Abstract:
The present disclosure is directed to a tool that can be used to order, dispense, locate, request and administer medications as well as locate, issue and administer medical items and supplies for patients from a plurality of entry points into the system, e.g. handheld devices, mobile cart, etc. New workflows and functionality for various devices such as dispensing devices (automated dispensing cabinets) and issuing devices (e.g. open shelving) are also disclosed. Because of the rules governing abstracts, this abstract should not be used to construe the claims.

Description:
[0001]    The present invention is a continuation application of U.S. application Ser. No. 10/996,835, filed on Nov. 24, 2004, which claims priority from U.S. application Ser. No. 60/525,396 filed Nov. 26, 2003, and entitled Integrated Suite of Medical Tools, each of which is hereby incorporated by reference in its entirety. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    The present disclosure is related to computer operated devices for controlling the ordering, dispensing, issuing and administration of medical items including drugs and supplies for patients. 
         [0003]    There currently exists a number of devices that may be used in a healthcare setting for controlling the ordering, dispensing, and administration of medical items, including drugs and supplies, under the control of a computer. Performing such functions under the control of a computer allows data to be gathered that can be used for billing, reordering of stock as well as creating an audit trail. Such devices include, for example, imaging devices for inputting new prescriptions or new orders for patients into a central pharmacy system, computer controlled dispensing cabinets, hand held scanners that can be used for bedside administration of drugs, and open bins of supplies having a local computer into which information relating to the issuing of supplies for patients can be logged. Such devices can be purchased from a variety of vendors. 
         [0004]    Some devices, such as the handheld bedside scanners, require a substantial investment in infrastructure which may create a bather in the sales process. In U.S. patent application Ser. No. 09/998,121 filed Nov. 30, 2001 and entitled Method Of Issuing Medical Supplies And Dispensing and Administering Medications Through A Hand-Held Device And System For Doing The Same, which is hereby incorporated by reference, the assignee of the present invention has proposed integrating into their handheld bedside scanner the ability to issue medical supplies from open bin storage shelving. However, the investment in such infrastructure is not currently being fully leveraged to provide advantages for other devices used by nurses such as the imaging devices and computer controlled cabinets. 
         [0005]    From the user&#39;s point of view, integrating into one device the ability to dispense medications, issue supplies, and administer dispensed medications seems convenient, but the underlying infrastructure and rules applicable to each of these processes makes integration difficult. For example, medications are typically dispensed by a pharmacy. The pharmacy may be set up using a centralized dispensing model, decentralized dispensing model, or a combination of the two. In each of the three models, various combinations of automated (e.g. unit based dispensing cabinets), partially automated (e.g. carousels), or manual (e.g. open shelving) equipment may be used. As medications are dispensed, counts must be maintained to insure that the pharmacy does not run out of the needed medications. Counts may be maintained automatically in computer controlled devices, manually, or a combination of both. Provision must also be made to accommodate returned medications that have been dispensed for a patient but have not been administered, e.g. the patient has been discharged, prescription has been changed, etc. 
         [0006]    The pharmacy must also be capable of interaction with other systems. For example, the pharmacy is responsible for communicating with insurance companies or clearing houses to determine if a patient&#39;s insurance allows for substitution and, if so, what are the allowable substitutes, as well as to determine what the patient&#39;s insurance will pay for. The pharmacy system must interface with the healthcare facility&#39;s billing system and systems for reordering medications. 
         [0007]    As might be expected, the pharmacy is governed by various rules. For example, in all cases, except certain emergency situations, medications dispensed for a patient must be reviewed by a pharmacist. Rules may be in place that require each prescribed medication to be cross-checked for interactions with other medications ordered for the patient and to be checked against known patient allergies. The pharmacy may also be responsible for tracking the age and lot numbers of medications to insure that expired medications and recalled medications are quickly removed from the distribution chain. When one considers that a pharmacy must perform all these functions and follow all these rules for perhaps thousands or even tens of thousand of prescriptions a day, it is easy to understand that the operation of a pharmacy has become a complicated and specialized process. 
         [0008]    In addition to dispensing drugs for administering to a patient, a nurse or other healthcare worker may also need to have supplies issued for a patient. Supplies are typically controlled by a materials management department within a healthcare facility. Supplies typically are not regulated as are medications and therefore materials management departments often do not need to follow the same strict rules that are applicable to pharmacies. Nevertheless, the materials management department must be able to keep track of current inventories to insure that all needed supplies are on hand. That can be a daunting task for several reasons. First, there may be thousands of items in inventory. For each item, that item may be available from various suppliers at different prices with each supplier using its own unique stock number. Also, supplies are often kept in open bins or shelving. When items are removed, it is up to the user to remember to document the items&#39; removal. Often times, such documentation is not performed, and items can be low or out of stock without the materials management department learning of such situations until a manual count is performed. The materials management department must interact with the healthcare facility&#39;s billing system and supplier&#39;s systems for reordering supplies. 
         [0009]    The nursing function is one way that the healthcare facility interacts with patients. Nurses dispense medications for patients, either from a centralized or decentralized pharmacy. Nurses also issue supplies for patients. It can be time consuming to dispense all the necessary medications and issue all the necessary supplies for each patient on the current round for that nurse as medications and supplies are not kept in the same storage locations, and both medications and supplies may not be where they are supposed to be located. Also the procedures for dispensing medications are different than the procedures for issuing supplies. For example, the procedure for dispensing a medication from a unit based cabinet is very different from the procedure for issuing a supply from open bins. Finally, the administering of medications to a patient is strictly governed by rules, whereas the delivery of supplies to a patient is not. The administration of medications must insure that the right patient, receives the right dose of the right drug, via the right route, at the right time. The administration process must also be documented to create an audit trial. Thus, in addition to tending to the needs of patients, a nurse must be aware of a variety of different dispensing and administering schemes for drugs as well as issuing and delivery schemes for supplies. 
         [0010]    Nursing has identified certain problems in dispensing schemes utilizing computer controlled dispensing cabinets. One problem is nurses taking central pharmacy dispensed medications from a patient specific cassette for another patient that is assigned to another nurse. In such situations, medications cannot be found where they are expected to be. Another problem is that nurses waste time waiting in lines at computer controlled dispensing cabinets at peak times. It would save significant time if nurses could either get all their medications in one place or if they knew exactly where to go to get the medications they needed. Existing infrastructure could also be leveraged if additional functionality could be added to devices currently being used for other functions. 
       BRIEF SUMMARY OF THE INVENTION 
       [0011]    The present disclosure is directed to an integrated suite of tools for controlling the ordering, dispensing, issuing and administration of medical items including drugs and supplies for patients from a plurality of entry points into the system, e.g. handheld devices, mobile cart, etc. New workflows and functionality for various devices such as dispensing devices (automated dispensing cabinets) and issuing devices (e.g. open shelving) are also disclosed. 
         [0012]    One embodiment of the present disclosure is directed to a system having an automated medication dispensing device. A computer located remotely of the automated dispensing device communicates with the dispensing device, or a database that maintains an inventory of items located within the dispensing device, and sends a queue of dispensing orders to the dispensing device. An authentication device confirms when the user is located proximate to the dispensing device. The dispensing device is responsive to the authentication device for performing the queued dispensing orders. 
         [0013]    Another embodiment of the present disclosure is directed to a system having a medication dispensing system and a computer located remotely of the dispensing system for communicating with the medication dispensing system, or a database that maintains an inventory of items located within the dispensing system, to identify a location within the medication dispensing system where items to be dispensed are located. 
         [0014]    Another embodiment of the present disclosure is directed to a method comprising: inputting logon information into a system via a remote computer; creating via the remote computer a list of medications to dispense; verifying that an authorized user is located proximate to a dispensing device; transmitting the list of medications to the dispensing device; and dispensing the medications on the list. 
         [0015]    Another embodiment of the present disclosure is directed to a method comprising: inputting logon information into a system via a remote computer; maintaining in a database an inventory of items located within a dispensing device; communicating with the database via the remote computer to build a list of medications to be dispensed; verifying that an authorized user is located proximate to the dispensing device; transmitting the list of medications to the dispensing device; and dispensing the medications on the list. 
         [0016]    Another embodiment of the present disclosure is directed to a method comprising: inputting logon information into a system via a remote computer; and identifying via the remote computer a location within a medication dispensing system where items to be dispensed are located. 
         [0017]    Another embodiment of the present disclosure is directed to a method comprising: inputting logon information into a system via a remote computer, maintaining in a database an inventory of items located within a dispensing system; and communicating with the database via the remote computer to identify a location within the medication dispensing system where a medication to be dispensed is located. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0018]    For the present disclosure to be easily understood and readily practiced, the present disclosure will now be described, for purposes of illustration and not limitation, in conjunction with the following figures, wherein: 
           [0019]      FIG. 1  is a diagram illustrating the use of a handheld device to control the operation of a variety of different devices; 
           [0020]      FIG. 2  illustrates a flow of data between a handheld device, an application server, a central server, a distributed dispensing cabinet, pharmacy automation, and prescription input devices; 
           [0021]      FIG. 3  is an overview of an exemplary workflow embodying the principles of the instant disclosure; 
           [0022]      FIGS. 4A and 4B  illustrate a workflow for building a list of medications to dispense and a document dispense workflow, respectively; 
           [0023]      FIGS. 4C ,  4 D, and  4 E are exemplary screen shots of information that can be illustrated at various points in the workflow of  FIGS. 4A and 4B ; 
           [0024]      FIGS. 5A ,  5 B and  5 C illustrate a workflow for generating and handling requests for missing medications; 
           [0025]      FIGS. 6A-6F  illustrate a workflow for collecting and dispensing medications; 
           [0026]      FIG. 7  illustrates a workflow for issuing supplies; 
           [0027]      FIG. 8  illustrates a workflow for administering medications and issuing supplies; 
           [0028]      FIG. 9  illustrates a workflow for handling waste medications; and 
           [0029]      FIG. 10  illustrates an alternative workflow to the workflow illustrated in  FIG. 6A  in the event that a cart is available. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0030]      FIG. 1  illustrates a handheld device  10 . The handheld device  10  may be embodied in a variety of platforms including personal computers, tablet personal computers, PDA&#39;s, and the like. One type of handheld device  10  is a commercially available device such as the AdminRx handheld device available from McKesson Automation Inc. Such handheld devices are typically programmed to operate as wireless medication scanners used at the point of care to verify and chart medication administrations while providing a legible, real time medication administration record as shown by box  12 . By scanning the medication, patient identification, and nurse identification, such handheld devices help to prevent life-threatening and costly medication errors by confirming the right patient, right medication, right dose, right time and right route. 
         [0031]    Vendors of handheld device  10  now offer CCD barcode scanners that support imaging. That will allow a nurse to use a handheld device to scan an image of a doctor&#39;s written prescription, or new order for a patient, and submit it for input to the pharmacy system as illustrated by the box  14 . The equipment represented by box  14  could also be, for example, a MedDirect product available from McKesson Automation Inc. 
         [0032]    With appropriate programming of handheld device  10 , a nurse could walk into a supply storage area with handheld device  10  and scan a barcode that identifies a particular storage location. For example, if open shelving  16  is provided, the nurse could scan a barcode, such as barcode  18 . The nurse could then use the handheld to begin scanning supply products to be issued for a chosen patient. Multiple nurses could work in an open supply area at the same time. Also, supply areas would not necessarily need a nurse workstation any longer, such as workstation  20 . If workstation  20  is eliminated, the replenishment function may be added to the handheld device  10 . Although the supply storage area illustrated in  FIG. 1  shows open shelving  16 , other types of storage may be provided such as, for example, towers, whether locked or unlocked, carousels, and the like. If the supply storage area is locked, the user would use the handheld device  10  to unlock the storage device. 
         [0033]    In the upper left hand corner of  FIG. 1  a dispensing cabinet  22 , auxiliary cabinet  24 , and lockable tower  26  are illustrated. By providing nurses with functionality on the handheld device  10  to later control dispensing from a dispensing device, it is possible to guide them to either the patient cassette and/or cabinet/tower/etc. to find their medications the first time. As a result, nurses would be less likely to borrow medications from another patient&#39;s cassette if they are steered to where they are certain they can find the medication. Nurses could also use the handheld device  10  to request medications be sent up stat from a central pharmacy. Nurses could also significantly reduce their time in front of a cabinet by logging on to the handheld device  10 , selecting one or more patients, and selecting the medications to be dispensed for each of the selected patients. Thereafter, when they step up to the dispensing cabinet  22 , they can transfer the information about the selected patient and the medications to be dispensed to the cabinet by any suitable means. For example, the handheld device  10  may be docked in cradle  28  or the information may be wirelessly transferred to the cabinet  22 . Thus, when the nurse has access to the cabinet, the nurse can immediately begin dispensing for patients instead of beginning the patient dispensing process by selecting patients and medications from touch screen  30 . 
         [0034]    The handheld device  10  could be replaced by a computer on a mobile cart (not shown). Other computers, located remotely of the dispensing devices such as shelving  16  and cabinet  24 , may be used to provide certain of the functionality illustrated in  FIG. 1 . For example, a computer at a nursing station could be used to scan new prescriptions and provide the functionality of box  14  as well as construct a queue of dispensing orders to be transmitted to the cabinet  22 . Clearly, if the remote computer is not mobile, it cannot be taken into a storage room where supplies are kept or to the patient&#39;s bedside. Thus, it is not necessary that all of the functions illustrated in  FIG. 1  be present in any particular device or system. 
         [0035]    By providing additional functionality, handheld devices  10  could become personal devices, assigned to and registered to a caregiver at the start of a shift. Alerts, messaging, and voice communications could then be added to the device. 
         [0036]    Various dataflows and workflows will now be described for purposes of illustrating the disclosure. The concepts disclosed herein are not to be limited to the illustrated dataflows and workflows. 
         [0037]    Turning now to  FIG. 2 , a flow of data for one particular architecture is shown for purposes of illustration and not limitation. Data flows between the handheld device  10  and a central server  34  through an application server  36 . The handheld device  10  may obtain order status from the central server  34 . The handheld device  10  may create override orders or send missing medication requests to the central server  34 . A central database  42  may reside on the central server  34 . The central database  42  may be a Connect-Rx database available from McKesson Automation Systems, Inc., although other database products may be used. The location of the central database  42  will depend upon the functionality to be provided by the various components such that the location of the central database  42  is not important in the context of the present invention. 
         [0038]    In  FIG. 2 , communication between the handheld device  10  and the dispensing cabinet  22  through the application server  36  is also illustrated. Resident on the dispensing cabinet  22  or associated therewith, is a local database  44 . Data in the form of a list of medications to be dispensed is sent to the local database  44  and information regarding the availability of the medications is sent from the database  44  to the handheld device  10 . A login procedure may also be executed between the handheld device  10  and the cabinet  22 . The dispensing cabinet  22  is also capable of creating override orders which are input to the local database  44 . The dispensing cabinet  22  is just one component of a dispensing system which may include, for example, auxiliary cabinet  24 , tower  26 , a virtual cabinet  47 , a patient cassette  48 , open shelving (not shown in  FIG. 2 ), a medication storage room (not shown), among others. 
         [0039]    A replication function  46  may provide override orders from the local database  44  to the central database  42 , as well as to insure that the information on the two databases is consistent. 
         [0040]    Missing medication requests may be sent to automation equipment  38  such as the McKesson Robot-Rx automation device and the McKesson MedCarousel automation device from the central database  42 . 
         [0041]    The central database  42  is also in communication with a McKesson MedDirect order entry system  40  or other prescription input device and a printer (not shown) to create medication orders, missing medication notifications and override order notifications. The reader should understand that the dataflow illustrated in  FIG. 2  is exemplary only and that other dataflows may be implemented depending upon the capabilities of the various equipment comprising the system. 
         [0042]      FIG. 3  is an overview of an exemplary workflow embodying the principles of the instant disclosure. In  FIG. 3 , a login procedure is carried out at  50 . The login procedure may be the normal login procedure used on a remote computer such as the Admin-Rx device. Thereafter, at  52 , the user may select a patient through any convenient manner, i.e., pick list, manually entered, scanning a bar code, etc. The user may then view the patient&#39;s ordered medications and may choose those medications to be dispensed so that they may be later administered to the patient. 
         [0043]    After the patient is selected at  52 , a due list is viewed at  54 . The due list indicates all of the medications which that healthcare worker is to administer in the next medical administration round (MAR). Thereafter, an inquiry  56  determines whether Connect-Rn is enabled. Connect-Rn refers to a software module that embodies the principles of the present invention. It is anticipated that in facilities currently using the Admin-Rx device  10  as well as McKesson dispensing cabinets  22 , that Connect-Rn will be a software module that can be purchased to enable the data flows discussed above in conjunction with  FIG. 2 . If Connect-Rn is not enabled, then process flow continues with a process  58 . Process  58  represents the collect and dispense medication process which is described in greater detail in  FIGS. 6A-6F . After the medications have been collected and dispensed through process  58 , an inquiry  60  determines if there are more Admin-Rx tasks for this patient. If the answer is yes, then other features available on the Admin-Rx device are used at  62 . For example, a process  64  may be carried out in which supplies may be issued in accordance with the work flow illustrated in  FIG. 7 . After the other features have been used, or if there are no more Admin-Rx tasks for this patient, an inquiry  66  is made as to whether there are more patients to view. If that determination is affirmative, process flow returns to  52 . If there are no more patients to view, then the healthcare worker may proceed to administer the medications and supplies according to the workflow illustrated in  FIG. 8 , represented by box  68  in  FIG. 3 . Thereafter, the healthcare worker may logout at  70 . 
         [0044]    Returning to the inquiry  56 , if Connect-Rn is enabled, then the user is given the option  72  of creating a dispense list. If a dispense list is to be created, the dispense list may be built according to the workflow illustrated in  FIGS. 4A and 4B , represented by the box  74  in  FIG. 3 . Thereafter, or if the dispense list is not to be built, process flow continues with the inquiry  76 . Inquiry  76  determines if any of the medications is missing. If medications are missing, a procedure for generating and processing a missing medication request may be performed as shown in  FIGS. 5A-5C , represented by box  78  in  FIG. 3 . Thereafter, or if no medications are missing, process flow continues with process  58 . 
         [0045]    Process  58 , as mentioned above, is implemented by the workflow illustrated in  FIG. 6A-6F  in which medications are collected and dispensed. An inquiry  80  is made to determine if it was possible to collect all of the medications. If all the medications were successfully collected, process flow continues with the inquiry  60 . However, if all of the medications were not successfully collected, an inquiry  82  is made as to whether Connect-Rn is enabled. If yes, a request for missing medications can be performed as represented by the process  78 . If not, medications need to be requested in another manner, such as calling the pharmacy. Thereafter, process flow continues with the inquiry  60 . 
         [0046]      FIGS. 4A and 4B  illustrate a workflow for building a list of medications to dispense and a document dispense workflow, respectively. In  FIG. 4A , the process begins at  90  in which medications and their locations are displayed. An exemplary screen shot is illustrated in  FIG. 4C  which illustrates one technique for displaying a medication together with its location. After the medications and their locations are displayed, an inquiry  92  determines if any medications have been previously dispensed but not yet administered. If answered in the affirmative, at  94  the drug and the person who dispensed the drug are illustrated. Thereafter, or if no medications were previously dispensed but not administered, process flow continues at  96 . At  96 , medications residing in a dispensing cabinet such as the AccuDose dispensing cabinet  22  may be selected. As seen from  FIG. 4C , various medications are shown as being available in cabinet station: 1. Those medications may be selected to build a dispense list. 
         [0047]    Thereafter, an inquiry  98 , is made as to whether the selected medications should be saved as a dispense list. If the inquiry is answered in the affirmative, then the dispense list is saved at  100  to the central database ( 42  in  FIG. 2 ) or, if answered in the negative, the dispense list is discarded at  102 . From both  100  and  102 , process flow continues at inquiry  104  which is an inquiry regarding whether to select non-due medications. If that determination is answered in the affirmative, a display of non-due medications is provided at  106 . An exemplary display is illustrated in  FIG. 4D . From  106 , process flow continues with an inquiry  108  which determines whether to add the selections to the dispense list. If that inquiry is answered in the affirmative, the selections are added at  110  to the dispense list on the central database or, if answered in the negative, the selections listed are discarded at  112 . From either  110  or  112 , the dispense list created may be displayed at  114 . An exemplary dispense list is illustrated is  FIG. 4E . As seen from  FIG. 4E , a variety of medications are available in patient specific cassettes, certain medications are available at a dispensing cabinet, while the location of other medications is unknown. After the list has been displayed, or from the “no” branch of inquiry  104 , an inquiry  116  is made as to whether more medications are to be selected. If yes, process flow returns to  96 . If no, process flow continues with the document dispense work flow illustrated in detail in  FIG. 4B , represented by box  118  in  FIG. 4A . Thereafter, the process terminates at  120 . 
         [0048]    Continuing with  FIG. 4B , the process begins with an inquiry  124  in which a determination is made if Connect-Rn is enabled. If Connect-Rn is not enabled, then preparation of the dispense documents cannot be performed at this time and the process ends at  140 . If Connect-Rn is enabled, process flow continues with inquiry  126  in which a determination is made as to whether the ordering physician is known. If the ordering physician is not known, the ordering physician is determined and entered at  128 . Thereafter, or if the ordering physician was known, an inquiry  130  is made as to whether this is an override order. If it is determined that this is not an override order, then process flow terminates at  140 . If this is an override order, then an inquiry  132  is made as to whether an override witness is required. If yes, the witness is recorded at  134 . After the witness is recorded, or if no witness is necessary, an inquiry  136  is made as to whether an override reason is required. If an override reason is required, the override reason is entered at  138 . Thereafter, or if no reason is required, process flow ends at  140 . The reader desiring more information about override situations is directed to U.S. Pat. No. 6,650,964 entitled Medication Dispensing Apparatus Override Check And Communication System and U.S. Pat. No. 6,671,579 entitled Override Having Built In Audit Trail For Medication Dispensing And Administering Systems, both of which are hereby incorporated by reference in their entireties. 
         [0049]    Returning briefly to  FIG. 3 , process  74  builds the dispense list as described in conjunction with the workflows of  FIGS. 4A and 4B . After the dispense list is built, the inquiry  76  determines whether any of the medications are missing. If medications are missing, the request for a missing medication can be made and that request filled as will now be described in conjunction with  FIGS. 5A-5C . In  FIG. 5A , an inquiry  144  is made whether the ordered medication for a patient is found in the unit. If it is, process flow continues with inquiry  146  which determines whether additional medications are to be found. If not, the process ends at  148 . If more medications are to be found, process flow continues by returning to inquiry  144 . 
         [0050]    At inquiry  144 , if it is determined that the ordered medications are not found in the unit, another inquiry  150  determines whether Connect-Rn is enabled. If Connect-Rn is enabled, then the drug and quantity may be selected at  152 . An exemplary screen shot  153 , connected to  152  via a broken line, illustrates the information which may be displayed and from which a selection can be made. After a selection is made, the selected drug and quantity is stored as a missing medication request in central database ( 42  in  FIG. 2 ) at  154 . Thereafter, the missing medication request is processed as will be described in conjunction with the process  156  illustrated in detail in  FIG. 5B . The status of the processing of the missing medication request may be displayed at  158 . The display may include an estimated time of arrival. From either  158 , or  150  if that inquiry results in a negative determination, process flow continues with inquiry  146 . 
         [0051]    Turning to  FIG. 5B , the missing medication request is stored in the central database at  160 . Inquiry  162  determines, based on user preferences, available hardware, among others, whether the request should be sent to a printer, some type of pharmacy software, or delivered directly to automation equipment for filling the missing medication request. The phrase Automation equipment refers to automated (e.g. Robot-Rx robot) or semi-automated (e.g. MedCarousel, NarcStation) hardware used for filling a prescription. In the case of delivery of the missing medication request to a printer, a missing medication request is printed at  164 . Printing typically indicates that the request is to be filled in a manner that does not rely upon automation equipment for filing the prescription. In the case of delivering the missing medication request to some type of pharmacy system, that may be accomplished by sending the missing medication request to a MedDirect device. A missing medication icon and information are generated and placed into a missing medication folder at  166 . An alert condition is created at  168 . From either  164  or  168 , an inquiry  170  is made if the request may be forwarded to automation equipment or if a manual pick of the medication is required. If the request may be forwarded onto automation equipment, or directly from inquiry  162 , the request is forwarded to automation equipment which executes a workflow as shown, for example, in  FIG. 5C , represented by box  172  in  FIG. 5B . After the medication has been dispensed at  172 , the medication is then delivered to the floor at step  174 , using any appropriate delivery system, e.g. runner, tube system, cart/cassette from a robot, etc. The incident is archived at  176  and the process ends at  178 . 
         [0052]    Returning to inquiry  170 , if it is determined that the request may not be forwarded to automation equipment, a manual pick is performed at  180 . After the manual pick is performed at  180 , an inquiry  182  is made to determine if the request came from a pharmacy system. If the answer is yes, then the status of the missing medication is updated at  184  in the pharmacy system. For example, the pharmacy system may be notified that the prescription has been filled so its status can be changed to delivered. Thereafter, or if the request did not come from a pharmacy system, process flow continues at  174  with the medication being delivered to the floor in any suitable manner. 
         [0053]    In  FIG. 5C , dispensing of the missing medication through the use of automation equipment is illustrated. A series of inquiries  185 - 188  determines the equipment in which the missing medication may be found. More specifically, inquiries are made as to whether the medication is in a robot  185 , in a carousel  186 , in a NarcStation  187  or in a med shelf or other device  188 . If any of those inquiries is answered in the affirmative, then a dispense is performed from the appropriate device. For example, if the medication is determined at  185  to be in the robot, a dispense from the robot is performed at  190 . If the medication is determined to be in a carousel at  186 , a dispense from the carousel is performed at  191 . If a determination is made at  187  that the medication is in a NarcStation, a dispense from the NarcStation occurs at  192 . If it is determined at  188  that the medication is in a shelf or other location, a dispense from the shelf or other pharmacy automation occurs at  193 . After the dispense  190 - 193 , the status of the missing med request is updated at  194 . The update  194  may be similar to or the same as the update  184  in  FIG. 5B . The process ends at  198 . If it is determined after all of the inquiries  185 - 188  that the medication is not in automation equipment, then the medication is manually picked at  196  and the process ends at  198 . 
         [0054]    Additionally, instead of being determined serially as shown in  FIG. 5C , followed by a filling process, a determination may first be made as to which automation equipment contains the medication, and then logic may be used to determine which automation equipment is best suited to fill the request, e.g. fill the prescription with the device having the oldest stock, the device having the least amount of stock, etc. 
         [0055]    Although not shown in  FIGS. 5A-5C , it is possible the missing medication request may be denied for a variety of reasons, e.g. out of stock, medication not approved for patient, etc. Under such circumstances, a message may be sent to the user indicating that the request has been denied or cannot be fulfilled. 
         [0056]    Not shown in  FIGS. 5A-5C  are additional inquiries that may be incorporated into the workflow. For example, an inquiry can be made to determine if the requested missing medication is in the next cart fill. If yes, an inquiry can be made to determine if the cart fill delivery will be timely. If delivery is timely, the missing medication request need not be filled again. If the medication is not in a cart being delivered, or if it is in a cart being delivered, but delivery will not be timely, an inquiry can be made to determine if a cabinet refill is pending. If yes, and the refill is timely, it is not necessary to fill the missing medication request. 
         [0057]    In  FIG. 6A , an exemplary workflow  232  for collecting and dispensing of medications is illustrated. The workflow  232  of  FIG. 6A  begins at inquiry  200  in which a determination is made as to whether Connect-Rn is enabled. If it is enabled, another determination is made at inquiry  202  as to whether the medications are identified as being in a cassette. If that inquiry is answered in the affirmative, or if it is determined at inquiry  200  that Connect-Rn is not enabled, the user needs to walk to the cassette as illustrated by  204 . At  206  the user determines which medications to dispense from the cassette. At  208  medications which are to be dispensed, and which are actually present in the cassette, are dispensed. It should be noted that some medications may be identified at  202  as being in the cassette, but not actually in the cassette due to various problems. 
         [0058]    After the medications are dispensed at  208 , inquiry  210  determines if Connect-Rn is enabled. If Connect-Rn is enabled, then the list of medications is updated at  212  to remove any medications on the list (indicating that they are present in the cassette), but not actually present in the cassette, and to decrement the count for medications that have been removed. Thereafter, process flow continues with inquiry  214 . If, at  210 , Connect-Rn is not disabled, process flow continues with inquiry  214 . 
         [0059]    At inquiry  214 , a determination is made whether the medications are in a dispensing cabinet, such as the AccuDose-Rx cabinet. If not, the collection of medication ends at  216 . If, however, the inquiry at  214  is in the affirmative, then a procedure  218  for collecting medications from the cabinet is performed, as shown in greater detail in  FIG. 6B . Thereafter, the process ends at  216 . 
         [0060]      FIG. 6B  illustrates an exemplary workflow  218  for collecting medications from an automated cabinet such as the AccuDose-Rx cabinet. The process begins with a login procedure  220  to the cabinet. The login procedure  220  is shown in greater detail in  FIG. 6C . After the login procedure  220 , a patient is selected by a process  222  discussed in greater detail hereinbelow in conjunction with  FIG. 6D . After a patient has been selected by process  222 , a determination is made at inquiry  224  if there are items in that patient&#39;s dispense list. If that determination is answered in the affirmative, then the selected patient&#39;s dispensed list is displayed at  226 . Thereafter, at  228 , medications are selected to be dispensed. The dispense list for an AccuDose-Rx cabinet is made up of all medications selected for the current patient regardless of how the medications were selected, e.g. from a Connect-Rn dispense list, an AccuDose-Rx profile, an AccuDose-Rx override list, an AccuDose-Rx inventory list, among others. 
         [0061]    The dispensing cabinet may then perform pre-dispense tasks as represented by the box  232  and as described in greater detail in conjunction with  FIG. 6E  hereinbelow. The medications are dispensed according to a process  234  discussed in greater detail in conjunction with  FIG. 6F . After dispensing of the medications, an inquiry  236  determines if there are more medications on the dispense list. If yes, process flow returns to  230 . If not, an inquiry  238  determines if there are more patients for which medications are to be dispensed. If yes, process flow returns to process  222 . If not, the process ends at  240 . 
         [0062]    Returning to the inquiry  224  as to whether there were any items in the patient&#39;s dispense list, if that determination is negative, a subsequent inquiry  242  determines the dispense mode. There are numerous possible dispense modes. In the exemplary workflow illustrated in  6 B, two dispense modes, dispense by profile and dispensed by inventory, are possible. If there is to be a dispense by profile, then the patient&#39;s profile is displayed at  244 . If there is to be a dispense by inventory, then the inventory list is displayed at  246 . From either  244  or  246 , process flow continues with  228  in which medications are selected to dispense. 
         [0063]    Turning to  FIG. 6C , an exemplary login process  220  is illustrated. An inquiry  250  determines whether Connect-Rn is enabled. If yes, the user uses an authentication device to confirm that the user is located proximate to the cabinet. The authentication device may take the form of a bar code which is scanned at  252 . Other types of authenticating devices may be used such as an RF ID tag embedded in the badge of the user, a fingerprint scanning device, or other biometric device, among others. 
         [0064]    After the user confirms that the user is located proximate to the dispensing device, the dispense lists are located on the central server at  254 . All lists created by the user for this cabinet will be transferred at  256 . The user&#39;s ID and PIN number are transferred at  258 . The transfer is preferably a wireless RF transmission, but could be by other means, e.g. physical docking of the hand held device  10  with a docking station (not shown). 
         [0065]    At inquiry  260  a determination is made as to whether an autologin is enabled. If yes, the user is automatically logged in using the user ID and PIN number transferred to the cabinet. It will be seen from the foregoing that if Connect-Rn is found to be enabled at inquiry  250 , and the autologin found to be enabled at inquiry  260 , the user&#39;s logon to the cabinet is seamless and transparent to the user. The user simply scans the bar code at  252 , or operates some other type of authentication device for confirming that the user is at the cabinet, and the user is automatically logged in. Thereafter, the login process ends at  264 . 
         [0066]    If, at inquiry  260 , the autologin is not enabled, the user must enter their PIN at  266  and press a login button, or take some other confirmatory action, at  268 . The process ends at  264 . 
         [0067]    Returning to the inquiry  250 , if Connect-Rn is not enabled, the user must manually login by entering the user&#39;s ID at  270 , entering the user&#39;s PIN at  272 , and pressing a login button at  274 , or taking some other confirmatory action. The login process ends at  264 . 
         [0068]      FIG. 6D  illustrates an exemplary workflow  222  for selecting a patient. At inquiry  280 , a determination is made as to whether Connect-Rn is enabled. If Connect-Rn is not enabled, a list of patients is displayed at  282 . For example, all patients in the user&#39;s, unit&#39;s zone may be displayed. At  284  a patient is selected from the list, e.g. the zone list, among others. The process ends at  286 . 
         [0069]    Returning to the inquiry  280 , if Connect-Rn is enabled, a determination is made regarding the number of patients for which dispense lists have been created. If the number is zero, the process continues at  282  by displaying a list of all the available patients. If only one patient has a list, that patient is automatically selected at  290  and the process terminates at  286 . If there is more than one patient with a list, the list of patients with dispense lists is displayed at  292 . At  294  the user selects a patient from the dispense list and the process ends at  286 . 
         [0070]    In  FIG. 6E , an exemplary workflow  232  for the document dispense process is illustrated. Beginning at inquiry  300  a determination is made if a dispense witness is required. If a dispense witness is required, the dispense witness information is entered at  302 . Thereafter, or if no dispense witness is required, a determination is made at  304  if Connect-Rn is enabled. If yes, then the document dispense workflow has already been completed as discussed in conjunction with  FIG. 4B  and the process ends at  306 . If Connect-Rn is not enabled, then the various inquiries, i.e. is the ordering physician needed  126 , is this an override order  130 , etc. are made as discussed above in conjunction with  FIG. 4B . When completed, the process ends at  306 . 
         [0071]    The process  234  for dispensing medications is illustrated in  FIG. 6F . The process for dispensing medications  234  begins with an inquiry regarding whether Connect-Rn is enabled. If not, the dispense quantity is automatically populated with zero at  422 , and if enabled, the dispense quantity is automatically populated based upon the administration dose at  424 . From either  422  or  424 , the user specifies or adjusts the quantity to dispense at  426 . The cabinet drawer and pocket are opened at  428 . At  430  the medications are removed from the pocket and a count is made of the medications remaining in the pocket at  432 . The count may be used to update inventory records. The pocket and drawer are then closed at  434 . 
         [0072]    An inquiry  436  determines whether Connect-Rn is enabled. If not, a waste medication process  438  can be performed as discussed in detail in conjunction with  FIG. 9 . If Connect-Rn is not enabled, or after the waste medication process  438  is performed, the process ends at  440 . 
         [0073]    Returning briefly to  FIG. 3 , it is seen that process  64  is a process for issuing supplies, which is described in detail in conjunction with  FIG. 7 . It should be noted, however, that the workflow for issuing supplies  64  need not be performed in the sequence illustrated in  FIG. 3 . For example, the issue supplies procedure  64  could be performed before the collection of medications procedure  58  or may be performed after the medications have been administered according to the process  68 . Furthermore, the issue supplies procedure  64  could be performed in a manner such that supplies are issued prior to the dispensing of medications. Thus, the issue supplies procedure  64  may be viewed as a stand alone procedure, the performance of which is unrelated to the creation of the list of medications to be dispensed, location of the medications to be dispensed, collection of the medications to be administered as well as the administration of the medications. 
         [0074]      FIG. 7A  illustrates an exemplary workflow  64  for issuing supplies. The workflow begins when the user goes to a supply location as represented by  320 . Thereafter, supplies are collected at  322 . At inquiry  324  a determination is made if Connect-Rn is enabled. If yes, at inquiry  326  a determination is made if the user is at the default supply location. If the user is at the default supply location, then the supplies are scanned at  328  and the process ends at  330 . Alternatively, if the user is not at the default supply location, then the supply location is entered at  332  and process flow continues with the scanning of the supplies at  328 . The supply location may be entered in a variety of ways such as scanning a bar code, automatically reading an RF ID tag, among others. 
         [0075]    If, at inquiry  324 , it is determined that Connect-Rn is not enabled, the user will be required to login to a supply issuing system, such as the Supply Scan system available from McKesson. After logging on through the supply issuing system&#39;s computer (See  20 ,  FIG. 1 ), a patient is selected at  336  and the supply scanned at  328 . The process can be repeated for additional patients. 
         [0076]    Another process for issuing supplies is illustrated in  FIG. 7B . The process illustrated in  FIG. 7B  assumes that Connect-Rn is available. After the user has gone to a supply location, the process begins at inquiry  340  where a determination is made as to the issuing mode. The issuing mode may be select by bed  342 , patient  344 , or by mapping charges to a unit  346 . If the select bed  342  mode is chosen, charges are mapped at  348  to the current patient in the selected bed. From either  348 ,  344  or  346  process flow continues with an inquiry  350  to determine if the supply is in a closed area. If yes, inquiry  352  determines if the doors are open. If they are not, the location bar code is scanned at  354  and all location doors are open at  356 . After the doors are open at  356 , or it is determined at  352  that the doors are already open, or if the supply is not in a closed area, process flow continues at  358 . At  358  the supply is scanned. At  360 , the supply count is decremented by one and the user picks up the supply at  362 . Inquiry  364  determines if more of the same supply is needed. If yes, process flow returns to  358 . If not, process flow continues with inquiry  366  which determines if supplies are needed which are not in this location. If the answer is yes, an inquiry  368  determines if anyone else is logged in and, if not, all doors are closed at  372 . After the doors are closed at  372 , or if it is determined that others are logged in at  368 , other locations the user is authorized to access are displayed at  374 . An inquiry  378  determines if the supply is in one of these other locations. If yes, process flow continues with the inquiry  350 . If no, process flow continues with  380  in which a supply request is sent to materials management. Feedback is displayed to the user at  382  and process flow continues with enquiry  384  which determines if the user is done issuing supplies. If yes, the procedure ends at  386  and, if not, the procedure continues by returning to inquiry  340 . 
         [0077]    Returning to the inquiry  366 , if it is determined that the user does not need supplies in another location, process flow may continue with the inquiry  384 . If desired, the determination as to whether anyone else is logged in and, if not, closing all the doors may be performed between the inquiry  366  and the inquiry  384 . 
         [0078]    Returning briefly to  FIG. 3 , the process  68  for administration of medications and supplies is shown in greater detail in  FIG. 8 .  FIG. 8  begins with the user going to the patient at  390 . The administration is validated at  392  using procedures appropriate to that healthcare institution. Thereafter, the administration is charted at  394 . 
         [0079]    At inquiry  396 , a determination is made as to whether Connect-Rn is enabled. If not, process flow ends at  398 . If Connect-Rn is enabled, process flow continues with the waste medication procedure  438  shown in detail in  FIG. 9 . Process flow ends at  398 . 
         [0080]    The workflow for the waste medication procedure  438  illustrated in  FIG. 9  begins with an inquiry  402  to determine if a medication is to be wasted. A waste situation can arise due to a number of different factors. For example, a patient may be prescribed a  250  milligram dose, but the medication is provided in a  500  milligram tablet. Under such circumstances, the tablet is broken in half, with one half being administered to the patient and the other half wasted. Should such a situation occur, the medication is wasted at step  404  according to whatever procedures may be applicable for that medication. At  406  the waste amount is entered. 
         [0081]    At inquiry  408 , a determination is made as to whether a reason for the waste is required. If yes, the reason for the waste is entered at  410 . Thereafter, or if no waste reason is required, process flow continues with inquiry  412  in which a determination is made as to whether the waste method must be documented. If yes, the waste method is documented at  414 . Thereafter, or if no waste method documentation is required, the process ends at  416 . 
         [0082]    Returning to  FIG. 3 , process  58  is for collecting and dispensing medications as discussed more fully in conjunction with  FIG. 6A . In  FIG. 6A , it is assumed that the nurse or healthcare worker is gathering medications and placing the medications in their pocket or perhaps into some type of container. The present invention contemplates the use of a mobile cart. In the event that a mobile cart is available to the nurse or healthcare worker the workflow of  FIG. 10  may be implemented in place of the workflow of  FIG. 6A . 
         [0083]    In  FIG. 10 , the workflow begins at  450  by moving the cart to the patient specific cassettes. An inquiry  452  determines whether any of the cassettes are for patients for which the nurse is to administer medications. If that inquiry is answered in the affirmative, the nurse scans the cassette bar code  454  and scans all medications in the patient specific cassette at  456 . By scanning all the medications in the patient specific cassette, the nurse is counting the number of doses of each medication and associating those doses with the patient. When the scanning is done, the quantity of medications in each cassette will be accurately documented. The cassette is then loaded into the cart at  458  and workflow returns to the inquiry  452  to determine if there are any additional cassettes for this nurse. If not, process flow continues with  460  where the cart is locked. An inquiry is made at  462  to determine if Connect-Rn is enabled. If not, the nurse proceeds to the cabinet as shown by  464 . If Connect-Rn is enabled, a determination is made at  466  if medications are in a dispensing cabinet. If yes, the nurse proceeds to the cabinet and either from inquiry  466  or step  464 , the nurse unlocks the cart at  468 . The nurse then performs the process  218  of collecting medications which has previously been described in connection with  FIG. 6B . After the process  218  of  FIG. 6B  is completed an inquiry is made at  470  to determine if there are medications to load. If the nurse went directly to the cabinet without Connect-Rn being enabled, it is possible that there were no medications in the cabinet to be dispensed and thus the determination  470  is needed. If medications have been dispensed as a result of process  218 , the nurse scans the cassette at  472  and then loads the medication into the cassette at  474 . Medication quantities dispensed as a result of process  218  are thus automatically added to the cassette&#39;s medication counts. After all the medications have been loaded, or if no medications were in the cabinet as determined by inquiry  466 , the cart is locked at  476  and the workflow for collecting medications ends. 
         [0084]    It should be noted that patient cassettes typically contain a day&#39;s worth of medications for a patient while dispenses from a cabinet are usually the next due medications. Thus, the dispense from the cabinet may need to be adjusted if the healthcare worker wishes to have a full day&#39;s worth of medications for patient&#39;s on that healthcare worker&#39;s rounds. 
         [0085]    The present invention provides additional functionality for nurses as set forth in the figures. The present invention also adds greater value to the wireless infrastructure investment. By integrating the functionality set forth in  FIG. 1  in a handheld device  10 , mobile cart, or other portable device, an integrated suite of tools can be provided which allows the nurse to perform his or her duties in a seamless manner regardless of the duty or location in which it is performed. For example, new prescriptions and new orders may be scanned and input to a pharmacy system as soon as they are written by a physician. Nursing time is saved in that nurses can either obtain all their medications in one place or be directed to where the medications needed for a particular patient are located. With certainty in obtaining the medications at the indicated locations, it is less likely that nurses will “borrow” medications from other patient cassettes. A nurse can “pre-pick” patients and medications on the handheld device  10  so that time spent at a dispensing cabinet can be spent dispensing medications, rather than picking patients and medications. Additionally, the nurse can take the same handheld device  10  into a storage area and select medical supplies for a patient. Thereafter, the same handheld device  10  can be taken to a patient&#39;s bedside for administration of the dispensed medications and supplies.