Florida Authorizes Use of Automated Dispensing Systems

For years, the state of Florida has authorized the use of automated pharmacy dispensing systems to provide medication to patients residing in hospice settings, long-term care facilities, and prisons.

To improve medication access in other outpatient settings, Governor Ron DeSantis recently signed legislation into law that gives community pharmacies authorization to use these systems.¹ Automated dispensing has the potential to alleviate the access-related issues of a high prescription-volume location, as well as in rural areas that may not have community pharmacies nearby.

Like mail-order pharmacies, automated dispensing is designed to increase the convenience of acquiring prescriptions for medications. Although convenience can maximize pharmacy revenue and is preferred by patients, it is hotly debated whether it is correlated to positive longterm outcomes. By contrast, automated dispensing may significantly contribute to medication nonadherence, which is costly for the health care industry and a significant preventable public health burden.²

Nonadherence is associated with approximately 125,000 deaths, 10%
of hospitalizations, and a cost of up to $289 billion annually.² Promotion of a patient’s medication education and an adherence assessment is often seen as a hallmark role of pharmacists. Unfortunately, this role is typically executed to a minimum in most community pharmacy settings because of the crushing workloads these pharmacists have. This has resulted in pharmacy staff members often resorting to distribution of printed handouts that likely won’t be read by patients or caregivers. Medication therapy management services are done by pharmacists in many pharmacies, but strict performance metrics may inhibit a thorough interview process. Decentralized automated dispensing may set a delicate precedent that further removes pharmacists from their role of adherence assessment and management.

The legislation enacted by the Florida legislature and signed by the governor allows community pharmacies to provide outpatient dispensing through automated pharmacy systems. The Florida Pharmacy Association prepared an information sheet on the proposed legislation, highlighting the changes that will result from the enactment and concerns with the proposal.³

The automated pharmacy system must be under the control of the pharmacy, and there must be a means of communication for the pharmacist to provide consultation to the caregiver or patient. The availability of counseling is required prior to the medication being released by the system to the patient, but there is no mandate that counseling occur.

The pharmacy must notify the board of pharmacy about the location of the automated dispensing system, and that location may differ from the location of the pharmacy on record with the board. No controlled substances may be dispensed using this technological approach, so none may be in the machine. There must be a pharmacist identified as being responsible for verifying the accuracy of the system and its activities, and the automated system must operate in a fashion that ensures confidentiality of personal health information.

The state pharmacy association identified some perceived drawbacks with the proposed legislation. The automated dispensing machine may be located remotely, away from the location of the controlling pharmacy. The association felt that the automated pharmacy system should be within the confines of the pharmacy that has the pharmacy permit issued by the board of pharmacy. The prior law addressing automated dispensing systems authorized their use at facilities where other health care providers were present on the premises; such a requirement was not part of this expansion. In addition, concerns were expressed about the security of staff members engaged in restocking the inventory in the machine, especially if located in remote areas. The legislation also would allow a pharmacist holding a Florida pharmacy license but living out of state to oversee and be responsible for the integrity and operation of the automated pharmacy system.

Rep. Matt Willhite, sponsor of the version of the bill introduced in the Florida House of Representatives, had this to say about the goal of the proposal: “With the passage of this bill, we hope to expand an individual’s access to their prescription medication. These machines will only dispense generic medications. Nonetheless, this technology will make it easier for busy parents and people living in rural communities to safely access the medications that they need.”⁴

Direct integration into the Centers for Medicare & Medicaid Services (CMS) 5-Star Quality Rating System could be the change required to motivate community pharmacies to update their practice models in ways that will meaningfully increase adherence. A general timeline of transitions from quantity-centered to quality-centered care in most health care settings closely coincide with the implementation of CMS’ star system.⁵ With this in mind, it is understandable from a business perspective that pharmacies are almost entirely volume driven because they are not incentivized by the quality-centered, pay-for-performance model.

Recent unrelated legislative developments also provide opportunities to maximize the opportunities of automated dispensing. As several states implement legislation allowing pharmacists to bill for nondispensing services, it is reasonable to hope that reduced strain on a team dispensing medication will result in more time and resources to apply to other facets of the pharmacist’s scope of practice.⁶ If automated dispensing increases opportunities for other forms of engagement, such as collaborative care agreements or medication therapy management, there may be a wealth of untapped potential.

D. Kelly Porter is a PharmD candidate at the University of Kentucky College of Pharmacy in Lexington.

Joseph L. Fink III, JD, DSc (Hon), BSPharm, FAPhA, is a professor of pharmacy law and policy and the Kentucky Pharmacists Association Professor of Leadership at the University of Kentucky College of Pharmacy in Lexington.

REFERENCES

1. Rule title: automated pharmacy system - long-term care, hospice, and prison. Florida Administrative Code & Florida Administrative Register. October 29, 2019. Accessed November 26, 2020. https://www.flrules.org/gateway/ruleNo.asp?id=64B16-28.607
2. Zullig LL, Blalock DV, Dougherty S, et al. The new landscape of medication adherence improvement: where population health science meets precision medicine. Patient Prefer Adherence.2018;12:1225-1230. doi:10.2147/PPA.S165404
3. Automated pharmacy systems HB 59. Florida Pharmacy Association. Accessed April 7, 2021. https://cdn.ymaws.com/www.floridapharmacy.org/resource/resmgr/docs_2020_legislative_session/automated_pharmacy_systems_h.pdf
4. Nicol R. Automated pill kiosks now permitted at pharmacies after governor’s signature. Florida Politics. June 30, 2020. Accessed April 7, 2021. https://floridapolitics.com/archives/344940-automated-pill-kiosks-permitted-pharmacies/
5. Medicare 2021 Part C & D Star Ratings Technical Notes. Centers for Medicare & Medicaid Services. Updated October 1, 2020. Accessed August 13, 2021. https://www.cms.gov/files/document/2021technotes20201001.pdf-0
6. Why automated prescription storage and retrieval kiosks matter: watch. Bell Howell blog. May 22, 2020. Accessed April 8, 2021. https://bellhowell.net/automated-prescription-kiosks-matter-series/