.

More information on CleanRoom Connect can be found here (PDF) and here (PDF)

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.

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.

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.

Check out the demonstration video below. I love the “vending machine” style dispensing idea. It’s something I’ve been waiting to see for a few years now.

The article discusses the process involved in redesigning the workflow within an acute care central pharmacy, but fails to mention the use of technology.

So let’s break it down a bit, shall we?

1. “During this process, it is important to consider whether a technician can perform some of the functions that pharmacists have traditionally performed and whether several tasks can be combined to reduce labor requirements.” – . Robotics, carousel technology, automated packaging, IV room technology, etc are all valuable tools that could easily create a pharmacy technician driven central pharmacy.
2. “A significant percentage of a pharmacist’s time is consumed by order entry, order verification, order clarification, and follow-up activities for orders. “ – Doesn’t this sound like that whole NUPOR thing again? Yep, I think auto-verification is in order.
3. “For example, patients’ medications are not always transferred (or returned for credit) in an accurate and efficient manner. Patient movement and inadequate transfer of drugs are two of the primary reasons why central drug distribution systems, patient medication carts, and patient server systems are difficult to manage, leading to lost doses, extra work by the pharmacy, and nurse frustration.” – Get away from the car fill model and move toward a decentralized ADC model.
4. “The chart should first list time-dependent activities (e.g., preparation of TPN solutions, drug delivery and return, chemotherapy preparation).” – Robotics.

Just sayin’.

Reference

1. Nold, Edward G. Redesigning the workflow of central pharmacy operations. Am J Health Syst Pharm 2011 68: 202-203

However, one trend I’ve discovered across the range of facilities is that the smaller the hospital, the less automation and technology the pharmacy has. Why? It’s quite simple. Automation and technology is expensive. It’s also time consuming to plan for, implement and maintain. Of course another argument is that smaller hospitals - and therefore smaller pharmacies – need fewer technological advances. That doesn’t make much sense to me. I agree that a small 50 bed hospital pharmacy may not need a giant robot to fill their med carts, but they can certainly benefit from clinical decision support, pharmacy surveillance software, bar code medication administration (BCMA), computerized provider order entry (CPOE), automated dispensing cabinets (ADCs), smartpumps, mobile devices, so on and so forth. The problem is that much of this technology is expensive and takes a sizable chunk out of smaller budgets.

Many hospitals with fewer than 200 beds have pharmacy automation budgets under $200,000.¹ While this is a lot of money for the average working man, it’s not a lot of money when it comes to purchasing cutting edge healthcare technology. I can’t quote exact dollars, but some of the technologies mentioned above could easily eat up a majority of those budgets with a single installation. And when you consider that more than 60% of the hospitals in the US are fewer than 200 beds you start to see the problem.²

It seems to me that the ideal place to install cutting edge pharmacy automation and technology would be in smaller facilities. I think they offer the advantage of being less hectic and easier to control. This may not always be the case, but I’ve found that it’s often true. A less hectic environment provides a space to work out bugs while keeping damage to a minimum. Think of it as experimenting on a small scale before going big. Unfortunately these facilities are the ones cutting the checks and don’t have the luxury of being a guinea pig for some all-encompassing healthcare initiative.

The lack of automation and technology in smaller healthcare systems has the unfortunate side effect of missed opportunities for patient safety. Some would argue that automation and technology isn’t the only intervention to improve patient safety, and I would have to agree. With that said, there are lots of ways to make the medication dispensing and administration process safer, but the addition of automation and technology like CPOE, smartpumps and BCMA can certainly add value to other patient safety measures. It’s true; don’t try to argue differently because you’ll only sound like a fool. Sometimes things really are as simple as they sound.

1. State of Pharmacy Automation. Pharm Purch Prod. 2010;8 http://is.gd/jaBiO 
2. American Hospital Association

Late last year ASHP began pushing the idea of a new pharmacy practice model, PPMI. The movement was a hot topic for a while, but seems to have lost a lot of steam recently – “Hence the name: movement. It moves a certain distance, then it stops, you see? A revolution gets its name by always coming back around in your face” (Tommy Lee Jones in Under Siege 1992) – Anyway, when the PPMI movement was still going strong many important people in the pharmacy world struggled with the best way to approach a new pharmacy practice model. Many believe, and rightly so, that the best way for pharmacists to reinvent themselves is to become the cornerstone of a more robust patient care model. After careful consideration I believe the best hope for developing such as model will be to rely heavily on pharmacy robotics to handle much of the repetitive dispensing duties now handled by pharmacist on a day to day bases. You know, free up the pharmacists. It’s not a new concept, but one that seems to escape us.

Obviously it will take some time to develop robotics to the point where it will be effective in such a system, and it certainly won’t be cheap, and pharmacists will have to fight with state boards of  pharmacy to accept it, and pharmacy administrators will have to work closely with their hospitals to develop such a systems, and someone’s going to have to be brave enough to step up to the plate and get stated, and so on and so forth. In other words it’s going to be hard and it won’t happen overnight.

Who’s up for a little project? For now let’s just take a quick look at some of the things that lead me to believe robotics is worth another look as a potential solution.

Medicine
Anyone that’s worked in healthcare for more than a day has surely heard of the de Vinci Robot. The de Vinci robotic surgery system has become quite a buzz word over the past few years. Places like UC Davis Medical Center even use it as a form of competitive advantage and advertise it as “leading-edge technology” in surgery. Hospitals like the one that previously employed me were leveraging such technology to get funding from the hospital board and gain support from the surrounding community and local media.

Back in October 2010 McGill University in Canada made headlines by performing the first all-robotic surgery with the da Vinci robo-surgeon and a robotic anesthesiologist named McSleepy. There’s no question that the surgical world understands the potential advantages of robotics; kind of like the automotive industry.

How about the use of small robots for spinal surgery that appear to reduce pain and complication risk for patients? An article in the December issue of Spine talks about the success of using SpineAssist surgical robot from Mazor Robotics to place robotically-guided spinal implants. Overall the data looks promising. The SpineAssist robot is currently in use in the United States, Germany, and Israel.

OctoMag micro robot is a nanorobot controlled by magnets. It’s designed to swim through the blood vessels of the eye, where it can perform various procedures. I can’t tell you how amazing this technology is, and it’s only going to get better.

It’s not just mega-million dollar companies that can advance robotics. Recently a group of engineering students from UW hacked a Kinetc for Xbox 360 from Microsoft with the idea of performing robotic surgery. Yeah, a gaming system appears to be the new frontier for advances in medical technology. Like I’ve said before, healthcare is way behind the consumer market when it comes to technology. Awesome.

Pharmacy
Not to be outdone by the surgery gurus, the pharmacy world has been quietly, and I do mean quietly, making robotic advances of their own.

To date the most well know piece of pharmacy robotic technology for use in acute care pharmacies is probably ROBOT-Rx from McKesson. This robotic dispensing system has been around for a long time. When you hear about a pharmacy using a “robot”, they’re generally referring to ROBOT-Rx. I’ve practiced in an acute care setting that used one and have formed my own opinions, but let’s just say that you need the right practice environment for ROBOT-Rx to be effective. Ask around and you’ll get similar responses.  

I don’t know of another inpatient dispensing robot similar to ROBOT-Rx. There are several outpatient systems like ScriptPro and Parata, but not in the acute care setting that I am aware of.

Companies like Swisslog make several robotic pharmacy solutions, including PillPick automated unit dose packaging, storage and dispensing system, as well as BoxPicker, an automated pharmacy warehouse system for storing and dispensing medications. In my opinion Swisslog stands out smong acute care pharmacy automation and technology, as they have some of the most advanced systems available at this time. Their concept of a futuristic pharmacy seems reasonable to me, and could go a long way in advancing a new pharmacy practice model.

There’s an interesting article about the use of PillPicker and BoxPicker from Memorial Medical Center in Springfield, Illinois. The article is an over simplified view of the entire process, but it gives you a general idea of where things fit and where such a system may benefit both the pharmacy and the patient.

My favorite area of pharmacy robotics, however has to be the use of robots for preparation of intravenous medications in the clean room. This area is a hot topic of discussion and appears to be advancing faster than most other areas in pharmacy automation and technology at the moment. 

Health Robotics has been quite prominent in the area of IV room automation with i.v.STATION for non-hazardous compounding and CytoCare for hazardous compounding.

I’ve seen i.v.STATION in action and think it’s a great start to the system I’ve imagined. Of the automated IV solutions I’ve seen I think i.v.STATION has the most to offer.

RIVA by Intelligent Hospital Systems is another fully contained automated IV preparation system. Secondary to i.v.STATION, RIVA is probably the most often cited IV room robot.

IntelliFill I.V by ForHealth Technologies, Inc is another automated IV solution that’s slightly different than i.v.STATION and RIVA as it specializes in preparation of small-volume IV medications. It’s hard to tell where IntelliFill I.V. fits because I rarely hear the system mentioned when talking about IV room automation.

It’s clear that IV room robotics is slowly becoming the next popular area of interest for many acute care pharmacies, but it’s certainly not the only area. Robotic delivery of medications also appears to be on the radar of many. When combined with RFID technology, small delivery bots can have a positive impact on patient care while improving pharmacy workflow with real-time drug tracking throughout the hospital. Aethon offers such a system. I had the opportunity to watch their little TUG robot in action at ASHP Midyear. I thought it was pretty slick.

1. “RRG/Learn More/History.” Robotics Research Group : The University of Texas At Austin. N.p., n.d. Web. 30 Jan. 2011.
2. Devito, MD, Dennis, Leon Kaplan, MD, Rupert Dietl, MD, et al. “Clinical Acceptance and Accuracy Assessment of Spinal Implants Guided With SpineAssist Surgical Robot: Retrospective Study.” Spine 35.24 (2010): 2109-2115. Print.