(upbeat music) - Welcome to the ASHP official podcast, your guide to issues related to medication use, public health, and the profession of pharmacy. - Thanks for joining us in this episode of Informatics Bites. Brought to you by the ASHP section of Pharmacy Informatics and Technology, these podcasts cover hot topics in pharmacy innovation. By the end, you will know things about health system pharmacy, drone delivery that you don't know now. My name is Tristan Edwards, and my team includes Billy Starnes, Audrey Rutolo, and Suluama Fa-a-Yuasso. Joining us today to share atrium health, Wake Forest Baptists experience using drone delivery is Beth Williams, system director of pharmacy, ambulatory services, and population health. We'll talk about their drone delivery use cases, medication use process implications, pharmacy roles, and challenges encountered along the way, which we hope others can learn from. Beth, thanks for joining us today. Let's get started. - Thank you, Tristan. It's great to be here with you and your team. - So Beth, how did you guys get started with drone delivery at Atrium Health? - Yeah, it was really an innovation partnership opportunity that began between Atrium Health Wake Forest Baptist and UPS Flight Forward in 2019, with a shared desire to develop a proof of concept for a more efficient future state delivery model. Atrium Health Wake Forest Baptist is, of course, an academic medical center located in the heart of the Piedmont Triad of North Carolina. And not only do we have a rich culture of learning, research, and development, as you might expect. We've also made a commitment to direct application and clinical practice. We have an innovation quarter in Winston-Salem that facilitates these types of industry partnerships and collaborations, primarily focused in biotech for the purpose of translation to clinical practice and patient care. So just to expand upon that a little further in terms of the problems we were trying to solve, really have a desire to make healthcare more efficient, reduce traditional logistics barriers, and improve turnaround times. And the proof of concept that was used for this purpose was the direct distribution of medications and supplies via drone delivery. But the ultimate vision is really expanding healthcare access and delivery across a broader regional footprint to underserved populations and rural communities in order to close gaps in care. So in terms of our first flight, and that's really what it's called in the industry, I joined the team in April of 2020. And as a reminder, that was shortly after the COVID-19 pandemic began. But our first flight was three months later in July of 2020. And at that time, two routes were established to deliver compounded medications from our main campus to off-campus locations. Interestingly, the COVID-19 pandemic was probably a catalyst that jump-started our entry into this space as a result of the FAA's approval of these routes in a more timely manner. So let me unpack that just a little further. The FAA or Federal Aviation Administration provides regulatory oversight of drone operations and programs in the United States, including the types of medical supplies that can be carried by drones. As you'll recall, the COVID-19 public health emergency extended flexibilities and certain allowances for various waivers to increase access to care. And one of these waiver opportunities extended by the FAA was in the use of unmanned aircraft systems or AUSs. That's the technical name for drone platforms. So UPS Flight Forward, our partner in this regard, submitted waivers for FAA approval to establish these first two routes and test various use cases for the delivery of medications and supplies. Guess it's an example of the silver lining in the COVID-19 pandemic cloud, if you will. But my role as a pharmacy leader and liaison on the project team was really to serve as the clinical lead for the application of drones and the transportation of pharmaceuticals and PPE, which really included process design, implementation and management, creation of standard operating procedures, et cetera. But the really fun part is my role in the opportunity just to contribute to the strategic vision for UAS operations in the Wake Forest Baptist Market, including opportunities for expansion, use cases and locations. Tristan, I will say before we go on, I'd like to share with listeners that the pharmacy's use of drone delivery of medications at Atrium Health Wake Forest Baptist currently is paused as a result of some of the limitations and challenges we've encountered and learned along the way. But I'm still a very big proponent of this technology and hope to be able to revisit our use of the technology for delivery of medications within the near future. I also think it's a tremendous opportunity for our profession and professionals who have interest in innovation and technology, especially for our colleagues who might be in the first half of their career and are likely to not only have the opportunity to contribute to design and defining use of this system, but really see it become more scalable and a primary aspect of medication delivery in our country. - Yeah, Beth, it's super interesting that you described the COVID-19 pandemic as a catalyst as opposed to a barrier for the introduction of drone delivery, what an innovation. - Yeah, yeah, it really did facilitate and jumpstart are getting started with pursuing approval from the FAA and leading up to that first flight in an expeditious manner. - So Beth, can you dig a little deeper for our listeners here? And can we talk through some of the use cases that your drone delivery program did go through, like which medication orders were in scope and other to bits you wanna share with us? - Yes, absolutely, thank you Audrey. So there are three primary use cases that I want to share with the audience. I already shared that in July of 2020, two routes were established to deliver compounded medications from our main campus to off-campus locations. Within visual line of sight, I want to highlight this visual line of sight or V-loss as it is commonly referred to. This is where drone operators literally have to be able to visualize the delivery from its origin point to its delivery point. But we were, on one of the routes, transporting scheduled infusion medications to an infusion clinic. These were high cost specialty infusions that pharmacy doesn't prepare until the patient has arrived. Some examples include Ben Lista or Rensia, Simponi or Actemra. The other route that was established transported on demand, so not scheduled, but on-demand PPE and non-sterile compounded medications, such as oral liquids and topicals to an off-site or off-campus retail pharmacy. And then six months later, in December 2020, we added a use case outside of pharmacy, but it's important to mention nonetheless of transporting lab specimens. So thank blood and urine samples from collection sites at the two existing routes to main campus where they would be processed. And then finally, in August of 2021, just a little over one year after our first flight, we conducted a flight transporting COVID-19 vaccine, was actually the first in the United States to transport COVID vaccine via drone delivery. And the use case really was transporting the vaccine to a high volume family medicine clinic where vaccine clinics were being held and open to the public. While that use case or the flight was successful, it really turned out to be a proof of concept flight. It was great in concept, but very challenging in practice because of all of the supplies that must accompany the vaccine. - If you could walk us through how you would know certain orders were going through the drone delivery process, how you set that up with your staff and the whole med use process, that would be great. - Yes. First, let me say that drone technology simply replaces the delivery of product from point A to point B that's probably occurring via some form of ground transportation. So the medication use process that we think about as pharmacists, right? From procurement, ordering verification, preparation and dispensing, administration and monitoring, it's not affected or changed in any way by this technology. Instead of being picked up by a ground courier, a pharmacy technician is taking the final product packaged in what's called a payload box to the drone launch pad. Now, I will say in terms of any potential technologies or operation to integrate into the medication use process, I have a couple of thoughts about that that I'd like to share. First, we did get some initial experience with an in-flight tracking tool or dashboard that UPS flight forward developed to schedule and track flights. But because the system exists outside of our routine workflow and is not integrated with our EHR where, as you know, in these days we spend all of our time, it was challenging to use and access without disrupting the workflow of the clinical team. Currently, there's no interoperability or integration between the drone delivery system and the electronic health record. As you know or could imagine that would require some kind of field in the EHR that would tag or indicate that an order should be or will be delivered by a drone, it would certainly be a nice feature to have, but it doesn't exist today. A couple of other future features that don't exist today but would certainly be nice is barcode scanning to confirm that the correct product is being loaded in the payload box, in the drone, and then received on the other end as well as virtual temperature tracking to monitor for temperature excursions when drugs need to be maintained in a certain temperature range. This is a topic that's pretty near and dear to my heart as I'll talk a little bit about later on. Those are the primary, I guess that's my technology wish list, if you will. Today, 100% manual, no integration or interoperability but certainly could see or envision some degree of integration in the future. - So Beth, we would like to know a little more about the pharmacy rules involved in this process. Were there any created or any rules that already existed when implementing the drone delivery? - Yes, well, first let me share, drone operators are licensed pilots that can fly large jets. If any of you in the audience are picturing pharmacy technicians remotely controlling these unmanned aircrafts, that's not happening. I suppose it could if the pharmacy technician happens to be a licensed pilot, probably a bit of a stretch there. Maybe not for the future, but certainly current state. So all of that to say the current role of the pharmacy professional in drone delivery operations is focused on three things, scheduling flights or the delivery of medications, packaging medications in the payload box consistent with manufacturer storage requirements and transporting the payload box by foot to the drone launch pad. So as you can imagine there's quite a bit of communication and collaboration between pharmacy teammates and the drone operator or pilot, which primarily occurs via phone in day-to-day operations. I sure wish it could occur via some type of in basket message, but right now today happens by good old fashioned mobile phones. And the other thing that I think I just want to take opportunity to highlight here is really these drone operators or pilots act or serve as an extension of our pharmacy team in order to ensure that the medication is delivered to the right location, to the right patient at the right time. So it really is as I indicated an important collaboration opportunity. Speaking of collaboration early on we worked closely with the UPS light forward operators to ensure safe and efficient handoff of the payloads. We identified and addressed opportunities to improve the workflow and handoff procedures. And we established direct communication channels for notification of delays and cancellations, albeit not via in basket messages. There were a couple of areas where we needed to work together on some staff training, education, and standard operating procedures. And the most significant of those were encountered in the packaging of the COVID-19 vaccine. And I want to really highlight a couple of the lessons learned from that experience. You'll recall that our first flight of the COVID-19 vaccine was in August of 2021. Well, August in North Carolina is very hot, very humid, not conditions suitable for vaccine storage, especially not Pfizer vaccine storage. So we had to do some temperature validation studies to determine the best packaging solution to maintain appropriate temperature in the payload box and subsequently create an SOP to ensure a standardized packaging process was followed by all of those who touched that part of the operation. In addition, the min-max temperature thermometer that accompanied the vaccine in the payload box contains an alkaline battery, which surprise is a hazardous material. Well, this, of course, required FAA approval to transport the hazardous material via drone. And as a result, anyone handling the thermometer, either packing or unpacking the payload box, or I should say the vaccine from the payload box, had to complete hazmat training. Well, that's not standard among pharmacy technicians or other pharmacy personalities, also not standard among pilots. That presented another type of challenge that we had to work around and accommodate in terms of our training, education, and SOPs. And hence my earlier comments about the challenges of delivering COVID-19 vaccine via drone grading concept, not so easy to accomplish in practice right now. - So Beth, you kind of already led down an topic that I was gonna ask about in terms of lessons learned. But were there any other challenges or barriers that you encountered along the way? Is there something that you know now that you wish you had known back in 2019 when you started on this? - Absolutely. I have a list primarily because there wasn't a playbook for drone delivery of medications in 2019, 2020. A couple of primary challenges that I'd like to highlight are those situations that we in pharmacy cannot control, but they ultimately create delivery delays. They are things like inclement weather, such as moderate rain, moderate wind or icy conditions that will ground the drone. In addition, there are air risk mitigation situations with other aircraft such as our medevac helicopters that are very common in academic medical center settings. They're coming and going from the medical center. I do think we've been more purposefully conservative in this regard due to the emergent need and safety of those in the helicopter, but an incoming or outgoing helicopter will delay scheduled drone deliveries by up to 15 minutes. So these situations, whether it be other aircraft or inclement weather require strategies to mitigate delays and avoid negative impact on things, such as infusion chair time and ultimately patient experience. Generally, we will revert to ground transportation if the delay is expected to be more than 10 minutes. I also wanted to point out or share a couple of limitations that we've discovered. So I've already alluded to the fact that flight paths require approval by the FAA. So they're fixed, right? I can't just add a new route today, even if it's within visual line of sight of the drone operators. In addition, the current payload capacity is limited to four pounds. That's one, two, three, four pounds. The size of the payload box is quite small. It is nine by six by five inches. So think of a child's shoe box. So in other words, we're really limited by the size or quantity of items that can be transported by drone today. I think about risk. And this is really safe technology. In the three years that the drone program, well, nearly four years that the drone program has been operational at Atrium Health Wake Forest Baptist. There have been no incidents, accidents, or adverse effects. Of course, I did allude to earlier that we might be taking a more purposefully conservative approach in our flight operations. But I would say that the primary risk might be more related to delays in care and patient experience, not with the operation itself. In terms of lessons learned, I would say to our colleagues out there that drone delivery in the healthcare setting is much more complex than one may think. Certainly more complex than I originally thought. I've already covered a couple of highlights here, but I'll just summarize some key takeaways. This area is highly regulated by the FAA. There are a number of restrictions that have to be planned for. There are, of course, limitations with regard to the aircraft and current payload capability. The impact of weather and shared airspace is real and the need to have a backup plan for deliveries is crucial. There are seasonal temperature needs that will require validation and potentially SOPs. In order to ensure good high quality plans, effective communications required between all of those involved, the drone operators or pilots, the clinical teams, the medevac or emergency communications crew. One thing that I've been reflecting on lately is the need for the launch site to be located in an area that's easily accessible for the clinical teams, just to expand upon that a little bit more. I've also been thinking about some future operations. I've had the opportunity to contribute to the design of future facilities, and I'm making sure that we're identifying space, appropriate space for drone operations. And that could require some not just space, but funds as well. Beth, this has been great so far, but I know that anytime new technologies are implemented, somebody's gonna wanna know what the return on investment is. Is there objective ways to measure success that you guys have any key performance indicators to sort of help you determine or help justify what you were doing in the drone program? - Yeah, great question. And you're exactly right. This was a proof of concept for a new approach to the delivery of supplies and medications. I think for pharmacy, the value add in situations, especially where patients are waiting, the value add is in longer distances from the point of origin. I'm not convinced that there's a return on investment when the location is a short distance away from the point of origin, but need to study that certainly further. I will share a couple of other things that I'd categorize as successes. At this point, we provided a platform to help UPS flight forward drive new and improve FAA regulations for drone delivery in healthcare, such as carrying hazardous materials, establishing beyond visual line of sight or BV loss routes. BV loss is up to eight miles and over high speed traffic areas. And this is the space that we'll be expanding into within the near future. We would also call a success, the contribution of experience and feedback on preferred technology to support our vision and use cases. And I'd point to our temperature validation, experience as well as flight scheduling and tracking feedback. Outside of pharmacy, there are specific outcomes that we've seen in the lab space with carrying lab specimens, specifically compared to the ground career model, the time from sample collection to results reported was reduced by over one hour with drone transportation. And that was still within those original two within visual line of sight routes. So really encouraged by what that could mean for other routes for a more scalable model. - So Beth, in short, before we wrap up, in a better world, a few years from now, where do you think drone delivery might have the best value or the most value? - A few years from now, hopefully we will have the ability to travel longer routes or distances of up to even 20 to 50 miles. We'll hopefully have the ability to carry greater capacities in terms of both size and weight. The next iteration of drone technology is expected to carry up to 40 pounds, four, zero pounds. I am also anticipating greater reliability in inclement weather and shared airspace situations, as well as improved flight scheduling and logistics coordination, including that kind of technology intra-operability wish list that we talked about earlier on. But when I dream about future use cases for drone delivery technology, I'm thinking about rural deliveries to reach underserved communities. We are seeing pharmacy deserts pop up all over our country with single community pharmacies closing in different communities. And I think this could be a tool to deliver care that's equitable, efficient and reliable. I am envisioning direct to home deliveries of home infusion medications and supplies. Direct to home delivery of medications and supplies for virtual visits or home-based care to keep patients out of the hospital, potentially even small devices that could be used for home-based testing and monitoring where currently today, the patient has to figure out a way to come to us. Outside of pharmacy, I think there are potential use cases in other areas too, not just blood and blood products or lab specimens, but also things like food and community outreach, things that are maybe a little proximal to pharmacy practice, but are critical to keeping people healthy. I'm really excited about the future. I'm excited about this innovation and technology and what it can mean to extending the reach of not just pharmacy practice and the services that we provide, but improving access to healthcare and all of our communities. - That's awesome. Well, Beth, it's been great fun being here with you today. It's fascinating to hear what you folks are doing at Atrium Health, and I'm looking forward to hearing about future developments in your drone program. For our podcast listeners, I encourage you to check out ASHP's Informatics Resource Center, where you can find member exclusive offerings, including articles, standards and guidelines, and helpful practice tools for pharmacy informatics and healthcare technology-related topics. Be sure to follow ASHP official on podcast platforms for more episodes and informatics sites from the section of pharmacy informatics and technology. - Thank you for listening to ASHP official, the voice of pharmacists advancing healthcare. 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