test Automation in Hospital Pharmacy Planning Selection Impact

test Automation in Hospital Pharmacy: Planning, Selection, Impact on Purchasing Practice Sam Colletti, RPh Director, Clinical Pharmacy Med. Assets Test ………………………. . CONFIDENTIAL – PROPERTY OF MEDASSETS. Med. Assets® is a registered trademark of Med. Assets, Inc. Copyright Med. Assets, 2009. All rights reserved. Kelly Froisness, CPh. T Pharmacy Buyer CHRISTUS Hospital- St Elizabeth Beaumont, TX

CHRISTUS Health 1999 two historic Catholic non-profit charities formed CHRISTUS Health: • Sisters of Charity Health Care System • Incarnate Word Health System Mission: To extend the healing ministry of Jesus Christ • Top 10 Catholic health system in U. S. • 43 hospitals / 16 long-term acute care facilities across 8 states and Mexico • Net patient revenues exceeding $2. 6 billion Confidential – Not For more than $4. 3 • Assets totaling Distribution Test…………… billion

Introduction 3 �Automation and the acquisition of capital equipment have become essential to the hospital pharmacy in recent years � Greater than 95% of all hospital pharmacies have some level of automation and 60% to 70% of facilities currently expect significant increases in their automation budgets over the next few years

Objectives 4 �Outline the progression of automation in hospital pharmacy �Describe the strategic planning process for incorporating automation into current and future practice �Define the selection process for automation that incorporates the clinical, dispensing, and purchasing functions of the pharmacy department Carousels Packagers �Discuss the impact of automation on purchasing practices A Buyer’s Perspective

History of Automation in Hospital Pharmacy Most texts refer to the early efforts in the 1960 s as the beginning of Automation. 1970 s- almost entirely manual processes. The largest facilities utilized main frames or mini-computers solely for billing. There were initial attempts at unit dose packaging. The most advanced technology was the memory typewriter. 5

History of Automation in Hospital Pharmacy 6 � 1980’s The progress of automation in general is tied to the emergence of PC’s in the pharmacy workplace Initially focused on IV labeling to replace the typewriters Beginning of simple programs that could balance TPN ions or do simple statistics Much of the software was written by pharmacists for use locally then passed on to others The beginnings of ADT/Order Entry/Profiles emerged as the storage capacity and speed increased The seeds of much of today’s pharmacy automation come from this decade

History of Automation in Hospital Pharmacy 7 � 1990’s – Explosion of Integrated Hospital Systems which included pharmacy Elimination of manual patient profiles for almost everyone Introduction of ADMs, Computerized Clinical Information Sources, Controlled substance inventory management, and Carousel, BMV , bar coding technology All of these efforts needed years of experimentation and improvement to get to the current levels

Technology Applied in the Medication Use Process 8 � Prescribing Clinical decision support software Computerized prescriber order management(CPOM) � Dispensing Carousel technology Centralized robotic dispensing technology Centralized narcotic dispensing technology Decentralized automated dispensing cabinets IV and TPN compounding devices Pneumatic tubes systems Unit Dose repackaging systems � Administration Bar Code medication administration technology Clinical decision support infusion pumps � Monitoring Electronic clinical documentation systems Web based compliance and disease management tracking systems

The Strategic Planning Process Impact on Deployment of Automation

Strategic Planning �Successful Planning and Implementation Integration with Facility/System Capital Plans � It is necessary to establish a long range vision of pharmacy services that can be consistently expressed to the C Suite � A formal plan provides long term continuity despite staff changes � A formal plan provides specific objectives to develop and the ability to present a single vision of pharmacy services over time � Solicitation of support for other disciplines that can benefit from changes in pharmacy Long term outlook for pharmacy services � Equipment can tie you to specific dispensing methods for years � Pharmacy is not perceived as requiring capital funding � Obtaining capital or operations funding for a large project can take several years to get approval 10

Strategic Planning �Define current and future states of both clinical services and dispensing operations for your facility �Define tools needed to support those services �Project realistic timelines for implementation of services �Evaluate alternate pathways to achieve goals �Five and ten year goals are realistic approaches the best chance for approval and successful implementation know your limits and make proposals fit Present proposals to fit your audience (CFO talk not Pharmacy talk) 11

2006 Strategic Pharmacy Plan

Transforming Strategic Plans into Action q. Create specific plans that give everyone a clear picture. q. Allow staff to weight in and take ownership in the project q. Give other involved departments a project scope and timeline q. Administration, Finance, Plant OPS/Engineering, IM 13

Automation that Directly Impacts the Buyer Carousel Technology Unit Dose and Bar Code Repackaging Systems

Selection Process CAROUSELS 15

What is a Carousel? 16 Carousel Storage Systems are industrial grade hi-density shelving systems with software that meets the specific requirements of hospital pharmacy. Functional Goals Increase dispensing accuracy and patient Safety Simplify workflow and improve productivity Utilization of barcode process to enhance BMV Reduce inventory space requirements up to 60% Reduce inventory on hand Automate Min Max Robust reporting inventory management

Cartfill or non-Cartfill Distribution Returns Hub Software Barcode Packager/ Labeler Patient Carts Pharmacy Information System Carousels Drug Wholesaler – Supplier Patient Orders Static Shelving & Refrigerators Automated Dispensing Unit = ADU

Carousel Selection Guidelines 18 Hardware Large variation in quality and vendors 7, 000 to 8, 000 pound boxes require engineering consults Significant redesign of pharmacy workflow Software The large variation among pharmacy vendors Interface Costs are significant Requires hand on demonstration Service of hardware and software is a major concern Significant variation is costs related to service Recommend doing a 5 year cost of ownership when comparing vendors

Carousel Selection Guidelines 19 � Innovation All vendors do the basic functions, but style and user interface varies Evaluate each vendor’s product for your unique requirements and their ability to adapt to your current and future needs. � Equipment Integration Currently for most vendors the Carousel and Hi-volume packager interface is proprietary

Example 5 Year Total Cost of Ownership Model 20

Example ROI Calculation – Carousel System 21

Product Comparison Table 22

Selection Process UNIT DOSE BAR CODING SYSTEMS 23

BMV- Bedside Medication Verification �Barcode Medication Verification- is a check system utilizing bar code technology to ensure each dose of medication given to a patient is correctly matched to a physician’s order including right drug, dose, time, and patient �A number of tools are required for the pharmacy portion of BMV Unit Dose Packaging Equipment – oral solids Liquid packagers Over-Wrappers Bar Code Labeling Equipment 24

Equipment Descriptions �High Volume Packagers – Canister packagers integrated into the pharmacy distribution process through Hub software to package in real time �Table Top Packagers – Traditional unit dose packagers producing batches of product for future dispensing 25

Equipment Descriptions � Manual Packaging – Disposable low volume packaging materials � Over Wrappers/Baggers – Produce sealed plastic bags with labeling and bar coding printed on the bag 26

Packaging Equipment Selection 27 �BMV is an all or none system. Avoiding gaps or workarounds is a primary goal �A “readable” barcode must be on every dose at the bedside �A variety of equipment is needed to resolve all the different product situations encountered �The decision process is complex due to the variety of packaging and bar coding solutions required in pharmacy

Initial decisions about operations determine equipment selection 28 �Questions: All packaging in house (90 -100%)? Outsourced Packager ( 50 -90%)? Manufacturer U/D bar coded Product with minimal in-house packaging ( 30 -80%)? What is the cost break point for each option? Which bar codes are actually readable by your bedside scan system? �Decision Trees

Medication Dosage Forms and related Bar Code Technology Solutions 29 � A bar code solution is needed for every type of product dispensed. Selection depends on facility size(dispensing volume), labor, and available capital A total cost of ownership should be calculated for each piece of equipment with an estimated cost per unit dispensed

Medication Dosage forms and related bar code technology solutions 30 �Oral Solids (Low Volume, Medium Volume, High Volume) �Oral Liquids �U/D Injectables & Inhalants ( vials, amps, respiratory meds) �Multi-Dose Containers (inhalers, topicals, ophthalmics) �Large Volume IV’s �Patient Specific Doses ( Admixed IVs, Non-formulary, nonsterile compounded products, home-medications, Insulin, Investigational Drugs)

Right Sizing Equipment to the Facility 31 �Selection Determination Availability of Capital Funding Labor Costs �Undersized Equipment Choices Reduced life cycle of equipment High Labor Costs / unit dispensed �Oversized Equipment Choices Poor return on investment Unnecessary labor to maintain system � 5 Year cost of ownership model for Leases and Capital Purchases is essential �Workflow and labor utilization analysis is essential

Equipment Choices by Facility Size 32

Conclusion 33 �Planning Vision of future pharmacy practice Discussions with team and facility to form a compatible idea Form ideas into a strategic plan time lines and priorities Create specific plans with actionable detail Search for products and vendors that can make it happen Don’t be afraid to modify plans along the way �Planning and Strategy first– then exhibit halls and vendors

Manufacturer and Review Websites 34 �In addition to your GPO there a variety of review sources Disclaimer- The vendor list is not exhaustive and new vendors appear regularly

A Buyer’s Perspective CAROUSEL AND PACKAGING AUTOMATION KELLY FROISNESS, CPHT 35

CHRISTUS Hospital – St. Elizabeth Mission: To extend the healing ministry of Jesus Christ § § § Established in 1962 in Beaumont TX 434 Licensed beds All acute care services 1, 700 associates 554 combined medical staff 133 Allied health practitioners

Current Pharmacy Environment 37 �Full BMV since 2002 �Currently deployed ADM’s in all patient care, surgical and clinical areas �Cartless workflow process for medication distribution �Two carousels and one high speed packager in the central pharmacy �Manual barcode labeling systems

Pharmacy Carousels - Pro’s and Con’s �Pro’s � Accurate inventory control � Quick & accurate order and restock � Ability to electronically upload current inventory level during yearly inventory � Electronic polling for ADM refill Decrease in quantity of medication errors �Automatically interrupts work flow for STAT/NEW orders Programming priority levels allow creation of Queue's and Over-rides �Con’s � Unexpected stock outs, typically user error

Carousel - Work Flow Changes for Buyer Before Automation: Buyer walks shelves (1 hour daily) – – – After Automation • Manually key in item numbers (30 minutes) Check for contract items (15 minutes) Transmit (send) Buyer will electronically run suggested order report. (5 min daily) – – • Medications manually received then placed on shelves. (2 -3 hours daily) • Medication electronically received (medication and quantity) – ESTIMATED TIME: 4 -5 HOURS Upload order to wholesaler (5 minutes) Check any static shelves(10 minutes) Check for contract items (15 minutes ) Transmit (send) The carousel rotates to the proper shelf allowing user to scan barcode to assure proper placement of medication. (30 minutes daily) ESTIMATED TIME: 50 MINUTES

Carousel/Packager - Work Flow Changes for Technicians Before Automation After Automation � Technician walks shelves picking � Medstation polling and first dose meds for ADM refills and new Orders � Technician manually credits returns and replaces stock to bins. � Technician must add low stock items to want list for buyer to review � Technician assists buyer with stocking new orders on shelves ESTIMATED TIME: 12 - 25 hours interface trigger automated response (carousel to roll) to correct shelf for proper medication dispensing � “Scan feature” allows a medication that is to be returned to be placed into queue for quick and accurate stock replacement � Established par levels make it unnecessary to have a “short list” for items stored in the Carousel ESTIMATED TIME: 8 -15 hours

Carousel Install Process - Technician • Formulary imported (by vendor) • • from hospital computer system Set pars (min vs max) Add wholesaler id Program barcodes Placement and arrangement medication on shelves Assign users Label bins Work time required Approximately 80+ hours

Packager-Pro’s � Electronic Pharmacist verification during refill of canister � Purchase bulk bottles for additional savings � Consistent labeling and bar code scan quality � Accurate inventory control � Quick/accurate order and restock � Longer expiration on pre-packed meds Medication not packaged until time of use � Electronic polling for ADM refill Decrease in quantity of medication errors � Medication is polled from ADM machine by pneumonic minimizing user error(s) Multi-tasking � Packages medication while tech is completing other tasks

Packager – Con’s • Unexpected stock outs, typically user error �Cross contamination possible in packager, typically user error (Caused by poor cleaning and improper canister placement) �Mechanical device requiring consistent cleaning and preventative maintenance If packager malfunctions it will take time to receive parts and a technician from company on site to make repairs. Backup packaging system recommended �Canisters are custom made for each NDC# making brand changes expensive If canister malfunctions it may take up to 8 weeks for replacement

Packagers - Work Flow Changes - Buyer Before Automation After Automation � All Tabs and Caps purchased in � ADM Fill - Hub Software polls U/D, batch packaged, or outsourced Carousel and Packager and intelligently sends fill request to all devices � Medication electronically received (medication and quantity) ESTIMATED TIME: 3 HOURS 45 MINUTES the carousel rotates to the proper shelf allowing user to scan barcode to assure proper placement of medication. (30 minutes) ESTIMATED TIME: 50 MINUTES

Install Process Packager- Technician • Formulary imported from • • • hospital computer system Set pars (min vs max) Assign locations (separation of look alike sound alike) Load canisters Assign users (Technician/Pharmacist) Pharmacist verification of medication Work time required – Approximately 30 manhours

Conclusion 46 �In conclusion although automated dispensing has made the work load of both the pharmacy buyer and the pharmacy technician quicker and more streamlined it requires daily upkeep maintenance �Both inventory control and Safety are greatly improved making the switch from manual medication storage to automated storage a great advantage

Thank You ! 47