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.

medGadget:

“Volatile anesthetics like isofluorane or sevofluorane, usually used in the operating room, have a much quicker wake-up time, but the size and cost of an anesthesia machine make them impractical for use in the ICU.

Sedana Medical (Uppsala, Sweden) seems to have overcome this limitation with the introduction of the AnaConDa (Anesthetic Conserving Device). The device features a syringe pump that delivers Isofluorane or Sevofluorane to a small carbon-fiber device which goes in-line with a traditional ICU ventilator. In many ways, this can be considered a disposable anesthetic vaporizer.
This month’s Anesthesia & Analgesia features a study that validated this device in an ICU setting and found that it is quite accurate (end-tidal concentration was within 13% of target concentration). Advantages of this device, in addition to quick wake-ups, include lower cost of the equipment as compared to traditional vaporizers and an overall decreased consumption of anesthetic.”

When I worked in the pediatric ICU we would use volatile anesthetics like sevoflurane on rare occasion. It was always quite an ordeal as the equipment necessary to deliver the gas wasn’t exactly portable. Anyway, the AnaConDa is a pretty cool piece of hardware.

You can get more information on The AnaConDa at the product website.

A fair number of the medications used in the ICU are prepared on demand for a host of reasons including stability, differences in concentration, difficulty in scheduling secondary to rate variability, etc. Any pharmacist or nurse reading this will understand what I’m talking about. Example medications that fall into this category include drips like norepinephrine, epinephrine, phenylephrine, amiodarone and nitroprusside.

Last year I mused about using devices on the nursing stations designed to package oral solids on demand at the point of care. I still like the idea for several reasons, all of which can be found in the original post.  Based on currently available technology the same concept could be applied to preparation of IV products at the bedside. Robotic IV preparation has come a long way and these devices could be used at the point of care to make a nurses, and patient’s, life a whole lot easier. The use of robotic IV preparation at the bedside could reduce wait times for nurses and lesson the workload on pharmacy.

The device would function much like automated dispensing cabinets do now. Pharmacy would evaluate the order and enter it in to the pharmacy system. With all appropriate clinical checking complete, the nurse could go to the automated IV preparation robot (AIVPR), pull up the patient and select the appropriate infusion to be made. Based on the needs of the nurse and patient the AIVPR would compound the preparation on the spot. If you really wanted a pharmacist to lay eyes on the product you could utilize remote monitoring to observe preparation of the product. Something similar to DoseEdge comes to mind. As long as appropriate quality assurance programs were in place, and you had a good audit trail, I don’t see a problem.

Some currently available AIVPRs include:

IntelliFill I.V. by ForHealth Technologies, Inc

Patient Safety Benefits

• Multiple safety steps assure the correct drug is prepared for the correct patient with precision and speed often not attainable by manual processes
• Vision system captures images of the source vial for each syringe for manual review and verification
• Weight confirmation performed for each dose
• Automated dosage-preparation trail for each dose dramatically reduces time and labor required to check doses for accuracy
• Barcode-verified drug selection at multiple locations
• Automated syringe labeling with verification
• WYSIWYG label formatting is drug specific to minimize errors
• Patient-specific labeling of first and routine orders
• Barcode-scanning capability for final bedside check
• Drug-specific labeling of flush and pre-made doses
• Unobstructed syringe barrel facilitates QC checks
• Eliminates risks of decentralized syringe manufacturing (unlabeled syringes and sterility)
• Syringe delivery benefits for fluid-restricted patients

RIVA by Intelligent Hospital Systems
I mentioned the RIVA device a little over a year ago. It is definitely too large for use on nursing units, but the concept and design are cool.

RIVA enhances the care of patients and health of your pharmacy team by improving the safety and accuracy of IV admixture compounding. By using state of the art safety features and practices, detailed electronic auditing, and integration to current hospital systems, RIVA ensures that hazardous and non- hazardous doses are accurate for paediatric, neonatal, and adult patients.

i.v. STATION by Health Robotics
I blogged about the CytoCare System from Health Robotics earlier this year, but I’m actually more interested in their i.v. STATION product.

i.v.STATION represents a revolutionary approach in the quest for safe, accurate, efficient, cost effective, and ready-to-administer IV Admixtures.

Constructed around a scalable, distributed, and fail-safe architecture, i.v.STATION offers unprecedented final container flexibility, life-critical patient safety, and robotic precision and performance.

i.v.STATION may be deployed in a variety of locations, including central and satellite pharmacies and direct patient care areas, due to its self-contained form, ISO Class 5 environment, and small “foot print”.

i.v. STATION actually looks like an ideal start to the system I’ve imagined. It even offers a decentralized architecture that allows modules to be installed in remote locations while remaining under the control of the central pharmacy via a network interface. It really is a neat setup.

I would have liked to provide video content for i.v. STATION in action, but the company website required registration to access the videos. And I just don’t feel like getting sales calls for the next twelve months. I’m just sayin’.

FLAVORx, a company in Columbia, MD has taken a lot of the experimentation out of the flavoring equation by creating a system for dealing with “yucky medicine”.

According to the FLAVORx website, their product is in use by over 35,000 pharmacies nationwide. The company website offers a handy Pharmacy Locator to assist you in finding a pharmacy nearby that can flavor your child’s, or your own, medication.

FLAVORx lets children and their parents customize the medicine to whatever they’d prefer it to taste like

Our scientifically tested FLAVORx™ Flavoring System is available at pharmacies nationwide and is designed to make any liquid medication easier for your child to take. Using our unique Bitterness Suppressor and Sweetness Enhancer, Pharmacists mask the unpleasant flavor associated with many prescription and over-the-counter liquid medications. And with our wide assortment of kid-approved flavors, your child (with the help of the Pharmacist) can customize their medicine to suit their individual tastes.

All FLAVORx™ flavors are sugar-free, gluten-free, dye-free, casein-free, inert, and non-allergenic. Our flavors are made from a blend of natural and artificial ingredients and we never use phosphates or other potentially harmful chemicals.

Available flavors include apple, banana, banana orange, bubblegum, chocolate, chocolate cherry, citrus punch, grape, grape bubblegum, grapeade, lemon, orange, raspberry, sour apple, strawberry, vanilla, watermelon and wild cherry.

Check out the FLAVORx Favorable Flavors tool (PDF)

RSC.org: A team led by Daniel Kohane of Harvard Medical School in Boston, US, harnessed the thermosensitive properties of poly(N-isopropylacrylamide) (PNIPAM) to form the basis of the new system. This material can form a hydrogel which is swollen in its native state but which collapses upon heating.

The researchers embedded nanoscale particles of PNIPAM-based gels in an ethyl cellulose membrane so that clumps of the particles spanned the width of the membrane. They also entrapped magnetite nanoparticles within the membrane matrix.

If the membrane is exposed to an oscillating magnetic field, the magnetite nanoparticles heat up, in turn warming the PNIPAM by a few degrees – sufficient to cause the particles to collapse but not so high as to affect surrounding tissue. This leaves voids in the membrane, opening up channels from one side to the other.

In this way the membrane’s porosity can be remotely switched on and off. To demonstrate the potential effectiveness of the system in drug release, the research team encapsulated the dye sodium fluorescein in the membrane and implanted it in rats. They showed that the membrane remained intact and ‘switchable’ over multiple cycles, that the amount of dye released was in proportion to the length of time that the magnetic field was applied, and that the membrane was non-toxic and biocompatible. By modulating the magnetic field it should be possible to fine-tune the rate of drug release, in addition to the frequency and duration of treatment.

Poly(N-isopropylacrylamide) (PNIPAm) is a an interesting polymer that has frequently been used in research as a possible drug delivery tool. When crosslinked with certain materials, in this case ethyl cellulose, it can form three-dimensional hydrogels capable of carrying a drug. At cooler temperatures the hydrogel remains hydrated, but when exposed to higher temperatures the membrane collapses, expelling the material held inside.

The researchers responsible for the latest breakthrough were able to control the release of sodium fluorescein from the PNIPAm hydrogel through the use of an oscillating magnetic field. This is particularly exciting because the drug delivery was directly proportional to the duration of the pulse. The researchers also discovered that they could stop the release of material from the hydrogel by removing the magnetic flux, basically shutting off the valve. Cool!