Chapter 5
Water, air, and cleanness are the chief articles in my pharmacy.
Napoleon Bonaparte
Between Prescribe or Order and the actual administration of a drug is the
Dispense/ePharmacy workflow. Thus, pharmacy has the unique opportunity to
become an important safety checkpoint in the medication life cycle. The focus
of this chapter is on the integration of the Dispense workflow with the EHR
(electronic health record) in general and the Medications system specificallyso
pharmacy may have all the information necessary to make the right dispensing
Small, community-based as well as large hospital pharmacies need automation
to dispense drugs safely and efficiently. This automation comes in many forms,
and it is introduced in this chapter: robots counting tablets or preparing intrave-
nous solutions and injections, bar code labeling, automated dispensing cabinets,
and so on. Realizing that currently most pharmacies use a mix of manual and
automated processes in their operations, the structured analysis can be applied
toa manual as well as a highly automated pharmacy environment.
First, we analyze the Dispense workow with a DFD (dataow diagram) and
then identify the data elements needed to support the Dispense processes.
138 ◾  Electronic Health Record: A Systems Analysis of the Medications Domain
Dispense Workflow
There are many types of pharmacies: community based, independent or chain
related, mail order, hospital based, specialty oriented (e.g., for chemotherapy),
and so on. While each type of pharmacy may use its own flavor of an opera-
tional model, our goal is to identify the recurring theme, the similarities of vari-
ous Dispense workflows, used by different types of pharmacy models.
Pharmacies need to safely and efficiently procure, stock, and dispense
drugs. This chapter focus is on the Dispense workflow: The pharmacist coor-
dinates the medications therapy of patients, who are often treated by many
Let us follow a drug during its life cycle and identify processes and entities
that may be involved in the Dispense workflow (Figure5.1).
Select Dose / Prepare drug
Manually Robot
IV Chemo
Pack & Label drug
Review Patient Data
Select Drug
Verify Dispensation
Pick-upADC Mail CartPneumatic tube
Check Availability
Rx / Order
Manually Robot
Figure 5.1 Drug life cycle: Dispense workflow.
Dispense/ePharmacy ◾  139
Pharmacies have similar requirements related to the Dispense workow (1,2):
Review patient data
Verify prescription (Rx)/order
Check availability in stock
Select drug and dose
Pack and label
Verify dispensation
During this workflow, the pharmacy communicates with others (prescribing
clinician, patient, nurse, billing, etc.) and considers the CDS (clinical decision
support) and formulary recommendations. Even with automated workows and
robots to help, safety risks and concerns during the Dispense workflow still lurk
in two areas (2):
Drug preparation
Drug labeling
A pharmacy with millions of dispensations per year and a low error rate may still
suffer from too many dispensing errors (3).
The error-prone process of manually counting tablets was the first to be auto-
mated: Pharmacy “robots” capable of counting tablets and capsules arrived in
pharmacies in the 1980s (4). Later, these counting machines were connected to
the inventory systems. The next step in the ePharmacy evolution was the auto-
matic process of labeling medications with bar codes at the unit dose level. The
concept of Unit Dose emerged as the amount of a medication to be administered
as a single dose: uniquely identifying a combination of Patient, Drug, Route,
Dose, and Time and connecting it, preferably via bar code, to an actual drug dis-
pensed (5,6). The safety benefits of the uniquely identified, bar-coded drugs from
the pharmacy were then extended into a Bar Code Medication Administration
(BCMA) system to ensure the right patient, drug, route, dose, and time are cor-
rect during the Dispense as well as the Administer workflow. The concepts of
BCMA and Unit Dose are further discussed in the next chapter.
In addition to the process of counting tablets and capsules, other areas of
pharmacy automation now include the robotic preparation of intravenous (IV)
solutions, injections, and total parenteral nutrition (TPN), automatic packing, bar
code labeling, and drug distribution.
The Dispense workflow in Figure5.1 covers most of the spectrum of phar-
macy operating models: from small, independent, community based and mostly
manual to large, highly automated pharmacy operations of academic medical
centers or multihospital healthcare organizations.

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