Surveys trending implementation of automated medication storage and retrieval systems (MSR systems) throughout the country show the popularity of this technology has been rising slowly but steadily over the past decade.1 However, for the subset of pharmacy departments serving hospitals with 400+ inpatient beds, automated MSR technologies have become commonplace, with a majority of hospitals in this category reporting usage of storage and dispensing automation.1 In fact, according to Pharmacy Purchasing & Products’ 2019 State of Pharmacy Automation survey, 76% of facilities with more than 400 beds utilize automated MSR systems.2

The benefits of these technologies are clear. Automated MSR systems facilitate efficient management of inventory record-keeping, increase safety through bar code technology at the time of dispensing, and improve the inventory footprint with high-density storage locations. All of these factors point toward the positive role these systems play in the management and operations of a successful pharmacy department.

While identifying the benefits of MSR technology tends to be a simple exercise for health systems, maintaining these technologies while ensuring system efficiency requires adjustments to the pharmacy department’s workload. Thus, it is crucial to plan for the following considerations:

• Management and maintenance of medication inventory
• Returns management and restocking of damaged products
• Technician resource allocation
• Automation management and ongoing support

Automation Factors

The Ohio State University (OSU) Wexner Medical Center comprises seven hospitals, totaling over 1500 inpatient beds coupled with 1.9 million outpatient visits per year. OSU’s pharmacy department provides comprehensive services across the spectrum of care, which includes 25 unique pharmacy locations.

MSR systems are utilized in multiple locations across the Wexner Medical Center enterprise, and play an essential role in our hybrid distribution model. OSU relies on MSR technology across the spectrum of distribution, including cart-fill, first-dose distribution, and ADC stocking.

In a November 2019 PP&P article, Choosing an Automated Medication Storage and Retrieval System,3 OSU director of pharmacy operations, Ben Lopez, explored the decision-making process surrounding the implementation of MSR technology. As more organizations implement these systems, resource allocation and internal process improvement practices will be key to realizing the full benefit of the automation.

Inventory Management

It is not uncommon for health systems implementing MSR technology to encounter challenges in executing and maintaining inventory controls for medications stored and dispensed through automation. Beginning with a drug’s initial load, managing the par levels through set minimum and maximum quantities will be a continuous process in order to best serve a department’s needs.

OSU uses inventory-tracking technology integrated within our EHR to set initial inventory parameters for a medication load; ideally, medications are maintained with 4 days (minimum) to 7 days (maximum) on hand at any time. Ninety days after the initial load, the medication is reevaluated to ensure that the inventory parameters are adequate. For formulary additions where dispense data are unavailable, stock levels are set with our best estimate for the same 4 to 7 day range and again evaluated 90 days post-implementation.

Of course, inventory management does not end 90 days post-implementation, and the ability to manage a large number of medications requires a concerted effort from dedicated resources. Therefore, our purchasing team works across the health system to optimize automation inventory. At regular intervals, the team evaluates our inventory’s ability to satisfy the medical center’s ever-changing medication needs. We have found it most efficient to target two specific groups within the automation: high-use and low-use medications. High-use medications are evaluated on a regular basis, as these contribute exponentially to stock-outs, daily reordering, and overall workflow interruptions. In several of our pharmacies, these fast-movers are grouped near each other in the MSR system to improve dispense time between medications. Conversely, slow-movers are targeted as they can contribute to dead space, high inventory carrying costs due to lack of turnover, and lowered robot efficiency when picking medications.

Medication packaging practices can often contribute to an overstock of medications. For example, a drug may have a minimum of 2 vials and a maximum of 6 vials, but due to packaging, be loaded into the automation as a package of 10 vials, causing an overstock of unneeded inventory. In this situation, our purchasing team may adjust the par levels and/or educate staff on correct stocking levels.

As noted, OSU’s EHR is fully integrated with the automated MSR systems. This not only allows for quick management of acceptable par levels, but also facilitates timely ordering and communication with our wholesaler on the front end of medication purchasing, and speeds up the process for order acceptance and check-in on the back end. The ability to work outside of the operations realm and collaborate with the pharmacy informatics team has allowed for greater automation integration throughout the health system.

Returns Management

A common issue identified during our MSR technology go-live and early implementation phase was damaged product packaging that found its way into stock during the returns process (see the SIDEBAR for Tips on Handling Medication Returns). Technicians found that during delivery, pick-up, and return to pharmacy, some packaging would tear and therefore could not be restocked in the automation. This narrowed the options for handling these medications to either wasting the medication due to the damaged packaging or repackaging it manually so that it could be reloaded into the automation. Both of these options were a drain on resources and in contrast with the efficiency goals set forward by our organization.

Seeking to push our automation to be as efficient as possible, we worked with our MSR vendors to identify a solution that would allow us to keep bar code safety features in place, but also ensure a quick, inexpensive repair of damaged packaging. With the help of our MSR vendors, we identified a third party whose adhesive product facilitates easy repair of the automation-friendly packaging. With the implementation of this product into our workflow, packages can be quickly repaired and restocked.

Technician Allocation

The allocation of technician resources in the management of automation is an ongoing effort, as department leaders must ensure that sufficient staff is dedicated to operating the automation, while also re-allocating staff to other roles as needed. For example, at OSU two technicians are dedicated to MSR system operations on both first and second shift. During third shift, a single technician fills this role, in conjunction with other general duties (see TABLE 1). This allows for the efficient operation of our automation, while facilitating re-deployment of technicians previously tasked with manual medication pulls to additional roles, such as narcotics management.

Ongoing Support

Another resource allocation consideration for automation is management of the hardware related to the MSR technology. Regular maintenance, refurbishment, and software updates are necessary to keep the MSR systems running at full capacity. Many departments will find outsourcing such tasks to their MSR vendor is a preferable solution. At OSU, the use of vendor-provided onsite support has several advantages, including the following:

• Provides the organization with expert knowledge without needing to spend time on staff training
• Enhances the working relationship with the vendor
• Ensures 24/7, site-specific support and expert troubleshooting

However, this is not to say that homegrown automation support is impractical. In fact, many health systems have developed successful automation support solutions.4 The advantages of such programs include a potential cost savings over an outsourced option, while increasing synergy between a department’s automation management and pharmacy informatics team. The decision on how best to support automation requires a review of the potential tradeoffs while considering the department’s ability to create and train an in-house automation support program.

Conclusion

Automated MSR technologies offer increased safety and efficiency within a variety of pharmacy environments. OSU has developed a culture of regular oversight, based on continual communication between our health system and our vendor in a collaborative partnership. A successful pharmacy automation program is one that involves the entire department, including administrators, pharmacists, and technicians. With a transparent understanding of how both operations and informatics, as well as clinical trends, impact essential inventory, significant efficiencies can be achieved through the adoption of automation.

References

1. Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2017. Am J Health-Syst Pharm. 2018;75(15):1203-1226.
2. Automated Drug Storage and Retrieval. The 14th Annual State of Pharmacy Automation Survey. Pharm Purch Prod. 2019;16(8):17.
3. Lopez, B. Choosing an Automated Medication Storage and Retrieval System. Pharm Purch Prod. 2019;16(11):14-16.
4. Rough S, Shane R, Phelps P, et al. A solution to an unmet need: Pharmacy specialists in medication-use systems and technology. Am J Health-Syst Pharm. 2012;69(19):1687-1693.

Harrison Jozefczyk, PharmD, MS, is the assistant director, operations, in the pharmacy department at The Ohio State University Medical Center. He earned his Doctor of Pharmacy from The University of Georgia, as well as an MS in health-system pharmacy administration from The Ohio State University while completing a combined PGY1/PGY2 in health-system pharmacy administration at Grant Medical Center.