Learning from An Expert: Remote Dispensing
An Interview by ComputerTalk with Advanced Pharmacy’s Jim Moncrief
Jim Moncrief knows a thing or two about remote dispensing for long-term care. He is chairman of Advanced Pharmacy in Houston, Texas, which just celebrated its 10th anniversary as an LTC pharmacy that has built its business and reputation on a proprietary version of this technology. Moncrief is proud to report that Advanced Pharmacy now has over 100 Passport remote dispensing systems installed in nursing homes across the country and operates pharmacies in Texas, Maryland, and Florida. In this interview with ComputerTalk’s Will Lockwood, Moncrief gives some background on remote dispensing and describes how it is different from other automation. He also offers his thoughts on why a pharmacy would chose to get into it, the benefits, the challenges, and a few ideas about what the future holds in this area.
ComputerTalk (CT): Jim, first of all, congratulations on Advanced Pharmacy’s 10 years serving LTC.
Jim Moncrief: Thank you. We’re very excited. It’s like, 10 years later, we’re an overnight success.
CT: Let’s get started by having you tell us what remote dispensing is and how it is different from other automation-driven dispensing for LTC.
Moncrief: For us it means in the facility medication preparation. So when a nurse is ready to do a med pass, she simply pulls out the prepackaged medications for her shift from the automation and she has everything she needs to stock her medcart and start her rounds. This is not just a first dose machine. We are actually packaging the med pass one shift at a time. So in a traditional nursing home, if a resident is checked in with 14 medications and 10 of those are blister cards, the nurse has to look through each blister card, determine the medication to give, pop it out, and put it in a souffle cup to give to the resident. With us she simply goes to the Passport and she pulls out her medications for her shift. They are already prepackaged for the patient.
CT: Just to be clear, Passport is your own proprietary technology, right?
Moncrief: Yes, we manufacture the automation. But there are at least three other providers of technology that allow for the kind of remote dispensing we are talking about.
CT: OK. So what are the benefits of remote dispensing, from the pharmacy and the facility’s perspective?
Moncrief: From the pharmacy standpoint, which is what we focused on when we first started, we have a machine that sits in a nursing home that does a little over 65% of all packaging. Once an order comes in and is entered and approved by the pharmacist, it is safe to say that 65% of the time those orders are not touched by human hands until the pills are ready to be dispensed. So as a pharmacy, we operate with substantially fewer staff than a traditional pharmacy. We also don’t have to run out and make stat deliveries because so many medications are available on-site at the facility. These two features help our operating bottom line considerably. We have a third fewer staff and in most cases we deliver once or twice a day, scheduled. We only make five stat deliveries a month on average. Some pharmacies I’ve talked to will make five stat deliveries a day.
CT: And the benefits for the facilities?
Moncrief: Nursing home operations have changed a great deal in recent years. Just while I’ve been doing this, they’ve gone from being almost custodial care to where they are taking knee and hip replacements and offering rehab services. There’s a lot more turnover in the population and a lot more new admissions. Hospitals want to move post-surgical patients out to the nursing home promptly, and they need their medications there immediately. Remote dispensing allows these newly admitted patients to get their medications in a matter of minutes and without waiting for a delivery, no matter what time the facility receives them.
It’s also beneficial for the facility because they can create their own formulary. And when a physician orders one medication that will take four hours to come in as a stat delivery, the facility can offer an alternative that’s in the remote dispensing system formulary and can be dispensed in minutes.
CT: What are the main concerns about remote dispensing that you encounter?
Moncrief: Pharmacists are mostly concerned about accuracy, and rightfully so. We have 10 years of experience, so we have a lot of information on accuracy to put that fear away. At the facility, the biggest issue we run into is that most skilled nursing homes just aren’t really into change, and this is a pretty disruptive system to the routines built around the med pass. When you suddenly eliminate half of the time needed for a med pass, the nursing staff then has to do something else. This is really an opportunity, but facilities have to be prepared to take it. We’ve also discovered, from the staff standpoint, that the technology almost completely eliminates diversion. Staff no longer has access to a 30-day blister pack of hydrocodone, just to one envelope with a few pills. Our process has been DEA approved since 2006 for this very reason.
CT: What kind of pharmacy is remote dispensing most appropriate for?
Moncrief: The key economics are that, if a pharmacy is serving 1,000 skilled nursing home beds, you can be profitable from day one by eliminating labor and delivery costs.
CT: So, if I’m an LTC pharmacist and I’m now convinced that I want to do remote dispensing, what are the key steps to get there?
Moncrief: You need to start with a countdown calendar. When we are bringing a new facility online, we assume it’s going to take at least 90 days until installation. We have a plan for what has to happen on each of those days, because we’ve learned a lot about what to do and what not to do in 10 years. The way we look at it, we aren’t just selling a machine, we are offering a medication delivery system.
CT: And so, as the pharmacy bringing remote dispensing to a facility, you need to focus on that process, rather than just the machine?
Moncrief: Yes, and there are a lot of little things that can trip you up. For just two examples, you have to make sure that a facility new to remote dispensing knows how to get drugs out and that, by the way, they don’t need to reorder the drugs that are dispensed from the automation. This is tracked and handled automatically. As far as introducing a new process, it’s all about education and improving the amount of time the facility staff has to spend on tasks other than med administration. But it can be almost like going from riding a horse to driving a car. It’s that challenging.
CT: How do you handle the 35% of medications that aren’t dispensed remotely?
Moncrief: We end up with 85% plus of all oral solids coming out of the machine, but the balance still has to be filled the traditional way. This group is made up of antibiotics, ointments, creams, and a few other things. But it’s also worth pointing out that, even with medications that can’t come out of the remote dispensing, there are ways that you can manage your formulary and make it reasonable to store certain additional inventory items on-site. Then you can do the first dose of an albuterol inhaler, for example, and that will get you through a resident’s first hours in the building. Figuring all this out is part of the learning process.
CT: What’s needed to maintain and stock a remote dispensing device?
Moncrief: For us, we have a 24/7 call center and it’s a lot like a bank ATM service center where you are watching all the ATMs for a bank. We have that kind of sophistication. We are monitoring all our machines and we know if they need service. If one does, then we can send out a field service tech. This is something that the facility and the pharmacy don’t worry about, because we have a process in place.
CT: Let’s step back from the detail and take a look at what the broader opportunities are within the current healthcare environment for pharmacies that want to use remote dispensing?
Moncrief: The opportunity is that when you talk to a skilled nursing home operator today, their main issue is med availability. They want ways to get the meds to the facility faster. This technology solves that problem. With remote dispensing we put 300 or 350 drugs inside the facility and they have immediate access to them. They no longer have to worry about it being Friday afternoon rush hour with the pharmacy on the other side of town. From the pharmacy standpoint, you now have a new way to control your employment and delivery costs.
We are also looking at new areas, such as assisted living. The reality is that some people in assisted living take more medications that those in skilled nursing. So we are looking to expand into that area. Remote dispensing is an opportunity that should continue to grow.
CT: Any last details your colleagues need to know about?
Moncrief: This is me saying this, but I think this is something that CMS has also been very vocal about, and that is remote dispensing is the best way to reduce waste. We’ve see waste reduced by 15% in all the facilities we go into. Whether you are using a 30-day or a 14-day blister card, there’s going to be waste. Residents in these facilities see a lot of medications changes these days and with remote dispensing it’s simply a matter of packaging the new order for the next med pass. If a doctor comes by at 7 pm and changes a warfarin order, you don’t have to pull the old card, wait for the new card, and then make sure you give the new order. With remote dispensing, it really all comes down to a few simple and compelling facts: you can save time and reduce costs for both the pharmacy and the facility, and you reduce waste and eliminate the possibility of med administration errors.