Automated drug dispensers become more popular in Fargo-Moorhead

FARGO – A screaming child with a late-night earache will make any parent’s skin crawl.

Not only may the pain trigger a trip to the emergency room, but the chances of getting needed medications before morning are often nil.

The InstyMeds machine at Innovis Health in Fargo dispenses prescription medicine much like a vending machine. (David Samson/The Forum)

Hospitals can’t stop ear infections, but several are addressing the prescription problem by installing ATM-style machines that dispense drugs.

These InstyMeds systems hold dozens of commonly prescribed medications, giving patients access to drugs after retail pharmacies close or saving them another trip when they’re not feeling well.

“For us, it was really about offering our patients the convenience factor,” says Todd Forktel, an administrator at Innovis Health. The Fargo hospital installed its system in April.

InstyMeds works much like an ATM machine, automatic car wash or any other type of automated kiosk.

A physician sends the prescription to InstyMeds via a computer. The patient receives a code that he or she punches into the machine to retrieve the medication, which is labeled and comes with instructions.

The system bills the patient’s insurance. Co-pays are accepted via credit card, debit card or cash. If problems or questions arise, patients can use an attached phone to reach an InstyMeds pharmacist.

“They’re so easy to use,” says Natalie Rund, emergency department nurse manager at Lake Region Healthcare in Fergus Falls, Minn. “I tell patients, if they can use an ATM machine, they can use this.”

Each hospital determines which drugs the machine will dispense. Limited supplies of antibiotics, anti-nausea drugs and pain relievers are among the most common.

InstyMeds doesn’t allow refills and most hospitals avoid filling it with medications designed for chronic conditions like high blood pressure.

“We’re not trying to compete with the pharmacists,” says Chris Harff, CEO at MeritCare Thief River Falls, Minn. “We just want to help patients who like the convenience.”

The technology fills a gap in communities that don’t have pharmacists ready to fill prescriptions 24 hours a day, seven days a week. For example, there’s no retail pharmacy open in the Fargo-Moorhead area after 10 p.m., Forktel says.

MeritCare in Fargo has a pharmacy open all the time for its emergency room patients, but not for the general public, says spokeswoman Carrie Haug.

MeritCare Thief River Falls installed its InstyMeds machine several years ago, Harff says.

“Patients love it,” she says. “If you’re sick enough to go to the emergency room, you don’t want to hang out at the pharmacy. They’re done when they leave here.”

Not everybody is fond of the technology. The North Dakota Board of Pharmacy discourages the use of dispensing machines like InstyMeds, says Howard Anderson, its executive director.

“Research has shown that the best scenario is for a patient to get information and counseling from a pharmacist,” he says. “We recommend physicians give the patient a starter supply of drugs and a prescription so a pharmacist reviews it as soon as possible.”

North Dakota has a telepharmacy program that allows patients to consult with a pharmacist even if one isn’t in the community, Anderson says.

“We’re not telling physicians they can’t dispense medications, but we’d prefer they look at this (telepharmacy) model,” he says.

Emergency rooms and urgent cares with automated dispensers still allow patients to get their prescriptions filled at a pharmacy. But patients who are comfortable getting cash from ATMs and checking in on airline flights via computer terminals have few qualms about doing the same for their prescriptions.

“In the evenings, everyone’s wondering how they’ll get medications,” says Dr. John Baugh, who works in the emergency room at Innovis Health.

Physicians, too, wonder if they’re giving patients enough drugs to last until they can get to a pharmacy, he says.

The popularity of InstyMeds has increased since Innovis installed its system in April. The first month, it dispensed 249 prescriptions. During three weeks in July, it dispensed 418 before running out of medications.

Baugh say, “Most patients seem to want to use it so they can get their medications and go home.”

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Dialing Up Medication Safety

When Lewistown (Pa.) Hospital decided to implement an electronic medication administration record, hospital executives decided patient safety was also going to get an upgrade.

The 139-bed hospital's in-house pharmacy was only open 14 hours a day. During that time an on-staff pharmacist would review all new prescription orders. Drug orders placed during off hours, however, would be reviewed and filled by nurses, who are well-versed in potential adverse drug interactions but lack the in-depth knowledge of pharmacists, says Richard Stomackin, director of the inpatient pharmacy at Lewistown.

So when the hospital deployed the electronic medication record, Stomackin also wanted to have 24-hour pharmacist review of drug orders. His first inclination was to hire two new pharmacists, but considering each position would require a six-figure salary plus benefits, finding two new staff members wasn't an attractive financial option. He also thought it would be difficult to attract qualified candidates to Lewistown's central Pennsylvania location.

Stomackin found another option in Rxe-source, a telepharmacy service from Cardinal Health, Dublin, Ohio. The telepharmacy enables a hospital to supplement its onsite pharmacy services by connecting to telepharmacists working at remote locations.

The telepharmacists receive faxed or phone drug orders, then evaluate a patient's medication profile, review necessary lab values, enter the medication into the patient profile, check for possible interactions and authorize orders for administration.

Lewistown began using Rxe-source in September 2005. The hospital's on-site pharmacy is staffed from 7 a.m. to 9 p.m. weekdays and 8 a.m. to 6 p.m. on weekends. When the on-site pharmacists leave, all calls and faxes are routed to the telepharmacy in Ohio.

Lewistown nurses typically fax the orders to the telepharmacy. The telepharmacists then connect via a secure Internet connection to Lewistown's medication administration record to check the patient's previous medications and medical conditions. The telepharmacist reviews the current order and calls a nurse or physician at Lewistown if any revisions are necessary.

After the telepharmacist approves the order, either via fax or phone, the nurse then retrieves the medication from cabinets that are stocked during the day with drugs the caregivers will need during the night shifts. If the medication is not available in a cart and needs to be administered immediately, a staff pharmacist is asked to come to the facility and fill the order.

Cardinal Health charges Lewistown a monthly fee based on the medication order volume during Rxe-source's hours of coverage. Lewistown declined to provide details about costs.

Initial setup of the telepharmacy was challenging, Stomackin says. Staff pharmacists had to fill out a 26-page survey that asked questions about the hospitals policies and procedures, as well as what drug substitutions the hospital allows and the facility's potential order volume. Lewistown also had to standardize order sets so the telepharmacist could follow standard protocols.

In addition, Lewistown nurses have had some run-ins with the telepharmacists, Stomackin says. "Nurses complain that the telepharmacy guys are stricter than we are," he says. "If you tell the telepharmacy this is hospital policy they adhere to it. This is different when we're here during the day when we have some flexibility to work things out."

Stomackin adds that because the pharmacists know the physicians and the personalities involved it's easier for them to make exceptions to hospital policy, whereas telepharmacists will stick to the rules.

But Stomackin believes the telepharmacy service has helped increase patient safety at Lewistown. "Any time you have an additional check you improve patient safety," he says. "It's one more safeguard to make sure that the patient is getting the right drug."

Another benefit of the service: by enabling the hospital to have 24-hour pharmacy coverage, it helped Lewistown improve its score during a recent review by the Joint Commission on Accreditation of Healthcare Organizations, Stomackin adds.

Pharmacists increasingly are in demand, and it's likely the need for telepharmacy services will increase, says Paul Johnston, senior consultant at Healthia Consulting, a Minneapolis-based health care I.T. consulting firm. The U.S. Department of Labor is predicting a shortfall of 157,000 pharmacists by 2020.

Rural areas that have chronic problems hiring full-time pharmacists are turning to telepharmacies to improve safety around the medication administration process, Johnston says.

"In an inpatient setting it's critical to have a pharmacist involved," he says. "The telepharmacist can check for harmful interaction, review current medications and perform dosage correction."

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