The goals of implementing pharmacy automation are to improve the safety and efficiency of medication use and to shift pharmacy staff effort from basic production tasks to more valuable cognitive tasks. Over the past decade, the expansion of technology and automation in health-system pharmacy has been profound. There has been an evolution in both the uptake and functional ability of technologies; pharmacies are moving from fragmented, piecemeal solutions to technology that is seamlessly integrated into operations and workflows.
One technology that clearly demonstrates this evolution is high-density medication storage automation. According to Pharmacy Purchasing & Products’ 2019 State of Pharmacy Automation survey, 44% of facilities utilize some type of medication storage and retrieval (MSR) system1; adoption of this technology exceeds 90% in hospitals with 600 beds or more.2 In addition, PP&P’s survey estimates that an additional 26% of facilities plan to invest in these systems over the next few years.1
From straightforward, stand-alone, rotating carousels with bar code technology, to single-bin pick systems with EHR-integrated perpetual inventory, a variety of solutions are available. The main benefits of MSR systems include:
Choosing a system that meets the specific requirements of the organization requires careful consideration and a robust evaluation of the available technologies. Moreover, facilities should incorporate strategies to maximize the use of this technology investment.
Medication Storage Automation at OSU
The Ohio State University (OSU) Wexner Medical Center, located in Columbus, Ohio, is a 1500-bed academic medical center supporting over 64,000 inpatient and nearly 2 million outpatient visits per year. Our department of pharmacy provides comprehensive services across the enterprise, including traditional inpatient services, outpatient infusion, investigational drug service, nuclear pharmacy, outpatient pharmacy, and more. In 2018, US News & World Report recognized 10 OSU Wexner Medical Center specialties in its Best Hospitals rankings, based on quality, outcomes, and reputation, for the 26th consecutive year.3
The OSU Wexner Medical Center employs both carousel technology and robotic box-pick systems for medication storage and retrieval across various pharmacy locations. Our distribution model is a hybrid, and we rely on decentralized ADC distribution as well as central pharmacy packaging and dispensing technology. The automated storage and retrieval systems support ADC replenishment, patient-specific first-dose production, and patient-specific cart fill. Thus, maximizing use of the MSR systems is crucial to our medication distribution strategy.
When choosing a system, the pharmacy’s size, physical layout, and infrastructure will impact the type of MSR system that can be implemented. For example, some MSR systems may require reinforced flooring or substantial overhead space, which may prevent an organization from retrofitting such a system into an existing space. Some vendors offer modular solutions that can be expanded as the health system grows. There are also options for ambient, refrigerated, and dual-temperature medication storage. Although cold-storage MSR systems offer the same safety and efficiency benefits as ambient temperature systems, the necessary connections to building infrastructure, such as chilled water, compressed air, and emergency power, must be considered. In addition, all MSR systems require the development of downtime procedures.
Specific factors for choosing an MSR system include the available space, necessary features, system capacity, efficiency, workflow, and inventory management.
Consider how the MSR system will be utilized within the facility. For example, a single, small carousel may be sufficient if the system will only be used to supply medications to one sterile compounding area. However, if the technology will support first-dose dispenses, cart fill, and ADC replenishment for the entire hospital, additional capacity will be required.
A review of the robust MSR system market will help establish the specific features that your institution may prefer or require. Consider whether vendors are well positioned to update their software to accommodate the ever-changing pharmacy environment. For example, in the near future, drug manufacturers will be required by the federal Drug Supply Chain and Security Act to include NDC, serial number, lot number, and expiration date in both human-readable form and machine-readable, 2D data matrix bar code format. Determine whether vendor software can leverage this data for expiration management, recall management, cycle counting, and other such activities.4
Whether supporting IV production or an inpatient central pharmacy, several factors should be examined to determine the system capacity needed. Internal historical dispensing data can be used to estimate dispensing volume, and evaluate the dosage forms dispensed and the associated temperature storage requirements (eg, unit dose tablet, dermal patch, prefilled syringe, premixed IV, etc). Calculate the desired days’ supply to set par levels and reorder quantities. Medication cost should also be considered in order to reduce the quantity on hand of higher priced items.
MSR technology can be leveraged for the cleanroom to enable inventory management of these typically high-cost medications. In addition, the systems can be integrated into the physical design of the IV production area to facilitate technician selection of compounded sterile product components. For example, our system provides dynamic, adaptable storage for both refrigerated and ambient products, and utilizes bar code scanning and a single-bin retrieval system to reduce the opportunity for selection errors. It can also accommodate medications of various sizes, from small vials for reconstitution to large premixed IVs, which improves organization and increases safety and efficiency when producing large IV batches.
MSR systems improve efficiency compared with manual systems, and the functional pick rates of both types of system are comparable. Further efficiency gains can be realized by maximizing the number of medication line items stored in the MSR system, and by timing dispensing activities in alignment with operational needs.
The more line items included in the system, the fewer locations a pharmacy technician will need to search during medication retrieval, so reducing the number of manual picks outside of the system should be an important goal. In addition, at the time of purchase, be sure to allocate sufficient MSR system capacity for the management of drug shortages and potential volume growth; this approach can help limit remote inventory or overstock. While it is not possible to anticipate future drug supply interruptions, engage with pharmacy buyers to review historical purchase data and allocate some automation storage capacity to shortage management.
When planning for ADC replenishment and cart fill, adopt an approach that aligns with clinical and operational needs and spreads the work evenly across shifts. For example, it is unlikely that all ADCs will require restocking at the same time of day; consider staggering ADC replenishment for off-peak medication administration times, which may differ depending on a given unit’s patient population. Some clinical areas (eg, the critical care area) will require more frequent ADC replenishment than others (eg, the onsite ambulatory clinic).
The same approach can be taken with cart fill. While the cart fill interval can still be set at a traditional 24 hours, it may be advantageous to stagger cart fill times for selected units to break the work into manageable segments that align with delivery times.
Operational changes should not occur in a vacuum; collaborate with frontline pharmacists and pharmacy technician leaders who are familiar with the current processes, as well as any potential pain points. Technicians should be heavily involved in process design and execution.
MSR systems offer inventory management software with a variety of features, from basic data detailing inventory movements and turns to the ability to integrate with wholesaler ordering platforms; some software can even calculate and suggest par levels. OSU chose to implement an integrated perpetual inventory management system via our EMR. This offers some advantages over the MSR vendor inventory management software as it tracks all inventory movements across our entire organization, whereas MSR vendor inventory systems are typically not as holistic and may not include manual inventory locations such as refrigerators, emergency carts, or overstock areas. Note that the less integration an inventory management system has, the more often it may rely on the use of virtual shelves or remote locations, which requires frequent manual documentation.
Our EMR inventory system is integrated with essentially all dispensing and inventory movement activities, including the ADCs, robotic box-pick system, and IV compounding robots to facilitate visibility across all inventory by location or by medication. As such, when managing a drug shortage, we can see the volume of a given item in the central pharmacy, satellite locations, and ADCs, which helps us make well-informed, data-driven decisions regarding operational changes or alternative medications.
The EMR inventory management system automatically records all inventory movements into and out of the box-pick system. Thus, pharmacy technicians are able to electronically receive and bar code scan the wholesaler order into the MSR system, which automatically updates the inventory count; patient-specific dispenses, cart fill, and ADC replenishments are automatically deducted from the inventory count.
Whether using an integrated inventory management software system or the MSR system’s inventory software, a process for completing routine cycle counts is required to ensure accurate data and to correct any discrepancies. Some MSR system software has specific cycle count functions; others require cycle counts to be tracked manually. In both cases, complete cycle counts should be integrated into routine technician workflows and be conducted every 30 or 60 days.
No matter which type of MSR system is implemented, policies and procedures for downtime management should be developed and incorporated into technician training. The downtime procedure must be up-to-date and easy to follow. Because downtimes should not occur frequently, table-top drills or other methods for maintaining staff knowledge and competency should be developed. Table-top drills should be case-based in their design, and should reflect real scenarios that staff may encounter, including both planned and unplanned downtime. Such drills can serve to reveal gaps or lack of clarity in downtime policies, and can also inform staff of proper procedures. If possible, facilitate interdisciplinary drills; at OSU, we engaged with prescribers, pharmacists, nurses, and technicians, because of the integrated nature of our EMR and the potential impact of downtime on medication distribution.
During system downtimes, medications can still be retrieved manually; however, certain safeguards, such as bar code scanning, may be unavailable, and inventory movements are typically not logged. Once system functionality is restored, complete a cycle count to correct and document any inventory movements that occurred during the downtime.
MSR systems are an established, well-adopted technology, designed to enhance safety, increase efficiency, and improve inventory control. In complex, dynamic pharmacy environments, the successful implementation of these systems requires integration across other technology platforms, detailed operational design and oversight, and frontline pharmacy staff engagement.
Ben Lopez, PharmD, MS, MHA, BCPS, is the director of pharmacy operations at The Ohio State University Wexner Medical Center in Columbus, Ohio. He earned his Doctor of Pharmacy from West Virginia University.