Flash showing methods of medication scheduling for patients, including traditional plastic pill boxes, pill boxes with alarms, digital pill boxes, pill organizers, medication blister packs, medication alerts via pager, Palm PDA devices, and modern Blackberry and Smartphone medication scheduling systems.

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November 2013
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10 Ways to Remember to Take Your Meds

Here is another way to “keep it routine” so it’s easier to remember to take your medications.

If your prescription says: “Take 1 tablet at bedtime.” When do you take it? Just before you turn the light out? What if you change your bed time? What if you stay up very late one night? Is very late still “bed time” ?

If your actual bedtime is variable, those “bedtime” doses can be a real challenge and can cause many missed doses.

The actual relationship with “going to bed” is not critical. Doctors may write “take at bedtime” to be sure it’s the last dose of the day and it probably will be taken on an empty stomach so it won’t interact with food. Here again, it’s better to set a specific time for those doses late in the evening (say 10PM) and take them routinely – around the same time every night – regardless of when you actually put your head on your pillow.

Irregular eating habits are another challenge. If your prescription says: “take with meals”, skipping meals may cause you to miss doses, too. That’s not good for you. Routine mealtimes are always better, but you can set a reminder to have a supplement drink and take your drugs with that, if it’s uncertain when you’ll have time to sit down to a meal.

Many diet plans require several small meals per day to avoid getting that “hungry” feeling. These plans usually get the best weight loss results. It’s easy to set reminders to eat something or drink a supplement routinely throughout the day, and stay on your diet or on your medication schedule.

There hasn’t always been easy and convenient reminder technology like OnCellRx. Now that some of us are becoming independent via such technologies, it is a good idea to clarify some of the medication prescriptions so we can properly follow the Doctor’s orders.

Getting Older is Getting More Expensive for America

The State of Aging and Health in America 2007

A report out of the Centers for Disease ControlThe State of Aging and Health in America 2007” says that the aging of America is getting more expensive for America.

The cost of caring for aging Americans will add 25 percent to the nation’s health care bill by 2030 unless people act now to stay healthy, the U.S. Centers for Disease Control and Prevention said Thursday (MSNBC http://www.msnbc.msn.com/id/17518459/).

From the Executive Summary of The State of Aging and Health in America 2007:

The United States population is rapidly aging. By 2030, the number of Americans aged 65 and older will more than double to 71 million older Americans, comprising roughly 20 percent of the U.S. population. In some states, fully a quarter of the population will be aged 65 and older. An enhanced focus on promoting and preserving the health of older adults is essential if we are to effectively address the health and economic challenges of an aging society. The cost of providing health care for an older American is three to five times greater than the cost for someone younger than 65. By 2030, the nation’s health care spending is projected to increase by 25% due to demographic shifts unless improving and preserving the health of older adults is more actively addressed.

The State of Aging and Health in America 2007 report presents the most current national data available on 15 key health indicators for older adults related to health status, health behaviors, preventive care and screening, and injuries. The “State-by-State Report Card” provides similar information for each of the 50 states and the District of Columbia, and enables states to see where they are on each indicator as well as in relation to other states.

According to MSNBC coverage, an advisor to the CDC on this report confirms that “prevention is the key” to controlling healthcare costs:

“We are going to see an increase in health care costs, but the goal has to be to restrain the rate of increase. Prevention is the key to that,” said Bill Benson, a health care benefits and policy analyst who advised the CDC on the report.

If prevention is the key, then shouldn’t we see prevention as a priority for government spending and legislation? Well, some states are already acting on this. According to TwinCities.com:

Minnesota employers accepted a challenge from the nation’s top health care executive Thursday to drive down costs by giving workers better information so they can make wiser medical choices.
The pledge occurred the same day state lawmakers announced a sweeping health reform proposal that includes a mandate that all Minnesotans have health insurance.

The common thread is the idea that individuals can control the runaway costs of the nation’s health care system if they are well-informed consumers who have access to medical care through insurance. “Competition works. It works in health care”, said Michael Leavitt, secretary of U.S. Health and Human Services, during his visit to Minneapolis. “When people have information about quality and cost, it drives quality up and costs down.”

Empower the health consumer and increase access to information. What about patient adherence and medication compliance specifically?

See related posts:

My favorite non-compliant patient story

At one time I was working in a pharmacy in Gainesville, Florida, and have to mention one favorite experience I had with a patient who wanted his last antibiotic refilled. It had been filled 2 weeks prior, so it was a good bet that he had stopped it too soon. When I asked if he had taken all of them for the full 7 days, he sheepishly said he hadn’t because he felt fine after 4 or 5 days. He didn’t see the point.

So I proceeded to explain how that had allowed the remaining bugs to have enough “baby bugs” to make him sick all over again. I then (with a smile, of course!) made him promise to take them ALL this time! …or else he’d have to answer to me again!

He said, “Wow! I’ve been chewed out by some tough refs, but I’m not messin’ with you. I’ll take this like a man!” When he left, the pharmacy clerk asked me if I knew who I had just chewed out. I said no, and looked at the name on the prescription – R. Maris. She said that was Roger Maris, the famous baseball player!

He actually came in again a couple of weeks later and proudly told me he had taken all of his pills, and thanked me for taking the time to explain why it was important. How cool was that?!

Side note: From the Roger Maris fan web site:

Roger and teammate Mickey Mantle entertained baseball fans throughout the summer of ’61 as the two New York Yankee sluggers chased the record many called the most cherished in all of sports. Mickey dropped out of the home run race early due to an illness, but finished with a career high 54 home runs. Roger tied Ruth on September 26, hitting his 60th home run. He then hit his 61st home run on the final day of the season, October 1, 1961, against the Boston Red Sox to set a new record. The Yankees won the game, 1 to 0, and later went on to win the World Series.

See that? Roger beat Mickey mantle in a race to break Babe Ruth’s record, and he did it by staying healthy!

Doctors Paid More if they Talk to their Patients

Effective January 1, 2007, the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services, will increase the reimbursement paid to physicians for the time they spend talking with Medicare patients, evaluating their health, and advising them on preventative care measures. According to a recent statement from CMS, “The hallmark of this rule is a stronger emphasis on the physician-patient relationship.”

That’s great news! Based on the old idea that prevention is worth more than a cure. Can we influence the doctors prescribing medications to spend some of that talk time discussing compliance, and how patients can manage the often complex and cumbersome medication schedules? Convenience technologies like OnCellRx and OnTimeRx are very low cost and work with existing cell phones and personal devices, yet patients need to be introduced to them.

Here’s another idea. A medication reminder service like OnCellRx.com would cost less than 25 cents per day for a patient taking an expensive once-a-day cholesterol control tablet. That’s a fraction of the cost of the pill. Could Big Pharma find a way to bring the OnCellRx technology to the patients to help ensure the medication is taken so it can be effective? Sounds to me like a great idea. What do you think?

ref: http://biz.yahoo.com/prnews/061206/sfw011.html?.v=82

Medication Mistakes Common and Costly for Older Adults

When the doctors followed Medicare patients for a year, they witnessed 129 adverse events caused by patient errors. In half of those cases, the patient error was made after a doctor had changed the medication schedule, medication, or dosage. Also, patients taking 4 or more drugs were twice as likely to make mistakes. Patients on 7 or more medications were 3 times as likely to make mistakes. Among the most common underlying causes for patient error? Confusion, and sensory problems.

One common observation: when a new drug replaced an old drug, patients would take the new drug but at the old prescribed amount. This could and sometimes did have serious medical consequences.

What we can learn from this:

    • Medication compliance is important
    • Patient errors are costly, and more costly as we get older
    • Patient compliance depends on cognitive factors! Safety is not just about the drugs!

We can do better! :

    • Use mental reminders and medication reminder systems like OnCellRx to keep things on track and prevent us from making mistakes
    • We need more attention paid to the process of prescribing and re-prescribing medications, to prevent PATIENT errors

It seems to me, if we can see what the problem is, we should be able to fix it:

“Patients taking 4 or more drugs were twice as likely to make mistakes; patients on 7 or more drugs were three times as likely to make mistakes”

Patients with these conditions and multiple medications require special attention to help manage the more complex schedules.  Why aren’t they getting the help they need?

“The most common underlying cause for patient error? Dementia, confusion, and sensory problems.”

Why can’t patients with these conditions and multiple medications get special attention to help manage the more complex schedules?

Baby Boomers and their peers are more and more tech-savvy these days, with cell phones and organizers and smart phones. It’s so easy to add a medication manager system to a personal organizer, and even easier to sign on to a web-based medication reminder system that sends automated alerts to an ordinary cell phone.

It’s great to see more research findings, but it would be even better to see more action taken based on the findings. Big pharma. has the most to gain, and the most resources to make a positive difference.  When are they going to step up to the plate and provide real compliance tools so everyone benefits?

Source:  A Reuters report on Yahoo about a study in the Journal of the American Geriatrics Society, February 2007

From the abstract :

OBJECTIVES: To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors. DESIGN: A subanalysis within a cohort study of Medicare enrollees. SETTING: A large multispecialty group practice. PARTICIPANTS: Thirty thousand Medicare enrollees followed over a 12-month period. MEASUREMENTS: Primary outcomes were ADEs, defined as injuries due to a medication, and potential ADEs, defined as medication errors with the potential to cause an injury. The subset of these events that were related to patient errors was identified. RESULTS: The majority of patient errors leading to adverse events (n=129) occurred in administering the medication (31.8%), modifying the medication regimen (41.9%), or not following clinical advice about medication use (21.7%). Patient-related errors most often involved hypoglycemic medications (28.7%), cardiovascular medications (21.7%), anticoagulants (18.6%), or diuretics (10.1%). Patients with medication errors did not differ from a comparison group in age or sex but were taking more regularly scheduled medications (compared with 0-2 medications, odds ratio (OR) for 3-4 medications=2.0, 95% confidence interval (CI)=0.9-4.2; OR for 5-6 medications=3.1, 95% CI=1.5-7.0; OR for >/=7 medications=3.3, 95% CI=1.5-7.0).

Microsoft Windows VISTA: for “Mature Audiences”

With the launch of Windows Vista in Las Vegas last month, Microsoft has begun a series of focus groups in preparation for the launch of a selection of Seniors PC Offerings in the near future.

AmeliaPlex, Incorporated is pleased to announce that OnTimeRxR for Windows has been selected by Microsoft to be included in their latest Generation-Specific Product SKU’s. The first AARP focus group was convened in Seattle with some very interesting results. All participants agreed that they would have liked to start using PCs sooner than they did, because they see the benefits of life-long learning experiences. The preference for a desktop or a laptop computer was evenly divided and it mainly depended on space available.

Since most seniors are intensely interested in all matters relating to healthcare, being able to surf the web for health information, drug prices, and other resources is a big plus. With OnTimeRx available on these Generation-Specific computers, seniors will be able to easily maintain a personal health history, manage simple or complicated drug regimens, set reminders for doctor appointments, exercise schedules, and much more. OnTimeRxR for Windows is a desktop program that “Works with Windows Vista” and interfaces with both Palm and Pocket PC hand held computers.

Professionally and philosophically, I love the idea of a simple-to-use computer pre-loaded with “Generation-Specific software” for many reasons. My background comes from 18 years as Pharmacy Director in a wonderful 400 bed long term care facility. My passion is helping all patients manage their own care so they can stay healthy enough to remain independent and age in place, hopefully making nursing homes a thing of the past.

As people age or mature, their circle of friends may begin to diminish and they can become increasingly disconnected, as their world shrinks dramatically. This is especially true if they no longer drive or have no means of transportation. An internet-enabled computer can change all of that and actually expand one’s horizons. Being able to stay connected with family and friends through email and chat, being able to communicate with like-minded friends and support groups all around the world via the Web, means they can remain at home and enjoy many new activities—even some which were never possible before. That’s exciting!

Now seniors have access to our OnTimeRx medication management software for Palm, Blackberry, Smart Phones, PDAs and of course a Windows VISTA integrated medication manager system, as part of a Senior PC program supported by the major computer and computer software distributors. More details will follow regarding availability of these “senior PCs” from HP, the technical services from the Geek Squad.

Related Links:

Where are the Compliance Tools?

Every major health related website talks about Compliance, because compliance it is a well-documented waster of healthcare dollars. In my opinion, those sites could and should be doing so much more. 

None of the major disease-specific sites I checked offer effective or useful compliance tools. – other than the usual list of some general ways to remember to take your pills:  “Take your pills with meals, put the bottle by your bedside, etc.” I’m guessing the reporters, writers and editors behind the sites don’t have to take medications, and don’t understand how huge the problem really is. 

Some very effective compliance tools exist, but most patients don’t know about them, don’t realize that they need them,  and/or don’t know where to look for them. The major health web pages represent an opportunity to educate, yet compliance is missing from the message. I’m going to look closely at Health Tools On The Web, and see just how badly we need to bring some awareness of compliance tools to these editors and web masters. I’ll start with American Heart Association, American Stroke Association, and the American Diabetes Association.


Dropping Statins shown to Raise Heart Attack Risk

A few days ago I posted about how Doctors are to be paid extra for taking time to talk with their patients, and I suggested that Big Pharma would be wise to help bring independent living technologies like OnCellRx.com to their customers, so patients would be better able to actually benefit from the expensive medications they are buying. At a mere $0.50 per day (or less!) a service like OnCellRx seems like an excellent value-add for an expensive life-saving pill.

Now we see a report with hard data supporting my suggestion:

LONDON (Reuters) – Worldwide thousands of people taking cholesterol-lowering statin drugs are suffering unnecessary heart attacks because they are not complying with the recommended treatment, Dutch researchers said on Thursday. The researchers estimate up to 9,000 European and 7,000 American statin users have heart attacks that are avoidable.

According to the research:

“Getting users to stay on statins and to use them persistently saves lives, and doctors must get over to patients the message that complying with treatment is essential,” Dr Fernie Penning-van Beest, of the PHARMO Institute in Utrecht, said in a statement

In the study, half of the 60,000 statin medication patients stopped taking their medications during the two year test period. They weren’t supposed to; they failed to remember or skipped or for some reason didn’t follow the medication schedule. And the patients who fully complied with the prescriptions, taking the drugs at the proper times routinely? A 30 percent reduction in hospital admissions for heart attacks compared to that non-compliant group. A separate study had already estimated that every year up to 400 statin medication patients in the Netherlands suffered avoidable heart attacks.

So people are buying expensive medications that help prevent heart attacks, but for some reason a large number of them are failing to take their drugs properly, and suffering avoidable heart attacks. We know why. They need to be reminded. We want to remind them. We want to bring them OncellRx.

But we need help from pharmaceutical companies, doctors, pharmacists, family members, and everyone else who can see the benefits and help get OnCellRx.com working for the patients who need it. Is that you?

FAME Compliance Study: Federal study of Adherence to Medications in the Elderly

Dr. Rick Lange, Professor of Medicine at Johns Hopkins Medical Center presents a podcast(mp3) which mentions the blister pack compliance study I covered here on December 9th. In that podcast, Dr. Lange calls it the FAME Study, for “Federal study of Adherence to Medications in the Elderly”. Like I did here, Dr. Lange noted the high cost of the preparations done by pharmacists, calling it “a very time-intensive program” and noting that it is “not realistic to think that the pharmacists would have the time to spend 2 hours with every patient“. He also agrees with me about the hard costs: Dr. Lange says that “even putting these things into blister packs was very difficult, because it’s really not an automated way to do it right now“.

But Dr. Lange is optimistic about the outcome, and feels that as a concept study, it demonstrates that with enough patient education and attention, a 95% compliance level is achievable.

I did also learn from Dr. Lange at Johns Hopkins that there was a serious amount of patient edcuation involved in the study, with each patient getting an initial 2 hour consult but also an additional 30 minutes of review every two months. These patients were drilled about the medications, the patients’ conditions, the rationale for those medications, and the possible side effects.

Dr. Lange said that in his field, 50% of cardiovascular admissions are due to non-compliance with the medications.  And I agree, that kind of patient education is vital to increase awareness and understanding about the importance of compliance.  But as I’ve said many times in many venues, education only serves as a basic foundation.  It simply isn’t adequate to be aware without having the tools to handle the day-to-day challenges of remembering to take medications routinely.  Without being provided with some simple, yet practical medication reminder tools in the education process, patients won’t even come close to solving the compliance problem on their own. That understanding has been the key driver for our development of the OnTimeRx and OncellRx Medication Reminder systems. 

Doctors, nurses, and pharmacists are thoroughly educated and fully understand this problem, yet they fall victim to non-compliance – just like everybody else – sometimes even more so.  Everyone needs to be reminded.

Like Dr. Lange, I am also optimistic about the outcome.  We know that with the proper tools, patients can easily achieve 95% compliance level or higher.  A Penn State Family Medicine study is underway and preliminary results show many subjects are reaching 99% compliance. It’s always important to have the right tool for the job.

Do Blister Packs Solve the Medication Compliance Problem?

USA Today recently reported on a study where medication blister packs were used to improve patient compliance. Blister packs are those cards of pills backed with foil that are used by many over the counter cold remedies. In this study the pharmacist tossed aside the normal pill bottles, and combined the patient’s daily medications into one set of custom blister packs. For each dose time, there is a pre-filled collection of medications to swallow. According to the researchers, compliance was much greater than normal; patients did a better job of taking their medications.

As an experienced pharmacist dedicated to the issues of patient adherence and medication compliance, I don’t have any problems with what was reported. However, I have a problem with what was not reported.

Blister packs have been around for years. They’ve mainly been used in nursing homes or similar care settings, but only one drug is packaged and dispensed per card. The multi-pill-per-cup idea reported by USA Today has been tried for many years by pharmacists independently trying to help their patients handle this complex task more easily at home. But there are many issues with the method which were not mentioned in the article. Here are some I am familiar with:

  • Cost: Even though this article implies that blister packs are a cost-effective means of packaging medications, the material cost they cite is only part of the overall cost:

The blister packs were cheap; each cost just 14 cents a month to produce

Wow! Fourteen cents sounds good, but 14 cents just pays for the actual packaging materials. I’ve used these “bingo cards” in my practice as a pharmacist and it takes the pharmacist a lot more time to divvy up an assortment of pills into each of the blister pack cups than it takes to fill pill bottles. This is a labor intensive process. Pharmacist/technician time is money, too. I can’t see how that additional cost could have been counted within that 14 cent accounting. Also, remember that modern pharmacies continue to improve efficiency through automation, and this custom blister pack approach can not be achieved with the same automated, computerized pill counting systems in place at pharmacies today. Someday maybe, but not today.

  • Expert Judgement: One of the real hard issues faced by patients taking multiple medications (often prescribed by different healthcare professionals), arises from the communications disconnect between those prescribing doctors. Often the specific instructions provided by separate doctors for different medications seem to contradict. One may say “take with food” while another is labeled “after meals”. While this may seem to be a trivial conflict to a trained healthcare practitioner (such as a pharmacist deciding how to prepackage those medications into a blister pack), it can stymie a conscientous patient trying her best to adhere to instructions. Again, the pharmacist loading custom blister packs is handling those sometimes complex decisions on behalf of the patient. Again, not included in that $0.14 cost estimate, and neither are the phone consultations a good pharmacist will initiate when truly conflicting instructions are discovered.
  • Errors and Liability: Whenever medication prescriptions are filled, there is a possibility of a filling error. Patient safety is addressed through quality control (check, double check) and it is safe to assume that more complex combinations bring more opportunities for filling errors (even if we don’t recognize that automated pill counters and pill inspection machines are already on the job in many pharmacies). With a custom blister pack, a pill may be left out by mistake, or 2 of the same pills may wind up in the same cup. How can anyone double check, or triple check that? And who shoulders the added responsibility for that additional Quality Control?
  • Flexibility: Not every prescription is a fixed, long-term solution. What happens if a doctor changes the patient’s meds in mid-month? What happens to the pre-packed blister cards that have already been made? Some pharmacies may pick up the unused blister packs and re-use the medications in a new assortment, but legally this is a gray area because the drugs have not been in pharmacist custody the whole time. Can they be safely re-distributed? Even to the same patient? There is also the obvious additional labor of collectng, breaking open, and re-packaging, which must be balanced against the alternative costs of simply throwing the unused drugs in the disposal. Some patients may be able to pick out pills that have been discontinued, or find a way to make it to the next delivery of properly configured blister packs, but, I wonder, will that aid in adherence or hurt it?
  • Safety: Prescribing doctors are not the only health practitioners concerned with drug safety. The intended patients are not the only people who handle these medications. Medications are packaged with disclosure documents describing side effects, hazard labels and even accidental poisoning data in some cases. Poison control technicians and their pharmacist directors have worked very hard to get these materials into the packages and onto the labels. If we “toss aside” the pill bottles and pre-package combinations, where is the documentation? The labeling of custom blister packs can get very complicated in order to comply with state and federal laws, thereby adding an additional layer of confusion to this “simplification” process.
  • Compliance: Packaging is not the only barrier or answer to compliance. Many patients will still need a reminder to take their medications, even if the blister pack does make it easier to adhere to the proper dosing regimen. I can imagine a new crop of questions that need to be answered, such as “I missed one dosage of everything. Do I play catch up and take all of them together, as soon as possible? Should I skip some, but be sure and immediately take others, and if so, which ones?”

Think about this: if the patient forgets to take a pill out of a bottle when it’s time to take a dose, wouldn’t it follow that the same patient might also forget to pop open the blister as well? What tells this person when it’s TIME to take a medication out of any container? Do they rely on some internal clock or daily routine to remind them? Do they set an alarm clock or use some other alerting device?

This system of blister packs certainly can help some patients, but I don’t think it is a universal compliance “answer”.

Finally, according to the report:

“Your grandmother isn’t going to take her pills if she doesn’t know why the doctor gave them to her”, says Allen Taylor

I’ve known plenty of conscientious patients who take a variety of pills routinely while having no idea what they are for or why the doctor prescribed them. This is exactly why I believe Medication Therapy Management services (Medicare Part D) is so vitally needed. Under the MTM scenario, an independent pharmacist serves as a patient advocate, and takes an unbiased look at all of the medications a patient is taking, at least once a year or every 6 months. That review provides additional expert judgement, helps in overall safety and quality control, and can facilitate the additional communications that might be needed when multiple medications are prescribed by separate doctors. Every patient should seek the services of a pharmacist/patient advocate who will look at the big picture and advise accordingly.