Pharmacy Automation Systems

The application of automated dispensing systems within the pharmacy practice began the early 1960s.

The medication use process 5 domains:

1. Purchasing/inventory management

2. Prescribing/medication determination

3. Medication preparation, dispensing and counseling

4. Medication administration

5. Patient monitoring/assessment

Primary drivers of automated dispensing systems:

1. Corporate and organizational goals of reducing costs

2. Improving operating efficiencies

3. Growing revenues

4. Enhancing safety and quality

5. Providing outstanding customer service

Pharmacy managers are often expected to improve efficiency by reducing pharmacy staff and nursing workload while increasing
quality through reducing medication delivery time and improving patient safety and clinical programs.

TECHNOLOGIES AND AUTOMATED DEVICES APPLIED THROUGHOUT THE MEDICATION USE PROCESS

Prescribing

1. Clinical decision support software

2. Computerized prescriber order entry

Dispensing

1. Carousel technology

2. Centralized robotic dispensing technology

3. Centralized narcotic dispensing and inventory tracking devices

4. Decentralized automated dispensing devices

5. Intravenous and total parenteral nutrition compounding devices

6. Pneumatic tube delivery systems

7. Unit dose medication repacking systems

Administration

1. Bar code medication administration technology

2. Clinical decision support based infusion pumps

Monitoring

1. Electronic clinical documentation systems

2. Web-based compliance and disease management tracking systems

Benefits

1. Better security of medications: controls access in the central pharmacy with user-defined drug classes and the requirement of a
user name and password

2. Reduces medication errors: helps pharmacists ensure the right medications are stored in and retrieved from the right locations

3. Maximizes floor space and storage capacity: improves space efficiency up to 60%

Features

1. For use with Central Pharmacy Manager software

2. Automatic chain tensioner lowers risk of downtime caused by shifting items

3. Offers flexible shelf configurations

4. Safety system with light curtain improves operator safety

5. Consolidation of pharmacy inventory in carousel reduces shrinkage by up to 5%

6. Integrated control of the automated Pharmacy Carousel in Central Pharmacy Manager software allows intelligent grouping of
medication retrievals (picks), priority management, and synchronized picking with multiple carousels

7. Receive, stock, pick, and return bar code verification to reduce medication errors

8. Pick-to-light technology displays item location, detailed item description, and picking quantity, reducing order processing time by
up to 50%.

9. Ergonomic design: automatic carousel positioning reduces operator repetitive motion injuries

10. Single-door design enables easier opening and closing

11. Integrated high speed label printer, wireless bar code scanner, and operator workstation all-in-one

Centralized robotic dispensing technology

-Increases efficiency and accuracy in the central pharmacy.

-Helps to prevent medication errors, reduce pharmacy labor, and lower medication inventory.

-Automates medication storage, selection, return, and restocking functions while supporting accuracy, control, and compliance

-Eliminates time-consuming tasks, freeing time for pharmacists to focus on clinical care

-Supports filling across multiple facilities to maximize system-wide efficiency and minimize costs

-Updates include faster and quieter operation with new aesthetics and enhanced acoustics, Windows control systems, more precise
barcode scanning, and increased dose and line item capacity with an extra-small package option. A new envelope design helps
pharmacy and nursing maintain accountability for dispensed and unused medications.

Centralized narcotic dispensing technology and inventory tracking devices

-Restock information is sent to Central Pharmacy Manager which queues up the items needed for each satellite facility

-Inventory management reporting

-Works with any medication distribution model

-Prioritized picking queue

-Pharmacist verification

-Cycle count

-Expiration date tracking

Decentralized automated dispensing devices

Automated dispensing systems (ADS), also known as automated dispensing cabinets (ADC) or automated dispensing devices (ADD),
have been put forward as technologies that help increase the effectiveness of hospital pharmacies and potentially reduce the rate
and risk of ADEs.

Over the past decade, the use of this technology in hospital pharmacies has been on the rise with 97% of US hospital pharmacies
using ADS as of 2014.
This increase serves to indicate the benefits of an ADS including improved safety and efficiency through reduced dispensing times,
improved storage capacity and stock control, more appropriate allocation of staff to tasks with minimal time wastage and reduced
dispensing errors

Intravenous and total parenteral nutrition compounding devices

-provides a separate source-tubing line and color-coded IV tubing spike for each of the TPN base components (often called source
solutions and are held within source containers) comprised of up to eight different pump stations.

-In partially automated TPN compounding, the TPN base solution is prepared using an automated compounding device (ACD).

-The TPN base solution is formulated using a TPN compounding device, such as an automix compounder, and the TPN electrolytes
and most other additives are prepared by a special automated device called a micromix compounder.

-Fully automated TPN compounding is a common procedure in facilities that prepare large numbers of TPN solutions each day

Pneumatic tubes

-(or capsule pipelines; also known as pneumatic tube transport or PTT) are systems that propel cylindrical containers through
networks of tubes by compressed air or by partial vacuum.

-They are used for transporting solid objects, as opposed to conventional pipelines, which transport fluids.

-Pneumatic tube networks gained acceptance in the late 19th and early 20th centuries for offices that needed to transport small,
urgent packages (such as mail, paperwork, or money) over relatively short distances (within a building, or at most, within a city).
-Some installations grew to great complexity, but were mostly superseded.

-In some settings, such as hospitals, they remain widespread and have been further extended and developed in the 21st century.

Unit dose medication repacking system

-A BCMA (Bar code medication administration) system consists of a barcode printer, a barcode reader, a mobile computer (with
Wi-Fi), a computer server and software.

-Each drug in the hospital is labeled with a unique barcode. When a patient is prescribed medication, it is faxed, sent electronically
or hand delivered to the hospital's pharmacy and entered into a computer system by a pharmacist.

-The pharmacist dispenses the barcoded dose of the drug to the patient's floor.

-When it's time for the clinician to administer the medication, he uses a handheld device to scan the barcodes on his identification
badge, the patient's wristband and the drug.

-If the barcode point-of-care (BPOC) system cannot match the drug to be given with the order in the system, it alerts the clinician
with a visual warning.

-Each patient's barcode holds all the vital information about the patient and his medication.

Infusion Pump

-Intravenous medication administration using conventional infusion pump technologies may be delivered accurately when the
infusion pump is properly programmed.

-However, these conventional infusion devices have been linked with medication errors and adverse drug events. Human error can
occur when programming the device.

-Human Factor studies have demonstrated that, with current resource constraints, double-checking the programmed dose is unlikely
to occur, and even if it does, it is still possible that either the information regarding dosage limits is not readily known or the
misprogramming is not caught.

-In addition, a nurse could program the infusion pump with the right medication and dose, but inadvertently program the wrong
rate of administration—older pump technologies would not catch such an error.

- In particular, if a ‘high risk’ medication is being used, then the programming error could result in a serious adverse event for the
patient.

-Additional identified user problems have included incorrect flow rate, dose errors, and air-sensor problems. In some cases, the
intravenous tubing in the pumps may be misloaded, however, if the condition were undetected by the misloading sensors, overor
underinfusion would occur.

Electronic clinical documentation

-also known as computerized documentation or computer-based documentation is an electronic information system used by nurses
and other health care professionals to systematically document clinical information that pertains to the health of an individual.
 System Maintenance

Key Definitions:
Electronic Health Record Systems-software programs designed for use by clinicians to electronically store clinical
information related to patients.

Formulary-a health system’s specific list of medications approved for use by its clinicians.

Maintenance-work that must be done to a software program to ensure that the system is updated and accurate.

Medication Masterfile-compilation of records that individually contain data elements that compose the medication
information presented for use in an EHR system.

Order set-compilation of medication and procedure orders that can be accessed and ordered from a single source in the
EHR. These are analogous to paper pre-printed order forms.

In an EHR system, the pharmacy IT support team will focus its maintenance activities on updating medication masterfiles,
formularies, clinical decision support tools, and clinical order sets.

Types of Maintenance Required:

Maintenance Type Examples of required maintenance activities Key points

Medication masterfile -Drug discontinued from the market -Frequency of database updates

-New drug approved by FDA -Post-update data validation/testing

-System availability to end users during

-Plan for data elements being deleted

-Impact of data changes on existing

-Post-update build

Formulary and related -Drug addition to the formulary -Timeliness of formulary updates
drug information
-Drug deletion from the formulary -Setting clinician expectations for
maintenance
delivery of updates
-Links to drug information sources updated
or changed -IT support must work with inventory
personnel

-Commercial vs. Homegrown drug

Clinical decision support -Dose alerts added to the system -Complexity of CDS

-New allergy cross-reactivities added to the -Commercial vs. home-grown CDS rules
system
-Frequency of updates
-New laboratory triggers added to a drug

Order sets -changes in clinical practice require -quantity of order sets needing
medications to be added or removed updates

-medication masterfile changes -manual vs. automated update process

More Frequently Less Frequently

Advantages -Latest FDA approvals available -Post-update data validation and testing done
less frequently
-Drugs withdrawals from the market not
available to clinicians -Less system down-time required

Disadvantages -In custom-built databases, greater number -Latest FDA drug approvals not immediately
of resources needed to keep up with available for use by clinicians
frequency of updates
-Drugs withdrawn from the market still
-Post-update data validation and testing must available in the system
be done more frequently

-System may be unavailable more frequently

Medication safety

Adverse drug event that can be prevented with an EMR

Prescribing errors -incorrect drug selection

-contraindications

-drug-allergy ordering conflicts

-drug-drug interactions

-wrong dose prescribed

-wrong administration techniques or instructions

-illegible prescriptions

-wrong dosage form error

Dispensing errors -wrong dose-preparation error

Administration errors -omissions

-wrong time error

-improper dose administration error

Monitoring errors -monitoring error

REPORTING AND DATA MINING

Business intelligence-an umbrella term that describes the strategic integration of technology and processes that allow
organizations to leverage their data to make better decisions.

Dashboard-common report format used to quickly evaluate the performance of a business process. Dashboards
commonly use visuals such as dials, gauges, or stoplights to represent results.

Data Integrity-the accuracy, completeness, consistency and validity of data.

Data Mining-broad term that encompasses numerous method used to identify patterns and relationships in data.
Examples of data mining techniques include neural networks, rule induction, and genetic algorithms.
Data Warehouse-centralized repository of data from an organization’s individual information system that is organized
into integrated subject domains for reporting or data mining. Data warehouses may be implemented with relational or
dimensional data models.

Data Query-general term to describe a “search” of a database that returns data for use in reporting or other analyses.

Dimensional Database Model-an approach to designing databases for the purpose of maximizing end-user friendliness
and query performance as well as to preserve data history. These features stand in contrast to the strengths of the
relational database model.

ePHI-electronically protected health information. Individually identifiable health information stored electronically by
healthcare providers.

Fitness for purpose-a property of data that is appropriate for a given use. In reporting or other data analysis, fitness for
purpose is evaluated along dimensions of timeliness and relevancy for the task at hand.

On Line Analytical Processing (OLAP)-a class of applications to support complex queries and analysis across multiple
dimensions. OLAP systems often implement a dimensional data model and are closely related to data warehouses.

On Line Transaction Processing (OLTP)-a class of application designed to support transaction based operational
processes such as order entry or packaging. OLTP systems often rely on databases that implement a relational data
model.

Open Database Connectivity (ODBC)- standard interface for accessing modern database systems.

Relational Database Model-an approach to designing databases based on mathematical set theory. Proper application
of the model helps ensure data integrity is maintained during transactions that update, add, or remove data.

Reporting-the concise presentation of relevant operational or clinical data for decision making or performance review
purposes.

Structured Query Language (SQL)-standard language used to query and manage databases. Pronounce “sequel”.

Elements of Data Quality

1. Accuracy-Data that correctly represents its real-world value.

Ex: an automated dispensing machine’s calculated quantity on hand of 50 tablets that corresponds to an actual
count of 45 tablets.

2. Completeness-data that contains expected values .

Ex: The user name of the pharmacist who verified an order is missing.

3. Consistency-Data that is represented the same way in all systems.

Ex: Male gender is coded as 1 in the billing system and 0 in the pharmacy information system.

4. Validity-data that is recorded within an acceptable range or format.

Ex: dates that are expected as MM/DD/YYYY being entered as DD/MM/YYYY

Ex: Using reports of yesterday’s IV compounding workload to drive staffing assignments today.

6. Relevancy-data that is useful for a given task.

Ex: using the number of orders entered per day to measure the workload of pharmacists assigned to a
pharmacokinetic dosing service.

*Data quality is critical to any analysis. Quality refers to both data integrity (accuracy, completeness, consistency, and
validity of data) and its fitness for purpose (timeliness and relevancy).

*Keep your reports simple and actionable.

*Data warehouses and data marts usually provide a ready source of high quality data that is optimized for reporting and
data mining. Use them whenever possible.

*Data mining techniques are powerful, but remember to assess the models for “clinical significance” not just statistical
significance.

PLANNING FOR DOWNTIME

Affected systems- identification of pharmacy information/automation systems as well as hospital information systems
that support pharmacy operations and the medication use process. These systems usually consist of the pharmacy
information system (PIS), automated dispensing cabinets (ADM), pharmacy robot, TPN compounding machine,
pharmacy’s intranet and/or hospital’s internet sites, admitting or registration system (ADT/registration) for patients
access, financial systems, carousel inventory cabinets, bar code medication administration systems (BCMA), clinical
decision support (CDS), computerized provider order entry (CPOE), electronic medication administration record (eMAR),
clinical results/electronic healthcare record, laboratory information systems, etc.

Cost of downtime-associated costs including: (1)direct costs-staff salary, downtime equipment, lost revenue, downtime
supplies, and (2) indirect costs-delays in medication delivery, increase in medication errors, staff stress levels, etc.

Evaluation/Outcome measure-post downtime review to determine if existing policies and procedures, planning, and
staffing worked, and what needs to be changed.

Levels of downtime-duration of downtime that will require different activation of the downtime plan to maintain
pharmacy operations, for example: (1) short duration-up to 2 hours, (2) medium duration-2 to 7 hours, and (3) long
duration-greater than 8 hours.

Recovery period-time period post downtime for entry of data generated during downtime to update pharmacy
automation/s systems that were affected during downtime.

Scheduled downtime-system outage that is scheduled for pharmacy information/automation systems allowing for
prospective downtime planning; most common reasons include planned hardware or software upgrades.

Unscheduled downtime-system outage that is not scheduled for pharmacy information/automation systems, resulting
in no prospective downtime planning. Most common reasons include unplanned hardware or software failures, power
outages, and extreme weather conditions.