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In December 2001, I penned an article entitled the CTD120P Syndrome (Is it Really Close the Door after 120 Prescriptions?). In this article I referred to workplace stress and strategies to rearrange aspects of pharmacy practice, amalgamations, and automated dispensing machines.
To get a sense of the direction in which my articles are evolving, I have asked the readers on each occasion, to revisit my earlier articles, in sequence.
I would again request this, and the link references are illustrated at the foot of this article.
With the recent announcement by the Pharmacy Guild of its rollout of an IT plan for community pharmacies, I thought it appropriate that I extend some of the points in my last article, particularly in relation to automated dispensing.

The real question is "Have we moved forward as a profession with the announcement of a new Guild IT rollout?". The concensus of opinion with some at i2P is that the Pharmacy Guild may finally have the basis of a good IT plan. If it simply provides the support mechanisms for each pharmacy's IT strategy without seeking to dominate or control the process, then it will succeed. If not, then it will lose support and individuals will go their own way.

With prescription dispensing numbers out of control, coupled with diminishing monetary returns, a sensible pharmacist would have to begin to find a solution..and quickly. Of course, you could refuse to dispense prescriptions and find an alternative mix and balance of services, or you could continue to regard dispensing as "core business" and look at alternative methods.

The solution that I propose is to retain core business and set up an Internet pharmacy, with a difference.

The Internet pharmacy I propose is not one that is necessarily advertised to the general public (but it could be, if desired). I further propose that this Internet pharmacy be owned by all the existing community pharmacists within a town/region and provide a dispensing service for all member pharmacies.
That is, you completely outsource the assembly component of your dispensing.
Of course, some of the rules would have to be changed, particularly the one where the HIC currently prohibits agency type dispensing. It may be necessary for some of the members to be able to have a fiduciary interest in more than the legislated number of pharmacies allowed within the state of operation (depending on existing circumstances), and it may be necessary to move forward the proposed legislation relating to incorporation, so that efficient business structures can be put in place, to encourage such mergers.
This is not "rocket science", just a commonsense relaxation of rules that have suddenly become outdated.

This new type of Internet pharmacy would need to accommodate each member pharmacy online, and prescription details would be delivered online from three sources, via each member pharmacy:

* Direct from a doctor's surgery on patient instruction.

* From a patient "smart card" presented at a member pharmacy.

* From manual input by member pharmacy staff (this type of input would all but disappear over time).

Completed prescriptions would be returned to the member pharmacy, or delivered direct to the patient, depending on circumstances.

Of course, the "while you wait" dispensing offer within each community pharmacy has to completely disappear (it never was a sensible or valid service to offer in the first place). In its place, you would have to develop an appointment schedule so that a patient would know exactly when to return, and if counselling has to be built in, then you now have the time to do it.
Counselling could be done at the initial point of contact with a patient, and home delivery arranged, if there is urgency or incapacity connected to the prescription.
In other words, a complete reversal of your current procedures.

Because patients simply cannot walk out on you if you do not provide immediate supply (all other pharmacies close by are assumed to be part of the scheme) you are gradually able to induce a permanent culture change in regard to patient expectations. Along the way, and within this process, you are developing time to deliver more of the cognitive services you really want to provide.

The centre-piece of the Internet pharmacy has to be an automated dispensing machine and an efficient courier service. The courier service could comprise of a locally owned service (even owned by the Internet Pharmacy) integrated with a national courier and Australia Post.

Automated dispensing machines have been slowly evolving over the last 10 years or so, and have arisen from a combination of mechanical vending machines and robotic technology. Early adaptations for pharmacy use have been moderately successful and there have been limitations.
The most publicised versions, of course, originated in the US.
But the most efficient versions have been quietly developed in Europe, particularly Germany.
One product in particular, the Rowa Speedcase, has recently shot to prominence, and has had a successful installation in St Thomas's Hospital, London.
It was conceived by a German pharmacist located in a rural area, who needed extra space to provide counselling and clinical services to the local community. The pharmacist identified an industrial robotic picking device, which was successfully connected to his dispensing computer. He set the device up in the basement of the pharmacy building, and so was born the Rowa Speedcase, which has been continually refined and is now utilised for complex hospital dispensing solutions.
The system is easily networked among a number of computer terminals.

Physically, the Rowa Speedcase can be adapted to fit most locations.
In the St Thomas location, it utilises two identical machines, side-by-side, and working in tandem with each other. Each machine has two sides of 3 metre high floor-to-ceiling shelves, which are adjusted to eliminate any space between stock and the shelf above (no room is required for a hand selection). The combination of high density shelf stacking and a shelf system that extends beyond the regulation 1.6 metres high, creates a significant space saving.
A robotic arm is located within each machine.
There are two input points for filling the machine, two output points for delivering picked items, and two main computer terminals.
The system is simply a mini-warehouse.
To put items into the system, a barcode on each pack is scanned. This enables the robot to identify product, brand, strength and pack quantity. The product is then placed on a conveyor belt leading to one of the input points of the system, and the machine then electronically measures the dimensions of the pack. The robotic arm picks up the pack and randomly allocates a space for it on a shelf which has the correct dimension for that pack, and then stores it on that shelf. The computer remembers exactly where it has placed the various items and different items can be input simultaneously on the conveyor.
To create maximum efficiency, the machine is filled at night, after which the robot automatically sorts the products, so that high velocity products are located to the front of the machine.
Velocity location improves the speed of picking a product by the robot, during an actual dispensing.
No special skills are required for staff loading the machine. Orders from suppliers are simply unpacked, scanned, and placed on the conveyor belt. The machine does the rest, and in the process, eliminates the possibility of human error.

When dispensing from one of the computer terminals, a product is selected through the computer (after an input of all patient details and instructions for use). The robot identifies the product and its location by barcode, transports it to the output conveyor belt, which send it to an appropriate chute in the dispensing area. The chute selection is determined by the computer, which in the St Thomas location is one of three (inpatient dispensing chute, outpatient dispensing chute, discharge dispensing chute). The robot also makes its selection according to datecode and picks the shortest expiry date.
The whole process, after computer input, takes less than 15 seconds per item delivered to a chute, where the product is labelled and checked by a pharmacist. This checking point is crucial, for the one process where human error can occur is when prescription details are input. Other forms of input may also be flawed if utilised in the Internet pharmacy I have described (smartcard or doctor online), so the necessity for a thorough check before a label is applied, requires a pharmacist with appropriate experience.

The maximum capacity for the Speedcase installed in the St Thomas location has not yet been determined, but is estimated at 20,000 packs (plus or minus depending on pack size mix).
The system will handle most items (including injections, inhalers, eye drops).
Legal restriction preclude the loading of Schedule Eight drugs and unlicensed drugs.
Items that exceed a certain weight or volume also have to be excluded.

The installation at St Thomas's has reduced storage space requirements and increased workspace in the dispensary. It has eliminated errors in the manual process of putting stock received away on shelves and in picking stock items for dispensing. Order processing time has been cut by 20 percent and has reduced the need for skilled staff. The goal of releasing pharmacists for patient education has also been realised, but more "fine tuning" of the system is still required to obtain maximum benefits.
The system has allowed a redesign of the pharmacy with a more aesthetic appeal, which allows more natural daylight into the area. A tracking system for patients and completed prescription, has also been developed, and this could possibly be adapted for the Internet pharmacy system I have described above, in collaboration with the selected courier service.
It is not beyond the realms of imagination that a wholesaler could be plugged into the system to deliver a stream of automated "just-in-time" orders to fill the machine. If this means one delivery point for one Internet pharmacy servicing a number of individual pharmacies in a given town/region, this must represent a scale of economy that would attract most wholesalers.
If not, it represents an opportunity for a group of like-minded Internet pharmacies to collate their "virtual orders" and go straight to a manufacturer, who packs the orders (in shrinkproof plastic wraps in original outers), and arranges the various drop-off points for each Internet pharmacy, through an order fulfillment operator (utilising barcode technology on the outside of each order to control the process).

Since the introduction of the Rowa Speedcase at St Thomas Hospital, two other UK locations have installed automated dispensing, one of which has won a "Healthcare Information Technology Effectiveness Award" (The Wirral Hospitals NHS Trust). The award was given for the best example of technological innovation and the overall award for the best use of IT in the health service.

So I am not describing "pie in the sky" systems or applications. They actually exist.
It will only take an alliance with all the players to make it work, but the impetus should come from community pharmacists. The workload is intense now, and it will temporarily increase with the introduction of Internet systems, but it does allow a vision to develop that pharmacy can be the creative and interesting profession it once was, and still has the capacity to be.
Alliances of interested parties need to be established, and the Pharmacy Guild has the opportunity to be a key cordinator for the process, as it develops its IT strategy rollout.
Perhaps some of that government grant could be dedicated to this kind of B2B process, and given a preference over retail e-commerce development, which, while important, would represent the lesser of the two needs initially.

Please check out the following links to my previous articles (the publication order reads from bottom to top):

* Dealing With the CTD120P Syndrome
(Is it Really Close the Door After 120 Prescriptions?)

* Innovative Workplaces

* The Consultant Pharmacist Model..Value Adding to Services

* The Consultant Pharmacist Model..Developing Services

* The Consultant Pharmacist Model...Integrating the People

* The Consultant Pharmacist Model..Extending the Boundaries

* The Consultant Pharmacist Model..Bridging the Gaps

* PRACTICE MANAGEMENT A Model for Consultant Pharmacists

* MANAGEMENT Improving Team Performances

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