Pharmacy systems have been in use in community pharmacies now since the late 1980s, and pharmacists are used to the functions that these systems provide, namely labeling , stock control and ordering , together with provision of a patient medication record, to enable pharmacists to review a patient’s medication history (see Chap. 6 ).
As well as these traditional functions, community pharmacy system suppliers have now developed functionality to deal with MURs and other enhanced services.
Commentators have emphasised the importance of IT and automated systems in streamlining supply and administrative functions, to enable community pharmacists to concentrate on near-patient clinical activities. Since the publication of the Pharmacy in England White Paper in 2008 [ 32 ] , extended roles for community pharmacists has very much become the policy direction in the UK and, even despite the current uncertainties about service provision and commissioning in the UK NHS at the time of writing, because of the proposed NHS reforms , pharmacists are still being encouraged to embrace extended roles.
While automated dispensing using pharmacy robots is now common in hospitals, experience with automated dispensing in the community is less widespread. While automated dispensing would be bene fi cial in many larger community pharmacies, in order to deal with a high dispensing volume, the use of pharmacy robots has gen- erally only been embraced by larger multiple pharmacy operators, and a number of independent community pharmacy innovators.
However, in addition to pharmacy systems and pharmacy robots, there are IT systems with the potential to support speci fi c aspects of the community pharmacy service. An example of this is the use of IT systems to support methadone dispens- ing. A number of systems, such as Methameasure and Methasoft, have been devel- oped to automate the dispensing of methadone to substance misuse clients in community pharmacies. Methadone dispensing and supervised consumption com- prises an important element of a community pharmacist’s work. In a national survey conducted to assess the impact of national guidelines on opiate substitution pre- scribing [ 33 ] , it was found that, between 1995 and 2005, the number of prescrip- tions for opiate substitutes doubled, with methadone still making up the bulk of the prescriptions (>80 %). During the survey period, the average daily dose of metha- done increased (from 47.3 to 56.3 mg), and the frequency of dispensing increased (from 38 to 60 % of prescriptions as daily instalments). During this period, super- vised consumption has also been adopted (36 % of prescriptions in 2005). These factors have caused the volume of liquid methadone dispensing by community pharmacists to increase in the last few years and, despite the availability of other opioid substitutes such a buprenorphine, it is likely that the dispensing of metha- done will continue to increase. Some community pharmacies dispense methadone for up to 300 clients per day [ 34 ] .
Furthermore, as well as the volume of dispensing, there are a number of issues that make the supply of methadone a critical process, and which increase the risks associated with the methadone dispensing process in a busy pharmacy. Firstly,
liquid methadone for clients with varying dose requirements must be dispensed extemporaneously, which is a time-consuming process. Secondly, in the UK, meth- adone preparations are Schedule 2 Controlled Drugs and their supply must be in accordance with the controlled drugs regulations (correctly generated prescriptions, maintenance of controlled drugs records, running balances and accurate dispensing).
Thirdly, the interpersonal factors with methadone supply are less straightforward that with other aspects of pharmacy practice. Because of their addiction, clients receiving methadone may dispute the quantity supplied and may use subterfuge and deception to obtain additional supplies. In addition, they may attempt shoplifting, which might place pharmacy staff under increased pressure to deal with them quickly so that they can leave the premises.
Consequently, the supply of methadone in community pharmacies is a prime area where robust procedures are needed to ensure that the supply process is ef fi cient, legal and safe. It is recognised from studies of electronic prescribing and other medicines management IT systems that these applications can reduce clinical and professional risk, streamline working processes and enable better ways of working. Consequently, the process of methadone dispensing and super- vised administration is therefore eminently suitable for the use of automation, where an automated system deals with the repetitive dispensing and record keep- ing process, allowing the pharmacist to deal with more intuitive aspects of the service – namely dealing with prescription anomalies and the client-facing super- vision process.
A number of systems have been developed to automate the methadone supply pro- cess in busy community pharmacies where there are many methadone service users, and they consist of a computer-controlled measuring and dispensing unit. The software runs on a laptop computer and is attached to a cabinet containing two peristaltic pumps , one for standard methadone and one for sugar-free methadone. These pump the metha- done from a bulk container to a dispensing nozzle, when the user selects a patient’s methadone dose for dispensing. The pumps are highly accurate with a variance of less than 0.1 %, and the system maintains a running balance of methadone levels, from which printed CD register pages are generated at the end of the day.
Figure 4.4 shows the Methameasure system in operation at a UK community pharmacy.
Automated methadone dispensing systems offer the following bene fi ts:
automation of the dispensing process, thus saving time and reducing the poten-
•
tial for dispensing errors (especially in busy premises)
no need to use bottles, when methadone is dispensed direct from the machine,
•
thus reducing the cost of consumables .
veri fi cation of client by photo record and/or fi ngerprint identi fi cation reduces the
•
risk of dispensing incidents (either errors on the part of the pharmacy or attempts at deception on the part of the client)
automatic production of
• controlled drug record documentation for the day, thus saving time for the pharmacist, and reducing the risk of discrepancies in the CD register.
116 4 Pharmacy Automation
A study has been conducted on the operation of the Methameasure system in ten pharmacies [ 35 ] , but this study focussed primarily on fi nancial savings in terms of staff costs and consumables, following introduction of the system, in order to help pharmacies formulate a business case for introducing the system. The study found that the average net saving afforded by installing the Methameasure system was
£2,296.84. However, two pharmacies were excluded from the analysis, because the authors claimed that their data might skew the results, so the data were from just eight pharmacies.
With automated methadone dispensing systems, as with other medicines man- agement IT applications, there is a need for large-scale quantitative data on broader system bene fi ts, in particular the reduction of dispensing errors and the types of dispensing error reduced. Such data would contribute to a full understanding of the risk issues involved in the methadone supply process and would drive the adoption of these technologies as standard in high risk situations such as methadone dispens- ing. It is to be hoped that academic practice research pharmacists with an interest in this fi eld might consider undertaking such work.
As with all IT systems used in healthcare, pharmacies installing automated meth- adone dispensing systems should check that the system meets all their likely require- ments. For example, users may wish to check how fl exible the system is with complex dispensing – for example, splitting daily doses, asymmetric dosing or changing installments during the prescription durations. Some of these use cases
Fig. 4.4 Methameasure system at Cox and Robinson Pharmacy, Horsefair, Banbury, UK
represent necessary control exerted by the system on the process but, in some cases, it may be possible to facilitate complex dispensing using con fi guration options in the system. Users should also check whether the methadone storage facility within the device complies with the legal requirements for storage of controlled drugs, and whether the system can be securely set up in patient consultation areas . Many sys- tems now have secure storage on their devices, which conforms to legal require- ments for the storage of controlled substances.
Conclusions
The use of automation has considerable potential to reduce risks of dispensing and supply errors and thereby improve patient safety. Automation can also improve the ef fi ciency of the medicine supply and administration process, and improve the quality of services. Following the publication of the Audit Commission Spoonful of Sugar Report, pharmacy robots have been widely adopted in UK hospitals.
However, there is still more scope for these units to be installed in the community pharmacy sector. Also, there is still little research information quantifying the bene fi ts of pharmacy robots and, at a time when patient safety and service ef fi ciency are of increasing importance to health providers, more studies would be bene fi cial.
Electronic medicine cabinets have the potential to reduce risks associated with medicine selection and administration on the ward, to improve stock control and management (with associated cost reductions) and to facilitate good medicines management. However, while use of these systems is widespread in other health economies, their use is still at an earlier stage in the UK, and there is little data on quantitative bene fi ts, as yet.
Automated methadone dispensing systems are likely to have a bene fi cial impact on the ef fi ciency, accuracy and safety of methadone dispensing in community phar- macy. The bene fi ts of the system for the community pharmacist have been described, and there is an algorithm to assess the fi nancial viability of the system in any given pharmacy. However, at present, there are no quantitative data available on the effect these systems have on the incidence of dispensing errors. These data would be bene fi cial for identifying risk factors in methadone supply, making standard operat- ing procedures more robust and maximising patient safety.
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For people in many countries, their predominant experience of healthcare will be of primary care , whether that is the general medical practitioner’s consulting room in UK or European medical centres, the family physician’s of fi ce in the United States, or through community pharmacies or nurse-led clinics in any of these settings. Throughout the Western world, many healthcare needs are met without the need for hospital refer- ral, and the allocation of resources re fl ects that. In the UK NHS, prescribing in pri- mary care accounts for around 80 % of the total medicines budget [ 1 ] .
Given the sheer fi nancial and human resources allocated to the primary care net- works in many health economies, it is essential that systems used for enabling medi- cines management and pharmacy practice in the community ensure high quality of care, ef fi cient use of resources and appropriate use of the skills of all professionals involved in the medicines user process. In particular, the relationship of the commu- nity pharmacist with other members of the primary care team is vital, and systems used for medicines management in primary care must support and enable this rela- tionship, so that the pharmacist’s unique knowledge and expertise is brought to bear to ensure high quality pharmaceutical care, and the minimization of adverse events.
This chapter will examine the functions of general practice (medical of fi ce) com- puter systems, in general but with a speci fi c focus on the prescribing process , and also the process of electronic transfer of prescriptions (eTP) in the community, which is being adopted in the US, UK and other countries, and how the eTP process could support pharmaceutical care.