 It gets started, is that too loud? Is the sound okay or is it too loud? Good, okay. So let me go ahead and get started since we have a tag team this afternoon for this medication management session. My name is Aurelia Basildou. I'm a clinical pharmacist, academician with the Health Science Center. I'm a faculty at the family medicine department. And I do have a couple of clinics where I see patients, the pharmacotherapy clinic, anti-crugulation clinic, and I teach medical residents and medical students and whoever else wants to learn about medication use and most importantly, patients. And so what we'd like to share with you today, I will be the high touch part of the presentation and Duane will be the high tech and Dr. Ratner will have some closing remarks. So our objectives for today are to describe the evidence of how health literacy affects medication use. And if you were here this morning, Dr. Davis actually took all my slides and discussed them. So what I will do is actually do some discussion so that you can tell me what would be on those slides in terms of how health literacy affects medication use. And then, and then what I will do is just share with you some practical experience, maybe some skills that you can actually use. I think some of you may already know about these, but hopefully you can learn a few tips from us this afternoon. Then Duane will talk about some high tech skills and websites and then we'll finish up with Dr. Ratner. So let me go ahead and get started here with a short little video. We've also noticed that there's a high number of patients who get admitted for things that they wouldn't need to be admitted for if we had a better handling on all of their medical issues. We've increased dosages on patients that were not compliant or accurate to their medications. And then inadvertently, we had overdoses when they finally did take their medications. Approximately one and a half million people are injured each year due to the incorrect usage of or lack of access to medications. And nearly 25% of ambulatory patients experience some type of adverse drug event. The Institute of Medicine has stated that the safety and quality risk associated with medication use in the United States is severe. Putting aside the toll of this issue on human life, the IOM has declared that for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by these medications. In effect, in this of our systems of care has been identified as one of the primary factors contributing to these unfortunate outcomes. So before I go on, I wanna hear from you. What do you learn from Dr. Davis this morning about how health literacy might affect medication use or perhaps you can share an experience you've had in your practice about how patients misunderstand their medications or have medication errors so that we can all share about our experiences. Anybody wanna go first? I have lots of them, but I don't wanna be the one. You're not sure what they should do or anything. So they don't know how to read and then they get righted on the medication labels and then, so how do you translate that before they leave? Yeah, something like that. Can everybody hear? I've done a picture diagram, like right on there, check out a picture of the medicine that starts with this letter, these two letters, and then a picture of the sun coming up. So pictograms? But doing it by hand, you don't have any kind of handouts like that. Okay. So hopefully we can share some websites that might be useful. So she says they actually try to do some of that education before the patient leaves anybody else. Either concerns, experiences you've had, yes? As you're talking, I have this idea that I never had before, but everyone that has iPhones that you can record, you can just videotape record them. Yes, we'll talk about that a little bit. So she's talking about the weight base or age base dosing that you find in the over the counter colonel or ibuprofen. And some patients, like in her case, she's too small, so she was off the charts in the too small size. And a lot of times we see the opposite, where they're off the charts and the kid's too big, but they're only one year old. So what do you do in terms of which dose do you choose? Good point. Anybody else? Any Eric? I'll tell you, I always take the back of the hospital. One little old nurse is not gonna get it. So you used your resources. So good. Thanks for your comment. Anybody else wanna comment on maybe why this is important for why you're here? Apparently you have an interest. We'll go with you and then one last comment. Good point. And now what they're taking first and avoid drug interactions. I work in an anti-fragulation clinic. I was there Tuesday and probably in the many years I've been there, it's probably the worst patient I've had. And he had three drugs that interacted with Coumadin and he's lucky that he actually did end up in the hospital with some bleeding. And one more comment. Overwhelming. And this is with family members like yourself that is educated. Can you imagine those that don't have that support? There are some seats up here. Please feel free to come up here. All right, so I'm gonna share with you. I think some of the things that we talked about in Dr. Davis talked about this morning, what does the literature say and how they relate to medication use and health literacy. So first, considering what does the patient really need to actually manage their medication as well? Just a few thoughts. One, you know how to read? First, okay. What else? The right language? They need to know math like Dr. Davis say, just calculating, adding, figuring out a chart. Because they might make it some other way. Yes, they should say by mouth and I see this all the time in children's medications. So they go and see the doctor for an ear infection and they get a moxicillin syrup, which is supposed to be taken by mouth but they went in for an ear infection so they put it in the ear. So you can go on and on about those different stories. So these are a list of the things that they need. So they need to be able to read the labels, read the dosing instructions. Just listen to the explanation. If we actually take the time to explain to them, just be able to listen to what the provider is saying. Talking again, someone mentioned that the doctors are so busy. So how does the patient actually feel confident enough to interrupt the doctor and say, I don't understand what you're saying because the doctor is busy and moving on to the next patient. They need to ask, we ask our diabetic patients to check their sugars and write them down or write their food logs. So they need to be able to do that to manage their medications. And the example that you're talking about your CHF family member, that's very common with lots of medications, lots of medical problems. Just keeping up with appointments, with heart specialists, the family doctor, the dietitian, there's so many things to keep up with. And then Kathy talked about calculations and annoying some math. How do I calculate this measured dose or how many do I take? So all these skills we are requiring our patients have to actually manage their medications. So I'm going to go just kind of run through, this is going to be quick because Dr. Davis touched on this and we can have more time for discussion. So what does the research say in terms of hearted effects or is related to health literacy? Excuse me, so knowledge. So just understanding the labels you saw in the video that the older lady came in driving but the labels that do not drive when you're taking this medication. So just understanding the auxiliary labels on there, they have trouble. In one study, they found that 65% of the patients that were studied were not reading those appropriately. And how many pills to take? So take two twice a day, it's hard for patients to understand. Is it okay if I take it at eight o'clock in the morning and then at 10 o'clock in the morning? That's twice a day, right? You'd think it makes sense but some patients may have a hard time understanding that. Also how many refills are left? And we'll talk a little bit about reading medication labels but a lot of patients don't realize that how many refills are left is actually under label. And at least in our clinic, they spend time driving into the clinic and asking for a refill when they don't really need to. So three to four times misinterpreting auxiliary labels. So many issues with this, first of all, as we get older, you probably cannot even see it. So much less understand it. And what Kathy was saying about reading a chart that has weight and age and then you need to figure it out. I learned this early on that some patients don't know about the X and Y axis to actually figure out what the answer is. Excuse me. So decreased medication management. How many of you take care of asthmatic patients or talk to asthmatic patients? A good number. So there was a study in chess a few years ago but basically what they found is that patients that had limited health literacy didn't know how to use their asthma inhaler. Even the patients that had higher health literacy didn't know but they were at least a little bit better. And I'm sure, does anybody have any stories on patients using their asthma inhaler incorrectly? I've had Dr. Weber know. She can go on and on I'm sure. But actually I'm gonna show you one that I thought was interesting. Maybe you've seen it on TV already. Sometimes doctors make mistakes. Anna, you need to try twice as hard to fix them. Are you using your inhaler? All the time, go through one a week. You sure you're using it right? Do I look like an idiot? Nope. Why don't you show me how your inhaler works? That's funny but it's really not funny because it does happen. Unfortunately, I've seen patients using it backwards so they just spray it and then just go like this and so different ways. But I don't mean to demean it because it's important that patients actually understand all their medications, especially their asthma medications that can be like or death situations. So, but I just kind of wanted to emphasize how really the, how big the problem is. So this is what Dr. Davis was talking about this morning and she was actually the lead author on this article that found that the patients can tell you I'm gonna take two tablets twice a day of this medication. Then when you ask them, they show me how you're gonna take it. And they can't figure out that it's two in the morning and two in the evening. You know, they say three or just take one twice a day and until her study, I didn't realize that problem. And so I think we really need to, again, emphasize the proper use of medications because as you saw in the beginning video, there are lots of medication errors and re-admissions again happen because of that. And we were talking about take-backs that our water system has here, San Antonio water system. And I don't remember how many, do you remember doing how many pounds of medications that were actually taken back? There were times actually of medications that were being taken back from the water system. But the first thing that came to my mind is all those patients that didn't get their antibiotics or the medications that they really needed, not to mention the cost. So this study also showed that patients, if they went into the emergency room, I know some people work in emergency centers and you ask the patient, tell me what medications you're taking or be able to identify their medications, they cannot. So again, the higher health literacy had a 68% of actually identifying their medicines, but ideally we want the 100, okay? So patients that had lower limited health literacy were less likely to be able to identify their medications. And this study is 10 to 18 times the odds of being unable to identify them. Just having them, they're in front of them already. And I get patients all the time, they bring other medications and so then I ask them, tell me how you're taking this medication and they cannot tell me. One, because another family member perhaps is helping them. That would be the best ideal situation. So how does it relate to adherence? Because ultimately that's really what we're interested in is the patient taking it so that it can improve their outcomes and hopefully improve morbidity and mortality. So the answer is still yet to be determined. There are a number of studies. The first three studies say that health literacy actually decreases adherence. There's another study that says it actually increases. And a few other studies that say there is no effect. So in terms of adherence, I tend to believe myself that there's actually a decrease in adherence in terms of relation to health literacy. But when you look at the literature, it's not as straightforward. So how many of you have patients that have difficulty paying for their medications? And so what do they do to try and get away? Take it every other day. I saw someone splitting it in half. They're not taking it, right? So this is actually interesting. I got called about a month or two ago from a radio station because they wanted to ask me about this new report that came out in consumer reports. And basically what they found is that patients were actually cutting corners to actually take their medications because they couldn't pay for them. And one of the things that they wanted to emphasize that it has been getting worse since the new economic downfall that we've had recently. So this is kind of one slide that I picked from here. So the orange and dark orange are patients that actually have prescription benefit. So as you can see, it hasn't really affected them too much. The blue patients are the ones that have no prescription benefit. And again, what they were trying to do is contrast 2011, which is the darker blue versus 2012. And as you can see, the first one says 45% of the patients studied or surveyed skipped filling a prescription because of cost. And we see this all the time from the emergency room or being discharged. We had a patient that went into the emergency room for pain in his knee. Had an emergency visit. And then I saw him two days later and I was doing a medication reconciliation asking about his pain. And he said, well, I still have pain and I have the prescription because I couldn't feel it. So that goes on all the time. The second part is talking about how many patients skipped a scheduled dose without really talking to a doctor or pharmacist. So that was 31% this year. And like I was talking about, some patients cut their pill in half because at least a little bit is better than nothing, right? So 19% cut their pills in half, at least of those that were surveyed. Okay, so what do we do about it? Not that we know it's a problem, not that we didn't before, but just to re-emphasize it. Any thoughts? So it's up to us, yes. So in keeping with time, I just want to run through a few thoughts of my own. And again, I think some of this you already know, but I like to just emphasize a few points. And that's just a summary of what I'll be talking about. So your patients have all these medications, right? So the first thing someone mentioned is, what are the patients taking? Because to me, that's the very first step and I teach my students, medication reconciliation is vitally important when they come into the emergency room to the clinic because if you don't know what they're taking, then how can you go to the next step? And so these are the general questions. So first, get a list from their medical record if you can get them, then ask them if they have their career medication bottles with them because a lot of times they know better by seeing the medication bottle in front of them. And then who is the person responsible for taking their medications? That's a vitally important part of the history because if it's their wife or their spouse and they're not here, then you're not gonna get an accurate record from that patient, so that's important. How many different doctors prescribe medications for you? Which pharmacies do you prefer? We have patients that, again, to cut costs, they go to Walmart because it costs $4 there and they use our hospital system because they can get it free there. And so as a result, you have patients going to different pharmacies and so there's no opportunity to catch drug interactions. So I won't go through all of this, but a complete medication history is important, not just prescriptions, but over the counters, herbal products. I ask them, do you bring medications from other countries like Canada or Mexico? We did a survey a few years ago in the flea markets and asked them if they'd find prescription products that are specifically antibiotics and about 14% said yes. And so you can imagine how that increases the likelihood of resistance in our population. And then adherence is very important. There is no good gold standard to measure adherence and the Moriski scale is the closest one. What I do is kind of a paint scale, zero to 10. So I ask them on a scale of zero to 10, how good are you at taking your medications every day? 10, you don't miss any and zero is you never take them. And we did a short try to validate study last summer, some silly value in that data to see how well that works. So anyways, medication history is important. Full of the allergies and so this is just an example of a medication list in case you're not familiar with any, but savemedication.com you can get just, again this one has nice pictures. You just make sure the patients are able to understand and read it. This is one of my favorites, it's called mymedschedule.com and it's from medactionplans.com. And I know I've been using it for years and it's been a free service or a free website. But I think either they have or they will surely start charging for it. So they hooked us in and now they're gonna charge us, but it's a very good schedule because it actually has a picture. So if it's a brand product, if it's a generic it'll just have a generic white picture, but it actually tells them exactly who went to take them and how many to take. So I like that format. How to read labels, we just went over this with our promotoras in our clinic. And again what I wanted to emphasize is that patients should know that they have a number of refills here so that they can avoid a trip to the hospital or the clinic when they don't have transportation. The other thing that a lot of people don't know is that prescriptions are good for a year. So however, they have refills like six refills and the year is already expired, then the whole prescription is expired, even though they have refills. So teaching that and then over the counter labels is also important to read, specifically to avoid toxicity. So a lot of patients don't realize that Tylenol and acetaminophen are the same thing. So the patient has the flu and they use nycule and then they have a headache and they go to pick some Tylenol or et cetera, then they get overdoses on Tylenol or whatever ingredient there. So teaching them about the active ingredients there is important. Consolidating pharmacies is another good point to try and do because again that'll minimize the medication errors, catch drug interactions. And then I think maybe you were alluding to that also about a patient with CHF. I see patients that take medications almost every three hours and because they think it's not good to take them all at once but what ends up happening is they don't take them at all or they miss them. And so what I try to do is I wouldn't make sure that it's appropriate to combine them but at least simplify it and just say, okay, you just have to take them twice a day. You don't have to separate them by these many hours. And they're just like so relieved because it'll make their life easier. Okay, so a few money saving techniques. So first of all, the patients should really communicate with their provider that they are not being able to buy the medication or pay for it so that the provider can at least try and help them as much as they can. Of course, generics, I always get the question is are the generics really just as good as a brand and for the most part the answer is yes. If you have a co-pay for example, if I have a $10 co-pay and I have, I'm taking lysinopul, so I pay $10 for that and I'm taking hydrochlorothiazide so I pay $10 for that. So ideally if you can combine it in a product that has both lysinopul and hydrochlorothiazide then you just have one co-pay. Yes, Dr. Weaver. Yeah, so sometimes I pay $10 for my co-pay but I can go get a Walmart for $4 and that happens but again, that just kind of more poly, not poly pharmacy but more pharmacies are getting into the picture but they have to do what they have to do. So the other thing is sometimes drug companies are sneaky because again if the patent for lysinopul is over then what they do is they combine it with another drug like hydrochlorothiazide or whatever drug and so now this combination now has a new patent and so that causes that brand product to be more expensive. So what you can do is actually give the generic of this one and the generic of this one and it's less expensive. So depending on what the situation is either combining them or separating them might save money and I'm running out of time here. Of course diabetes, hypertension, dyslipidemia, I tell the patients all the time with lifestyle modifications, weight loss you can avoid adding another medication. So sometimes mail order is also cheaper if you have that in your plan so I try to encourage that for our patients. And Medicaid, I just want to briefly before I run out of time here to help our Medicaid patients. So some programs are different but most of the time Medicaid pays for three medications for most adults and so patients that are taking six, nine medications that might be trouble but one of the things that people don't know is that they will pay for a 90 day supply. So on this example for example they'll get drug number one, drug number two and number three in January and in February they're gonna have to get the same drugs number one, number two and number three for 30 days but they do allow a 90 day supply. So what we can teach the patients to do is actually stagger them. So on January they can get drug number one, drug number two and drug number three but for 90 days. So the next time they have to fill it it's not until April. So now in February they can get drug number five, drug number four, five and six, okay and then that doesn't have to be filled until May. So theoretically they can get up to nine medications with this program. So this is sometimes something that they don't know. The downfall is that it's complicated, a lot of coordinating so you might, so we need to figure out how to make it easier for them. This is just a study where they actually get medications free and they were trying to find out whether this actually helped adherence and it helped a little bit but that was not the whole answer so there's a lot more to adherence than just paying for the medications. Visual tool that I use for our diabetic hypertensive lipid patients is like a traffic light system. So I show them because it's asymptomatic that if their A1C is greater than seven they're in the red means high risk. So just showing them a visual tool helps to understand the situation. Teach back, I won't go too much on this but I'm a big fan of teach back when educating patients and let's see. I just wanted to share one more thing here is an idea that because this is such a passion of mine and such a big need in our, not just our city, our state, but nationwide is I was happy idea after watching a Dave Ramsey program. I don't know if anybody's familiar with that with your hand. So what he does is actually he's a financial literacy video kit and so he teaches patients about people like me how to be better with their finances. So I got the ideas to develop a video kit on how to improve medication literacy for our population. So for example, one video would be how to read labels over the counter and prescription, how to keep track of the medications in the list. The savvy OTC customer would be another video. The next one would be just simple savings like I just ran through right now. How to make the smartest trip to the pharmacy when you go. Websites and helpful tools. Another one are natural medicines and websites and sorry the FDA inside that would be useful. So anyway, so we actually wrote a grant and we're not successful the first time but I think it's very important that I'm gonna keep on trying different avenues to see how we can get this through. And once we get this, the idea is to actually have trained the trainers. So the videos will be supplements and someone would be actually helping just teach the population just these simple tips about reading the prescriptions, how to save money, how to avoid drug interactions. And I know I went to a lot, but I wanted to just kind of give a general overview and I'm gonna scoot it over to Dwayne and hopefully have some time for questions at the end. We're actually, while we're switching microphones, anybody have a quick question or comments? I was just gonna honest, I don't know if you have any of these, but what we're used to doing, what we're doing right now is we have a big recipe to label and we have a well-cooked one. And if there's a name and where it goes, we feel expiry date, how many you take, what dose you take, and we have activities and the well-cooked and they go and like pass it and we have a good response on it. That way, a lot of the participants they now know how to make the recipes. Yes, I found some of our students getting good and I had worked with them and this was a technique for a meditation class in the scope of a great moment. It was interactive. Yes, sure. I also want to say, okay, this is for the repo list or this is for the doctrine of the image. So that's kind of the idea that I'd like to have is trying to do it at a later stage. Well, that's another, the high tech part, high tech part, going in to that is also a part of me. So I'm just gonna talk about some high tech tools out there that are available. We'll kind of talk about how the lower it is a check and then we'll go to the higher end. So just, curiosity, how many of you have smartphones? Most of you have smartphones. How many people have cell phones that are not smart phones? These are old cell phones. Are you kidding? I just got text messages. That's okay, that's great. My father, he just turned 65 and he came down to my graduation and I said something that's an intimate text message and he was like half of us are better than my parents are funny. He just decided about getting these messages because this is my only technology form. So I think that's really great that we have this technology available to us. So the first part I'm gonna talk about is basically tools to help with adherence to help us remember to take our medicine. So some of the things we want to consider when we're looking at applications that help us are the number of features, especially for folks that have a hard time with technology. The simpler they are, the better they might be whereas younger folks have grown up with this. All the features of those are great for them. So even if it's an important cost, so a lot of applications out there are free but there are some that range up to $20 or something. I'm just gonna go to the other side of this. Oh, sorry, sorry. So there are some that range up to $20 a month. So if you have phone calls, say if you take your medicine today, so there are options out there if you need. So other things we want to take a look at are just interoperability between devices. So if you have a computer and a phone, you can make those two together or web or the internet, so making sure all those things talk to each other. And then just different options that come available. So alerts, you want to apply it, you want to link it to, vibrate, whatever. And then just some optional ones, like being able to take a picture of your medicines and have that being part of the reminder tool. So just some things to think about when we talk about these different features. When we talk about calendars, most of us have access to the internet in some fashion companies. So Google, Gmail is very big, what it is out there, it's free to us, it has a calendar option. Other things out there, you can have the online reminder services that can send you emails and text messages, and there's also the self-advocations. But as we get more to the self-advocations, they become more difficult to use, but they have more features that can be possible. So it's kind of a local comparison. So when we talk about calendars, basically these are kind of some, no frills, simple to use, most of them have a paper calendar, it's just an electronic form of it. But the interesting thing about this is that you can, for folks that have the Waltz phones that don't have the smart phone capability, I'll show you later on in the presentation that you actually have an email address. So with your cell phone number and the company that you have your service with, you can send a text message or you can set up a service through Google or Gmail or Yahoo Mail or Hotmail or anything you use and you can have it remind you, set up a little reminder calendar and it's every calendar, and I kind of thought about this for my mother, she won't take her, send a frilly speech, she's like, oh yeah, I forget sometimes. So, thinking about setting this up for her, if it's, you know, send her a message, I can do this remotely, my folks in the Catholic countries don't have access to the internet. My dad just has the wireless G3 phones that they're using, so it's really good for them. I can do this in Texas, my folks are in Canada, so they can do this online, set it up and remind them, mom, hey, they're like, send a phone, don't worry about your blood pressure. But, if you need to be on the grid for this. So, other capabilities and then just different ways to, I said, you know, you have the old-style phone, I let it get the same dose. Now they have a lot of just push technology, so as long as you're connected, then, you know, as long as you're on the grid, like my phone, I get a new email message just as long as I'm on my phone, so there's nice technologies to have finder services that are available. I think I have a list in here, but it's kind of like, you know, one of them that we just showed you is mymedicineville.com, I think it's going to continue to be free, the other application that the parent company, I think they're going to start charging, this one's really nice. You can have the picture of the medication, you can print it out, we use this in our place quite a bit, a couple of occasions, but it also had to remind your picture, and I'm kind of setting up a couple different ways. I had it once in my phone, but I also have it in some email messages, so it's a couple different ways you can set it up depending on what you're reading. And it also has a Spanish shape of building, which is very nice for our population, through students coming out. And it connects to another system called the Microsoft Health Vault. This is a personal health record that you can keep for yourself. You can put it on your surgeries that you have, and be your doctor's dog or pharmacist, and you have this all together in one spot, and as you go and see different providers, you can collect all this information. So if something happens to you, you can take this to your new provider and say, this is my history, this is my information, and they're moving a step beyond this technology and trying to connect it to the providers out there, so all the providers can be all connected together. So the provider can update your record and you have access to it. Another provider can see when you go to your cardiologist, for example, if the health information works exactly in that direction. So this is an example of mymedschedule.com. Dr. Betz will do something great so you can also do half tablets, you can do text, if it doesn't really fit the schedule. But up here at the top is that remind me, but you click on that and just do certain medications that you have, remember your nighttime medications, they can slide just to the nighttime, but if you just have a morning, they can slide just that. So it has to do with the whole range. Another one out there is called Remember Now, it works very similar, and this also connects to the personal health record. The Microsoft Health Vault that I was talking about, it also has apps or features that can add into your health vault that can connect, it has a blood pressure on it all day, or it's kind of like your electronic health record, but it's your own personal one. It's also very similar. The nice thing about this is that if you look at Utah or Arizona, and you might explain to other states, is that they pull actually Medicare 20s to pull up your information. So maybe something happened that you didn't know about while you were in the hospital, they get pulled into your record. This slide, for those of you who don't know that you actually have an email address that detects your phone, this is kind of how it's set up, it's your intended phone number, ad, and then your provider. So for AT&T, Verizon, Sprint, and C-Mobile, those email addresses kind of trick your whatever application you have, and so instead of sending it to a phone number that's not available, if it's said, what email address do you want this message to feel to, this is your email address, it will actually turn it into a text message to your phone. It also works for smart phones. About the cell phone applications, now we're moving on to the more high tech, to be a little bit more difficult, with a lot of features, very rich applications. There are some problems with it. There's depending on the applications, there's some questions about data security, being on the grid, being to connect your information together, with updates, sometimes the stuff that you have in there, it's a race, it's a race, and that can be good, it's going to be frustrating. So I would say for cell phone applications, it's important to kind of give them a test run, before you decide that you really, you know, this is where it works for you, because they're all different. So I can say that there's one out there that would be perfect for everything that's not the case. So it's just, go out there, and figure, try it, if someone's luckily free, and they have some demo ones to try, and figure out what works for you. Of course, there's a lot out there. So for the Android and the iPhone, this is the team we're going to focus on. There's a, I actually have a web OS phone, kind of going off the window, but not a lot of applications there. And then the Windows phones, there aren't a lot of, I think Dr. Bird did yet, but they're getting there. But for the main ones, for the majority, like 80% of the population have an Android data phone. There are, for both platforms, there's a couple of several out there. So Med Helper, this is an example of Med Helper on the right, actually helps you track your appointments, or when you're refilled from the pharmacy, how much you're taking, you plug that in there, and as long as you're, can you see I'm taking it, it'll decrement the total number of days. When you get close, say I've sent a tablet but, it'll fill a reminder here saying, oh, probably pharmacy, get that refilled through your run-out, see. But I think that's a really nice feature that a lot of programs don't have. Here's some other ones for the Android, and some examples of just the warm types, and you can set them up throughout the day, when users support into the iPhone specifically, on the flash drive. There's also some other technologies out there, other than phone apps, we have electronic prescription bottles, apparently in a clinical transplant journal, there was, they looked at patients that had kidney transplants, and so, they wanted to figure out a way to improve adherence, and what they could use were electronic prescription bottles, and they added a microcircuit to them, that when they opened it and took it, it attracts that they were taking it, so they showed that there was improvement in adherence, and it's really important for our patients to take it. Seeking medicine, especially your immunosuppressive ones, will lead to a rejection, so we wanted to protect that, that work in the country. The new technology, this was approved by the FDA in July of 2012, this comes in a couple different forms. This one is called the Helios Smart Fill, and you wear a patch on your abdomen, and they can package the pills, or the communicator pulls a little microchip, that it turns it on to a little battery, and it passes that little sensor, it says, oh, you took it, and it tracks it, and it's downloaded to the app. Other things they have to do, that they talked about were these little green pills, pharmacy can actually package them into individual packs, so if you're at a 30-day supply, and you package this with each tablet, so you take both of them together, and that kind of works together, they're, I mean, it's not foolproof, because you can separate them out as long as you take it together, and you can assume that they took the other ones, but it's probably quite a bit. And then there's some games out there, so for app, the total applications, this one's called healthpriced.com, and it's kind of interesting, it's relatively new, but if you can track your medicines, it has shows you, has alerts, but it also has little quizzes about health topics, and you gain points, and it's kind of like, if you go up your point box, and then you turn that into prizes and items, like a bicycle and stuff like that, it's actually a partnership with pharmacy providers, the pharmaceutical industry, that's part of it. And then there's this other one that's called foster filler mine, here, this is kind of like old, I don't know how many, so 90 to head people with voice calls, it's called tomogatis, and there are little toys that you have, hell of a pet that you had to feed frequently, and to keep it alive, it's just similar. So this one is, you're trying to keep your tree alive, and so if I take your medicine, reminding you to take your medicine, you keep your tree alive, and then on the left side, then you forget your tree's birth to die, so one of the comments, and one of the logs for this was, I'm trying to take care of my tree more than, you know, taking care of myself, but together, now I am taking my medicine, so I'm trying to keep this tree alive. Then there's some other tools out there that might be helpful. The first two are actually some formulary tools that are out there, so if you have a patient that, you know, if you're not sure if a medication's on there, come on there, insurance formulary, or if you wanna afford all of it somewhere, this is a really nice tool, it's called Feverstift formulary, and when you go there, you take the state that you're in, and you need to take the health plans that are out there, so if you know your patient's health plan, it's like that, and it's like the drug, and it'll tell you exactly what's here of medication that is for them. It also has a cordial appliance, it also has all the Medicare plans, but I find this one, I use this one in the clinic quite a bit, too. Destination RX is very similar, but it's also some other health information that goes along with that. And then children's clinicians, you know, when you look up drug reactions, or when you know more about medicines, there's a couple out there that are free, I would advocate micro-medics, it's more one of the views of pharmacists, but it's a free tool out there, and it's a very large database, and it's about the drugs, it's about the reactions, kind of taking it, those seeing all that information. The property is okay, but the property has laws, but I don't think that's all I ask. Do you have any questions about the high-tech tools that are out there, or if any of you have any other ones to share, and I mean, I've tried myself, like I still have some reminders set up, and like every hour, I see all the reminders that I haven't set up yet, but the idea's a buzz, and I'm like, I don't really have any idea if they might want to pull it out on the tape, but for me, it's just like, it works, so it's a personal experience. If you're interested in maybe learning more about the smart medication university, or if you're interested in being involved, if I could have your name and email, again, it's still an idea, but I hope it will be a reality. Can everybody hear me okay? My wife says I'm mumbled, so I want to thank you all. First part of this presentation talks about how we can improve compliance. What about the other side of the spectrum? What if you have a patient who's perfectly compliant? Perfectly compliant and taking 25 or 30 medications. Anyone have patients like that? Well, let me tell you a story. I'm a radiologist, so I'm a picture doctor for those of you who don't know what a radiologist is. I don't routinely have patients coming to my office and see me and I write prescriptions for them. I don't do that. Several years ago, I started getting phone calls. Friends of friends, friends of relatives, not so many, I was getting these calls and it was always the same thing. This parent used to be in great health. Why were six doctors? This parent was getting sicker and sicker. I was just certain of it would work. I'm a radiologist in Texas. Why is it the same person who's a radiologist? There is a second population that really doesn't have a problem when we're talking about the first 45 minutes of this presentation, but they're the opposite problem. They're two different ones. We're physicians, we don't really know. We come up with this instruction when we're talking about the self-losing with the pharmacist. I'm sure that we'll roll in. I'm sure you'll see this, too. But at the end of the day it's a huge problem and it's an interesting one. It's such a big problem that we decided we're going to continue with the story. So, I get these calls rather than I sociar and understand it's the only thing that's a matter of too much access to the appropriate access. Single kids, five or six physicians can vary with specialists. You won't be a surgeon, maybe? Sometimes they have a primary care doctor. Sometimes they've been telling that patient or patients to come to close on our session today. But the single thought and the physicians who are working for them is critical to any pharmaceutical literacy success. If you have five doctors who are in the middle of the other guy's work or the other woman's work, what that means is that patient is essentially on this part of the presentation I like to call a surgeon. And we're hardly there to get to the rest of the stuff that many of you have seen this probably I don't know how to put it, maybe that's probably just as dangerous. It's absolutely incredible. I'm particularly interested in that stuff. I don't have to worry about that stuff. We've got a physician who meets his definition who wants to be able to, you have to know everybody gets you wrong. You have to know you're right. There's not so much you're wrong. I can tell you it's hard and hard to find. There's so many patients earlier just how our physicians don't have a lot of time. That doesn't mean that you can't find a physician who wants to. It also means that you're going to look for some apps that have ACO. ACO doesn't exist. It's funny, it doesn't even show an arm cycle. Like an ACO, an arm cycle of ACO is the worst thing you can do. So for what they're potentially seeing, I'll be getting the ACO. There's a talk about it, which is a transition on the ACO. Transitional ACOs in organizations are actually important. That's what's happening in some of the next phase of development. I call the SOCCA, which is a system of sustainability. How we can see that it's here to assume the normal care app stays at the course. Is it going to see physicians, hospitals, and other organizations get together to try to provide any way to care? Now, it sounds really good. It sounds really good. This is not the talk about this for hours. And we need to make it go together. So that's a fine order. It's working. I mean, it's a bit of a short one, too. If you are, if any of you are a consultant as a patient, these skills, I think are really what we're going to do. The importance of medications that get you re-inferred, because that's inferred. Any re-admission that gets you re-admitted within 30 days, I'm going to take. A lot of medications that we're not able to get re-activated, the infection got worse at the end of the vaccine, the hospital order. Whatever medications, so this is going to be even more important for getting re-inferred for it. Thank you all for your...