Information technology has proved to be a great enabler during the coronavirus pandemic. Now the falling cost of robotics and the use of ‘big data’ looks set to change the face of pharmacy practice.

Can machine learning and artificial intelligence safely do away with the need for a pharmacist to do a clinical check on every prescription? Will the falling costs of dispensing robots make hub and spoke an expensive white elephant for all but the largest operators? Has the pandemic led to de facto remote supervision?

These are all questions that have been posed by pharmacy IT providers over the past 12 months – and some of the answers may be coming sooner than you expect. Hub and spoke is back in the news, and at least one PMR supplier is looking to register its system with the MHRA as a medical device so that it can use machine learning and artificial intelligence to determine whether every prescription needs a pharmacist’s attention.

Bristol-based Invatech Health recently received a £900,000 award from the Government-funded Innovate UK to develop its Titan system. Since becoming EPS accredited in 2019, the first pharmacy system to do so for 15 years, Titan now has a 2 per cent share of the prescription market, processing over 1.5 million items a month, says chief executive Tariq Muhammad.

Titan’s cloud-based technology uses bar code scanning to help digitise workflow from end to end. “The majority of our pharmacies are now 100 per cent paperless – they don’t print out any tokens at all. That process was accelerated because of the Government exemption during Covid,” says Muhammad. “We have now reached a point where the pharmacist does not check the prescription at the end of the process – it is checked at the beginning.”

Much work has been done in the past 12 months to improve Titan’s reliability, speed and accessibility. Microsoft’s Power BI can be used to create reports, a ‘marketplace’ has been developed to encourage others to develop apps for the platform and, as with most other PMR providers, a CPCS module will be ready by September.

“We have been doing a lot of work with the BSA to get prescription payments reconciled in real time. We need to do better in reconciling the financials,” says Muhammad. “We have an end- to-end stock control management process and have created a process to eradicate splits. If a split pack is created during dispensing, the system creates a new bar code ID for it.

“Titan can access the NHS Spine via a secure VPN, which means you don’t need a N3 line. That has been a huge benefit with remote working. A pharmacist can work remotely while staff do the licking, sticking and packing – a game changer during Covid.” It also means a pharmacy can be set up with Titan within a week or so, with no lengthy wait for the installation of a N3 line.

Titan comes in two configurations, one for independents and the other an Enterprise option, which is more for specialist operators. The system is now installed in around 100 independents. “Independent pharmacies are our bread and butter,” says Muhammad, “but I do want the system to be out there with the innovators. We are setting up about 10 pharmacies a month in the independent sector and that will escalate towards the end of the year when Covid restrictions lift.”

The Enterprise option has attracted interest from online pharmacies and is now used by one of the largest. “Their system could not cope with the surge in prescription volume when the pandemic blew up. They chose to integrate with our system and from summer to mid-December last year secured a 400 per cent increase in prescription numbers,” says Muhammad. “It was a good win from the business point of view as it allowed us to prove that the system could cope.”

Enter machine learning

Tariq Muhammad’s boldest move is yet to come – something he describes as a “significant development” but one he also recognises as being politically sensitive.

“What pharmacists do in terms of checking prescriptions is largely a waste of time,” he says. “We are using big data to create a form of machine learning that will predict what a pharmacist will do when they see a prescription. We have created a form of machine learning AI that will determine whether a prescription needs a pharmacist’s attention.”

He describes it as a significant step towards a clinical future for pharmacists without them losing control of the dispensing function.

MHRA approval is required for any applications of this nature, so Invatech is seeking to have Titan recognised as a medical device. Approval is expected this month [March] or April.

“I am also talking to the GPhC and starting to challenge for hearts and minds on this one. It is not as controversial as it might have been 10 years ago,” he says, adding that others are probably also looking into similar use of AI in pharmacy IT.

A pharmacist can work remotely while the staff do the licking, sticking and packing – a game changer during Covid

Consolidation and integration

Consolidation among IT providers has helped with integration. Last year’s acquisition of PharmOutcomes and subsequent integration with ProScript Connect meant that EMIS could provide an end-to-end solution for pharmacies delivering this season’s flu vaccination programme. And with pharmacies now taking a growing role in the Covid vaccination programme they, like many other vaccination centres, will be using EMIS’s Outcomes4Health to record vaccine administration.

“Community pharmacists’ workload has increased dramatically during the pandemic and, without changes to the current dispensing model, is in danger of becoming unsustainable,” says Sima Jassal, head of pharmacy at EMIS. This is one reason why the company is developing hub and spoke technology that will enable independents to check and dispense scripts remotely.

Technology will underpin many of the transitions envisaged in the new contractual framework, she says. “EMIS has already released pharmacy appointment booking capability to 10 million patients via Patient Access along with an integrated PGD offering.”

The theme of better integration and improved connectivity with other healthcare providers is picked up by Tracey Robertson, pharmacy product director at Cegedim. “We recently went live with a prescription tracker that integrates with the NHS Prescription Tracker service to provide fast and intuitive access from within the PMR. Next will be more integration with NHS systems with CPCS provision. We are also gearing up to integrate more into the wider ecosystem, with collection robots and delivery providers,” she says.

“We are looking to think more digitally for our customers. An example coming later in the year will be a new intelligent stock inventory management system. Stock wastage is high within the industry, and overstocking is a problem. The new IM system will help alleviate these issues by giving a real time view of what that pharmacy or group has at any one time.”

Pharmacy Manager, which Robertson describes as a “heritage application”, is getting a major overhaul. “We have taken the PMR solution [apart] bit by bit and been re-imagining it and rebuilding it. We are getting ready to launch our new Pharmacy Intelligence hub. It digitally connects head offices to store operations. It is a true cloud- based platform that gives a real time view of store activity and provides actionable intelligence.

“It is aimed at head offices, superintendents and buyers but it also offers independents flexibility if the owner wants to work remotely. We shared our plans for a hub and spoke solution with AIM last year. Our phase 1 solution should be ready soon.” Systems need to evolve to be more flexible and more modular, she says. As regards the NHS, there will be more integration. “Our relationship with the NHS has gone from strength to strength in the past 18 months, and we need to prioritise those integration hooks.”

If at first you don’t succeed...

The Medicines and Medical Devices Bill, which received Royal Assent on February 11, gives the Government scope to introduce secondary legislation allowing hub and spoke dispensing to be introduced “across legal entities”. At present, of course, it may only be used within a single organisation.

Pharmacy minister Jo Churchill has said a consultation will take place first. Following that “the Government will report to Parliament and include a summary of the concerns raised... To ensure that we get the right model to assist pharmacy going forward, we intend to be totally transparent.”

The Department of Health still seems wedded to hub and spoke as a preferred option to drive down pharmacies’ costs, and the larger multiples have already invested considerable sums in such operations. However, this route has always looked less attractive for independents and smaller companies. The cost-benefits are being increasingly questioned, and legal issues around data transfer, stockholding and liability for any picking errors have to be addressed.

Legalities aside, how do the economics of having an automated dispensing system in-house compare to using a hub? There isn’t a simple answer to that question, says Joshua Akin-George, sales leader – Northern Europe, for BD Rowa Technologies. Automation continues to become more affordable with reduced timescales for return on investment, he says, but a raft of other factors needs to be considered when comparing ‘going it alone’ with buying into or setting up a hub and spoke service.

“It depends on factors such as size of the group, the existing infrastructure that you have in place to enable deliveries, and proximity to the hub of the premises to be served. All these need to be evaluated against the goals you are trying to achieve and the costings,” he says.

Like others, BD Rowa has been looking at scenarios that may emerge from the hub and spoke consultation. “We are seeing greater interest in smaller hubs which serve five to 10 local pharmacies that enable a faster response in the event of issues arising and quicker resolution of the problem. There will be larger groups, I’m sure, that will look to take advantage of their infrastructure and economies of scale,” says Akin-George.

BD Rowa has over 300 installations in pharmacies in the UK and Ireland, and continues to see strong demand mainly from independent pharmacies and small to medium sized independent multiple groups, Akin-George reports.

He predicts an increased uptake of automated robots in the future. At the moment Government support for businesses offers a once-in-a-lifetime opportunity, he says. Low interest rate loans, such as CBILS, can be used to invest now in automation to ensure the ongoing sustainability of a business.

Joshua Akin-George argues that the pandemic has made the need to automate pharmacies even more relevant. “The effectiveness of being supported by a robot has proven itself. Pharmacists have been able to continue to dispense medication effectively and accurately. They have been able to increase their volume of dispensed medication in line with the increased demand. It has allowed workflows to adapt by supporting distancing for pharmacy staff and in many cases enable the operations to continue with fewer staff.”

Omnicell looks to community

Omnicell has historically focused on the hospital environment. Cyrus Hodivala, the company’s medicines adherence sales director for UK and Ireland, claims that every open tender in the hospital market over the past two to three years has seen Omnicell replace the existing incumbent.

While admitting that the company has had some poor experiences in the past with getting PMR suppliers to develop interfaces, he says Omnicell is turning its attention to the community sector.

“We have nine RDS systems (full pack picking robots) in the retail sector but 50 in hospitals. We see the retail sector as a major growth opportunity. We reckon there are about 700 robots installed in UK community pharmacies. You can assume a 10-year life span. That means we could expect 70 inquiries a year just to renew equipment. We expect it to be two to three times that.”

Hodivala says the company hardly did any business in the first half of 2020, but after July inquiry levels went through the roof. “Many independents were seeing a surge in dispensing volumes. There have been massive staffing issues during the pandemic. Reliance on manual operations has been hard – and is now recognised as a huge risk.”

Omnicell describes its new Medimat as “the future of retail automated dispensing”. An input speed of 750 packs an hour is claimed to be one of the fastest available, with patented suction pads ensuring boxes and bottles are not damaged during the dispensing process.

The new model has a greater pack capacity than its predecessor and is available with up to 10m of conveyor belt. Flexible shelving gives the ability to manage larger pack dimensions, increasing the number of lines that can be automated. The system is available in bespoke sizes and configurations suitable for any pharmacy, says the company.

Size is a concern for many pharmacies when it comes to installing a robot. The smallest Omnicell offers is 3.75m long by 1.65m wide and 1.65m high, but you get a better outcome if you can go to 5m long and 2m high, says Hodivala. “We have a 3D modelling tool that allows us to show pharmacists what an installation will look like.”

While its robots have, in the past, come with a high degree of customisation, some standardisation is now being introduced. The company can offer units up to 6.5m in 25cm increments, but has created six standard heights. “That means we can offer some compelling price points,” he says.

Omnicell also offers a MDS option with its VBM blister card packaging machine. With a small footprint it can pack up to 40 sealed blister cards an hour. Linked to its eMAR system and using real time data, it aims to improve patient safety and foster cohesion between pharmacy and care homes. Each card has a unique code recognised by the eMAR, meaning MDS cards shipped to a care home can be checked in with a single scan.

“Filling MDS manually poses a risk, but once you get to a large number of patients it can become unmanageable. Robotic assembly allows you to do it accurately,” says Hodivala. Using MDS in a care home in London reduced the duration of the medicines round from two hours to 26 minutes, he adds.