Miles Bennett, DO, was always frustrated when a toddler with an excruciating ear infection was brought to the emergency department at midnight and couldn’t be sent home with antibiotics in hand.

“Even though I am in a large suburb with the city only minutes away, there are not any nearby 24-hour pharmacies,” Dr. Bennett said. “Patients would have to drive long distances to get their meds or else go home and wake up the next day to go back to the pharmacy.”

The process of obtaining medications was not just inconvenient for patients or their guardians; in some cases, it would also prolong their pain and discomfort. Sometimes the medications were never picked up.

Two years ago, Dr. Bennett, now chief medical officer at AdventHealth in Winter Garden, Fla., had a conversation with his director of pharmacy, Oscar Santalo, PharmD, about how they might fix the problem. Having outpatient pharmacies open 24 hours a day, seven days a week would be cost-prohibitive, but having a medication-dispensing kiosk in the ED might do the trick.

A Starting Point

The kiosk program started with one kiosk at his facility at AdventHealth Millenia ER, just outside of Orlando, Fla. There is now another at

AdventHealth Winter Garden, Fla. This program spares the patient a drive to an outside pharmacy, and any interaction with a pharmacy or a medication-dispensing kiosk. Medications in the kiosk are accessed for the patient by a health care worker. The patient receives the filled prescriptions at discharge and can go straight home.

So far, about 5,000 prescriptions have been dispensed from these two locations, and AdventHealth plans to expand the program to six more sites in the next six months. The machines can hold up to 800 bottles of medications at a time, and they offer up to 176 prescriptions made from up to 78 medications. A formulary determined by a committee made up of emergency physicians, pharmacists, and nursing staff determines which medications are dispensed.

“It is a data-driven decision based on what staff [are] using,” Dr. Santalo said. “I presented the top 100 fast-moving prescriptions, which helped us to standardize what’s in the kiosks.”

“Oscar keeps a close eye on things and is able to adjust on the fly during flu season, for example,” added Dr. Bennett. Florida law prohibits medication kiosks from dispensing controlled substances.

What’s the Cost?

As for prices, Dr. Bennett said they are competitive for self-pay, which is mostly the case for their patients, many of whom are tourists in the Orlando area. For over-the-counter items, Dr. Bennett and Dr. Santalo looked on Amazon.com and walked the shelves at Walmart stores to be sure their pricing was competitive.

“Patients have little to no copay on the medications, which are all relatively inexpensive. There are no chronic or high-cost medications in the kiosk,” Dr. Santalo said. “The price is determined by the cost of meds, plus the fees and labor. That’s how we’re breaking even. There’s no markup like with a regular pharmacy.”

The initiative began with research to confirm the rate at which patients were actually driving those long distances in the middle of the night (or otherwise) to pick up their prescriptions written in the ED. They found that there was a 30 percent prescription abandonment rate. Additionally, it turns out that when patients don’t pick up their medications, they frequently end up back at the ED; some are admitted to the hospital.

“The kiosks are preventing prescription abandonment by 30 percent, there’s a five percent reduction in ED revisits for kiosk patients versus opted out patients, and overall, ED revisits in 72 hours and 30 days are trending downward with the ability to use prescription drug insurance, which we started in June,” Dr. Bennett said. “We’re also seeing a significant impact on ED revisits resulting in admissions, with a five to seven percent reduction.”

Barriers to Implementation

There were some barriers to implementation at first because of the culture shift. “When you open a pharmacy, it’s solely that pharmacy’s responsibility to get the prescriptions,” Dr. Santalo said. “Whereas with the kiosk, the pharmacy’s work is done remotely.”

Additionally, there was also a bit of extra work for nursing staff as they facilitated delivery of the medications, as well as for physicians who had to change the specific ways in which they write prescriptions. “It was a culture shift, but ultimately everyone bought in because this has a positive impact on the patient, their care, and our community,” Dr. Bennett said.

Most uplifting of all for Dr. Santalo was that when he and Dr. Bennett presented the project proposal to AdventHealth’s finance leadership, they saw value in it and felt it made sense, even if they would not make money on it. “That makes me know I’m working for the right organization and that we are mission-driven,” Dr. Santalo said.

Renée Bacher is a freelance medical writer located in Baton Rouge, La. She is a frequent contributor to Wiley medical trade publications including ENTtoday, ACEP Now, and The Rheumatologist.