I, Robot, in the pharmacy

On one side of the double white steel doors is Remedi SeniorCare's present: a conventional pharmacy, complete with rows of shelves, hundreds of prescription drug bottles and staffers who fill thousands of orders a day for nursing homes and assisted-living centers.

It's adequate, but certainly not cutting-edge.

"This is the dinosaur of medication administration," said Michael G. Bronfein, Remedi's chief executive, during a recent tour of the 50,000-square-foot floor.

But push through to the other side of the white doors and you see Remedi's future: robots.

The Rosedale-based company has spent about $30 million to design and build an automated, computerized system that packages, labels and conducts quality control on thousands of individual drug orders a day.

Robotics has long played a role in the automation of industries from electronics to automobiles. Increasingly, robots are being deployed in health care settings to help cut costs and staff time, and improve efficiency and safety.

"It's like a big Pez dispenser," Bronfein said gleefully about two machines, each roughly the size of a cargo container. "But with a super-gigantic brain."

Remedi and its robots represent Bronfein's ambitious, high-tech re-entry into the world of long-term-care pharmaceutical services.

Bronfein, who grew up in Randallstown, co-founded NeighborCare, which started as a local pharmacy chain in the 1980s and grew into a massive player in the institutional pharmacy industry, which fills the prescription drug needs of nursing homes and assisted-living centers. That company was sold to a larger rival six years ago for $1.8 billion.

Now, Bronfein is starting over with a smaller company, but he's gearing up to go toe-to-toe with bigger institutional pharmacy competitors. With health care costs soaring, skilled-nursing and assisted-living facilities are looking for savings on prescription drug costs for their residents. So Bronfein and some other companies with access to capital are turning to automation for an economic and operational edge.

Using robotic technology to automate the drug dispensing and packaging process — a round-the-clock operation for institutional pharmacies — is still a rare technological step in a fragmented industry with scores of small local and regional companies.

Two national companies — Omnicare Inc. and PharMerica Inc. — dominate more than half of the long-term- care pharmaceutical services market, estimated to be worth about $14 billion in annual revenue. Most companies still use blister-pack technology: a cardboard card dotted with plastic bubbles that hold the pills.

'Bingo cards'

At Remedi's headquarters and pharmacy service facility in Rosedale, pharmacists and medical technicians oversee the filling of these "bingo cards" for each patient as part of the traditional side of its business. The cards are delivered daily to the nursing and assisted-living facilities Remedi serves.

With the bingo cards, which Remedi still produces for thousands of patients and residents, there is some mechanical automation involved, but not on the scale of what Bronfein has accomplished with his new robotic system.

The Paxit robotic system is able to dole out doses of more than 1,400 different medications to several thousand patients daily. Three to five people, including an on-call maintenance person, are required to operate the machine.

In the traditional pharmacy wing of Remedi, about 16 people would be needed to perform a similar volume of work.

Some in the industry say automation frees highly trained pharmacists from dispensing protocols, which can be performed faster by machines, and allows them to focus on managing medication for patients.

"I think automation is an efficient model for the dispensing portion, but the care portion is critical for the pharmacist to be involved with," said Shelly Spiro, who runs a health information technology consulting firm in Northern Virginia.

In the room dedicated to the Paxit system, the machine's mechanical whirs and pneumatic bursts of air provide the background noise to a complex, fully automated operation. At the beginning of the process, each pill is inserted into its own bar-coded and labeled blister packet.

Packets with different drugs are placed into plastic pouches, which are also bar-coded, labeled and sealed. High-definition cameras, with optical recognition software, detect glitches in the process and order the bulky automaton to fix the order, requiring minimal human oversight.

Some hospitals also are using robotic systems to dispense medication to patients, and at least one top pharmaceutical services company, McKesson Corp., markets a technology called Robot-Rx.

Like a wholesaler that delivers bread or milk to grocery stores in a region, Remedi delivers thousands of packets of medications a day to care facilities in several states. The company has installed two Paxit machines in Rosedale, and is planning to install two more in a distribution facility in Dayton, Ohio.

Target audience

Remedi is targeting a unique set of clients: long-term-care facilities, where patients and residents might have medication needs that evolve over time, or who might leave or die. These facilities typically use companies such as Remedi to manage daily medication needs.

Remedi and its larger competitors can afford to invest in computerized automation technologies; smaller firms rely exclusively on people to sort, package and label medications for their clients.

Bronfein says customers who use Remedi's Paxit system end up saving about 10 percent in drug costs per month.

"We're so much at the beginning of this," said Sue Janeczko, the director of long-term care policy and regulatory affairs at the National Community Pharmacists Association. "It's really exciting, but you have people going off in a lot of different directions just trying to see what will work."

After Bronfein left NeighborCare in the late 1990s, he kept a relatively low profile, working in venture capital with a local firm, which invested in Remedi. He helped Democrats with campaign fundraising and took over the chairmanship of the Baltimore Symphony Orchestra.

As Remedi grew to serve thousands of patients, Bronfein took over, first as chairman and later as CEO — and he led the development of the cutting-edge robotic system.

The business hasn't been without challenges. In 2009, a former employee filed a whistleblower complaint against Remedi, alleging that the company was billing the federal government's Medicaid program for returned medications that were later repackaged and sold to unsuspecting seniors at nursing homes.

Remedi denied the allegations but decided to pay a $1.3 million settlement to the federal government to put the allegations behind it, Bronfein said. The company didn't lose a single customer, and he blamed the case on a disgruntled employee, he said.

"It was cheaper to pay a settlement than prove your innocence," Bronfein said.

Under the Paxit system, the company doesn't deal with returned medications, as medications are delivered to residents as they need them, leading to little waste, according to Bronfein. On the traditional side of Remedi's business, any returned pharmaceuticals are disposed through a licensed medical waste contractor, he said.

Expansion

These days, Bronfein is ready to pitch the Paxit system to more potential clients. He said the robotic dispensing system can save each nursing home's staff significant time in distributing the medications to their patients, because the plastic pouches are easier to organize.

He's also finding that the facilities are spending 8 percent to 15 percent less on medications. Errors, though rare, are spotted immediately by the machine and automatically corrected, Bronfein said.

Besides complying with Medicaid and federal guidelines, Remedi also has to follow a panoply of state laws. Bronfein said the company has researched state pharmacy board regulations across the country, and concluded that 22 states — including Maryland -— are "friendly" to robotic and automation technology.

Anna Jeffers, the Maryland Board of Pharmacy's legislation regulations manager, said the state regulates Remedi and has guidelines for guiding pharmaceutical services companies who use centralized, decentralized and remote technology systems for dispensing medications.

"There are some positive things with technology," said Jeffers. "We are open to it but they have to comply with the regulations."

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