Stanford University Medical Center Pharmacy site visit [07 31 2013]

I just rolled in the door from Palo Alto, where I spent most of the morning visiting the Stanford University Medical Center inpatient pharmacy. And why not, I didn’t have anything else to do today. I picked up the phone, connected with the Director of Pharmacy, Mike Brown and was on my way.

First and foremost, the inpatient pharmacy at Stanford is nice. It’s also quiet, which is a bit unusual for a pharmacy servicing such a large facility. Interestingly enough most of the non-IV related medication distribution is handled with the use of very little automation; there’s an interesting story to go along with that.

The pharmacy at Stanford has a large investigation drug service (IDS) area, which is responsible for handling approximately 300 active drug trials at the moment. Impressive. They use IDS management software called Vestigo integrated with Epic to manage everything. It’s pretty slick.

My reason for the visit wasn’t for the non-IV medication distribution or IDS, however. What I really wanted to see was their IV room, and the associated distribution process. I’d heard through the grapevine that they were using a product called Phocus Rx to manage their chemotherapy preparation. I wrote about Phocus Rx in March of 2012. I’ve heard a lot about the system over the past year, but had yet to see it action.

The IV room didn’t disappoint, it was great. They let me change into scrubs, gown up and spend about 90 minutes in the cleanroom watching the pharmacist and technicians run through the process. It’s been a long time since I’ve done anything like that. It felt good. There was something right about it.

As far as Phocus Rx goes, in my mind it’s basically a less feature-rich version of DoseEdge (post Feb 2010). Both systems use cameras and software to manage workflow, but that’s about where the similarities end. Phocus Rx uses a different camera setup than DoseEdge, i.e. the camera is located outside the hood versus inside the hood, respectively. The other differences include how information is sent to the IV workflow system, different approaches to barcode scanning, inclusion/exclusion of clinical decision support tools, and their inclusion/exclusion of gravimetric analysis for dose verification. Phocus Rx is “considerably less expensive” than DoseEdge, although the exact dollar figures remain a mystery. Which one is better? Impossible to say. That question is completely subjective and depends on your needs.

The visit was interesting, and eye opening. The pharmacy personnel in the cleanroom were courteous, professional, and quite knowledgeable about the system. It was impressive to watch. I also learned a lot, which I will now add to my ever expanding personal database of IV room technology.

Swisslogs introduces next-gen RoboCurrier Autonomous Mobile Robot

Swisslog has been making these little robots for a long time, although I don’t see many of them in the wild these days.

They’re pretty cool in their own right. The robots themselves are reasonably small. The previous version was only 35-inches tall, and weighed in around 100 pounds. But they could carry up to 50 pounds worth of cargo and could navigate around the hospital completely on autopilot. I’m not entirely sure, but I believe they use RFID technology to navigate.

[Update 08 01 2013]: According to Swisslog the RoboCurrier “utilizes an obstacle avoidance system and mapping software that’s set up during installation“.

One of the coolest features though is use of a prerecorded message to announce its arrival.
Continue reading Swisslogs introduces next-gen RoboCurrier Autonomous Mobile Robot

Pre-packaged unit dose from the manufacture or repackaging yourself?

Like it or not barcoding at the point of care has slowly become a standard of practice in acute care pharmacies all over the country. The question is no longer whether or not we should use barcoding technology, but rather how do we use it. And with that comes the need to make sure that all medications dispensed from the pharmacy have a machine readable barcode for nurses to scan at the point of care, i.e. at the patients bedside.

The concept is simple, but causes a lot of headaches inside the pharmacy. While a lot of oral solid medications are available from the manufacture in pre-packaged unit dose packages, some aren’t; sometimes oral solid medications are available in both pre-packaged unit dose as well as bulk.

When oral solid medications are available in both pre-packaged unit dose and bulk containers pharmacies are forced to make a choice. It’s always been a no-brainer for me, purchase medications in manufacturer prepared pre-packaged unit dose packages whenever possible. I look at it as a safety issue. Humans make mistakes, and whenever I can remove humans from something like repackaging oral solids I do it. Manufacturers have been known to make mistakes, but their process is much more rigorous than anything you’ll see in a pharmacy. In addition, manufacturers must adhere to good manufacturing practices (GMP), which are quite extensive.

Recently I’ve come across situations where pharmacies have actively chosen to purchase all oral solid tablets in bulk and repackage the oral solids themselves. I’ve thought about why a pharmacy would make that choice and two things come to mind: cost and efficiency.

Purchasing oral solid medications in bulk is often less expensive. The advantage may be extended if a single location is repackaging for multiple facilities, i.e. centralized distribution. The same goes for efficiency. Repackaging oral solid tablets from bulk bottles may be more efficient during times of high volume, especially if multiple sites are involved. An example of this might be during ADU replenishment for multiple facilities when thousands of tablets may be needed. Picking 2000-3000 tablets from shelving locations may be less efficient than letting a packager run unmanned.

Options for repackaging oral solid medications:

  1. High-speed packagers – I wrote about high-speed packagers here in August of 2010 (Automated unit-dose packagers for acute care pharmacy). Little has changed since then so the information may still be helpful.
  2. Tablettop packagers (semi-automated) – I wrote about tabletop packagers here early this year in January. (Pharmacy tabletop unit-dose packager comparison). You wouldn’t want to use tabletops for large jobs as they require closer monitoring than high-speed packagers.
  3. Manual packaging – There are several out there. One that comes to mind is MTS. There is no way you’d want to use a system like this for any kind of high volume packaging. They work well for niche packaging like chemotherapy, high risk items, etc.

The choice to repackage oral solid medications from bulk or purchase them in pre-packaged unit dose packages from the manufacture is yours. Patient safety, cost, and efficiency should all be considered. In my opinion patient safety should trump cost and efficiency in the thought process, but then again that’s only my opinion.

Saturday morning coffee [July 27 2013]

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

It’s been a while. I feel a bit rusty.

The coffee mug below is from the ASHP Summer Meeting Twitter contest in Minneapolis, MN in June. I took third place, which is a bit of a disappointing as I was the reigning champ for a couple of years back in the day. I’ve had the mug for a few weeks, but haven’t felt like posting so it’s just been sitting in my cupboard. Thanks to ASHP, I’m certainly happy to add it to my ever growing collection.

ASHP SM 2013 Twitter Contest Mug
Continue reading Saturday morning coffee [July 27 2013]

Medication adherence, it should begin and end with a pharmacist

There’s no question that medication adherence is a problem. How big a problem? Well, according to an article in The American Journal of Medicine, 28% of new prescriptions never get filled, and among patients who do fill their prescriptions, adherence rates are less than 50%. The problem with these numbers is that they represent not only grief for the patient, but for the entire healthcare system.

According to Dave Walker, a pharmacist that blogs at pharmacy 2.0 and ½, “although the causes and proposed solutions to the medication adherence/compliance problem vary widely and are often debated, it seems one thing can be agreed upon by all… it is a very costly healthcare problem in the U.S. today. The cost of non-adherence was estimated to be $290 billion annually by the New England Healthcare Institute NEHI in 2009. It’s now estimated by some to be in the neighborhood of $330 billion or more annually.” That’s a lot of money.
Continue reading Medication adherence, it should begin and end with a pharmacist

Fresh application of older healthcare technology

I came across an interesting article in the July issue of Pharmacy Practice News. The article describes some of the posters presented at the 2013 ASHP Summer Meeting in Minneapolis. The technology covered is relatively old, and a little antiquated when you look at much of the technology floating around the world these days. Nonetheless, this technology still represents opportunity in healthcare.
Continue reading Fresh application of older healthcare technology