Saturday morning coffee [June 7 2013]: Fast & Furious 6, Peach Cobbler, PRISM, Pharmacy, MedPod

So much happens each and every week that it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….

The headline for SMC is a bit different today in case you haven’t noticed. I’ve taken the advice of a Twitter colleague, Charles Webster, MD (@EHRworkflow). Charles has recommended a couple of times now that I make my headline more descriptive. I like the idea so I’m giving it a shot. Feedback welcome.

My trip to Minneapolis, MN for the ASHP Summer Meeting has me waxing nostalgic. The coffee cup below was my trophy for winning the first ever ASHP Midyear Meeting Twitter contest. I’m not even sure what year it was, but I believe it was 2009; don’t hold me to that recollection though. At that time ASHP  was unable to use any of the official Twitter logos due to some time of licensing issues. So instead they generated a Wordle from my website and placed it on the mug you see below. My Twitter handle (@JFahrni) and web address (JerryFahrni.com) are displayed on the back near the handle.

ASHP Twitter contest mug

Fast & Furious 6 continues to generate pretty decent numbers as it was #1 at the box office again last weekend. I still haven’t seen it, but it’s on my short list.  The Internship hits the theaters this weekend, but I don’t expect it to be a blockbuster in any sense of the word. I’ll likely go see it at some point, but I just don’t get a good vibe from the previews. I actually think The Purge would be a more worthy recipient of my movie-going dollars. I’m not saying that The Purge will be a great movie, but the concept intrigues me. We’ll see. One thing is for certain, After Earth, as predicted is quickly becoming a box office flop. I’m actually quite happy about that; it’s the little things in life.

The most viewed post at jerryfahrni.com over the past 7 days was Why pharmacy continues to fail, again. It’s also the most visited post for the previous 30 and 90 days as well as for the whole of 2013 thus far; by a wide margin I might add. That particular post is more than a year old. Here’s the funny part, it still hold true today.

Great little article over at Medium.com about coffee vs. beer. “The best time to have a beer (or two) would be when you’re searching for an initial idea. Because alcohol helps decrease your working memory (making you feel relaxed and less worried about what’s going on around you), you’ll have more brain power dedicated to making deeper connections….Coffee meanwhile, doesn’t necessarily help you access more creative parts of your brain like a couple pints of beer. If you’ve already got an idea or an outline of where you want to go with your project, a cup of coffee would do wonders compared to having a beer to execute on your idea.” And there you have it, when to drink coffee and when to drink beer. Read the entire article, the author has some really interesting little tid-bits in there.

The Life of a Simple Chef: Skillet Peach Cobbler….dude, this looks good.

Ingredients:
peachcobler2C all-purpose flour
1 1/2C sugar
2 teaspoons baking powder
1 1/2 teaspoons salt
2 large eggs, beaten to blend
1/2C sour cream
1C whole milk
2 teaspoons vanilla extract
1/4C (1/2 stick) unsalted butter
2 pounds peeled & pitted peaches cut into wedges
2 tsp ground cinnamon
1C peach preserves

Method:
Preheat oven to 350°.
Whisk flour, sugar, baking powder, and salt together. Set aside.
Whisk eggs, sour cream, milk, and vanilla in another bowl.
Add egg mixture to dry ingredients; whisk until smooth.
Melt butter in a 12 inch cast-iron skillet over medium heat. Swirl pan to coat with butter.
Remove from heat.
Add batter to pan over the top of melted butter.
Mix cut peaches with ground cinnamon.
Scatter spiced peaches over batter.
Spoon dollops of preserves evenly over batter.
Bake until center of cobbler comes out clean
Bake @ 350 for 45-50 minutes

I had an interesting conversation with a friend this week about how I come up with my SMC topics. It’s really quite simple, just as I say in the opening sentence above I write a little blurb about each of the tabs I have open in my Chrome browser. Seriously, that’s it. When I see something that I might like to blog about I pop it open in a new tab. These days I rarely find time to write so I leave the tab open until Saturday morning. As I read the article and comment on it here I close the tab.

Unless you were under a rock this week, or simply disconnected from reality, you’ve probably heard about the big scandal swirling around the government illegally collecting data on U.S. citizens. The Washington Post dropped the bomb. “The National Security Agency and the FBI are tapping directly into the central servers of nine leading U.S. Internet companies, extracting audio and video chats, photographs, e-mails, documents, and connection logs that enable analysts to track foreign targets, according to a top-secret document obtained by The Washington Post. The program, code-named PRISM, has not been made public until now.” Both Google and Facebook are denying the allegations. Things that make you go hmmm.

Have you seen the 3D Printing section at Amazon? Yeah, it’s sic. I’ve been thinking about doing some 3D printing, but my company won’t let me touch theirs; apparently it’s too expensive for “just anyone to use”. My daughter’s high school engineering class has one and she brings home some pretty cool stuff. She’s offered to take my ideas to school and print them for me. That’s funny and cool.

I’m thinking about getting a Roku 3. These little dudes are impressive. I don’t watch a lot of “regular” TV anymore. Over the past couple of years I’ve slowly migrated toward Netflix, Amazon Prime, etc. The only question I have is about football. I watch a lot of football during football season; both NCAA and NFL. If I can’t watch 20+ hours of football on Saturday and Sunday then it won’t be worth it.

Roku3

The FDA this week eased up on Avandia (rosiglitazone) after hearing a new analysis of Avandia’s cardiovascular safety performed by Duke University’s Clinical Research Institute. The AP is reporting that “A majority on a Food and Drug Administration advisory panel voted Thursday to modify or remove measures that currently limit patient access to GlaxoSmithKline’s Avandia. Among those requirements, patients must sign a waiver before getting a prescription that they understand the drug’s risks.” That’s good news for GlaxoSmithKline, but it doesn’t really matter as the damage to rosiglitazone’s reputation was done long ago.

When I was still practicing pharmacy, one of my favorite areas of interest was pharmacokinetics. If you know anything about pharmacokinetics, then you’ll know that renal function can often play a significant role in calculations for several different drugs. The king of equations for estimating renal has always been the Cockcroft-Gault (CG) equation. People have tried to come up with a better method, and some have found niches where they work better, but the CG equation has always worked well for me. A recent article in the Journal of the American Pharmacists Association (J Am Pharm Assoc. 2013;53(1):54-57) compares the Modification of Diet in Renal Disease (MDRD) equation to CG for renal dosing.  The MDRD came on the scene many years ago, and in my opinion has failed to live up to the hype that surrounded it. The nuts and bolts of the paper were that the MDRD and CG equations gave significantly different results. In other words they aren’t interchangeable when calculating dosages based adjustments for decreased renal function. Want my advice? Choose one and stick with it. Consistency means a lot as you develop your skill set in your specific practice setting. Learning how to evaluate the situation and apply the principles is more important than crunching the numbers, trust me.

Here’s a great slide deck from the 3G Doctor presented at the Scottish Telehealth and Telecare Summit. Interesting 4 or 5 slides starting at #29; pharmacy, dude. Telehealth is going to continue to improve and grow in my opinion. The continued advancement of technology, especially mobile technology, will eventually drive consumers to become more comfortable with the concept. Just look at the generation that’s in school now. They are extremely comfortable using mobile devices for all kinds of communication.

There was a time when I worked as a compounding pharmacist in the Bay Area or California. Some of the most difficult things to make, but also coolest, were tablet triturates. There’s a great video at the UNC Pharmaceutics and Compounding Laboratory website on how to prepare and make tablet triturates. I would have embedded the video here, but couldn’t figure out how. If you have some time rummage around the UNC site, it has some cool compounding stuff. Compounding is an art form. It’s a shame that it’s going to be non-existent in another 10 years. I digress. While I was searching for information on compounding tablets I came across the video below from a company called LFA Tablet Presses. They sell a small hand held pill press. Never seen anything like it, until now.

Yesterday I came across the CVS Caremark medication adherence site. Say what you will about retail pharmacies, but this site has a wealth of information regarding medication adherence. “The information was compiled using CVS Caremark’s comprehensive database and looking at medication adherence factors for four common chronic disease states – hypertension, dyslipidemia (high cholesterol), diabetes and depression.” The interactive map allows you to drill down to various data points for each state. It’s pretty impressive. It’s also eye-opening.

There’s an interesting conversation taking place at ASHP Connect about cart-fill models versus cart-less models for inpatient pharmacy distribution. It’s interesting because it appears that things are beginning to cycle back around. I see quite a mix when I’m out visiting pharmacies. I would say that the cart-less, decentralized model remains the predominant model at the moment. I have, however, come across several pharmacies that are moving away from a cart-less, decentralized dispensing model in favor of “just in time dispensing”. That’s a bit of a misnomer because it’s not really just-in-time, but rather several small batches generated at key times throughout the day. The pharmacies that I’ve come across using this model seem quite satisfied with it. Honestly it’s six of one, half dozen of another if you ask me. The facilities that appear to be most satisfied with either model are those that have strong leadership and workflows that have been well designed to meet the needs of their particular practice environment.

MedPod by DayaMed is a pretty interesting piece of technology. I discovered it after following a Tweet from Charles Webster, MD. The article referenced in his Tweet has to do with using BlackBerry QNX in medical devices. From the article: “DayaMed, a developer, manufacturer and distributor of pharmaceuticals and consumer medical devices, is one company that has gotten behind QNX and the BlackBerry platform.” The device is slightly bigger than I thought it would be. Watch the video below for a better explanation of what the MedPod does; try to get past the cheesy marketing verbiage. Is it just me me, or do the menu buttons on the device (approximately 2:20) look like Android navigation?

The Candid Pharmacist: “A key tool in the implementation and success of the ACA is the creation of Accountable Care Organizations (ACOs).  These healthcare organizations are designed to tie provider reimbursement to “quality” metrics and reductions in the total cost of care for the patient population within the ACO. As you and I know in the case of pharmacy “quality” metrics can mean only one thing – churn out the scripts faster! …The only way to meaningfully lower labor costs in a pharmacy is to cut pharmacist wages and hours….These trends are onerous and fraught with danger for the patient.  There will be even fewer pharmacists checking more prescriptions with less time to screen for interactions and incompatibilities and less time to counsel.  Patients will leave the pharmacy not understanding how to correctly take their medication,  what side effects are possible, what the medication is for or what other drugs and foods they should avoid while taking it.” – The article is longer, and I’ve only taken bits and pieces of it, but I believe what he sees as a problem I see as the opportunity. Pharmacists shouldn’t “churn out prescriptions” nor should they be “checking more prescriptions”. This is the fundamental problem of the profession. Technology should be churning our prescriptions and a combination of technology and pharmacy technicians should be checking them. Pharmacists should be on the front end of things evaluating therapy, speaking with patients, developing methods to improve medication adherence, performing medication therapy management and so on. To do otherwise means the death of a profession.

I used my Samsung ATIV tablet extensively while at the ASHP Summer Meeting to take notes in Microsoft OneNote as well as follow along with presenter’s slide deck with PDF versions of their presentations. Even with the ATIV’s exceptional battery life – Atom processor – I ran into problems on a couple of long days. This makes me happy that I went with the Atom processor over the Core i5. The Core i5 machine would have been quicker, but honestly would have given me only about 50-70% of the Atom’s battery life. As a technology enthusiast I have to believe that battery technology is the next frontier for mobile computing.

It appears that Microsoft may be ready to drop the price on their Surface RT tablets. That makes sense to me as the Surface RT hasn’t garnered nearly the good press that the Atom-based Windows 8 machines in the same price point have. If the Surface RT really does drop to $399 I might pick one up just for my own experimentation. I’ll be in Los Angeles next week picking up my daughter from UCLA for the Summer, and there just so happens to be a Microsoft Store a couple of miles from the UCLA campus. Sounds like a visit is in order.

I am a big fan of hot chocolate. It’s the perfect companion on a cold morning, and I have my favorite recipes. With that said, I’ve never seen the method shown below. Katherine Anne Confections in Chicago has a pretty unique take on one of my all-time favorite drinks. Of course I won’t be making this anytime soon, but I’ll file it away for winter.

Only 89 days until the NFL season kicks off.

Have you ever wondered what would happen between Bugs Bunny and Elmer Fudd in real life? Well, now  you know…

That’s it folks, I am outta’ here. My goals for the day are to put up a new mailbox and rip out a tree before the mercury tops 100 degrees F. The high today is supposed to be 110. Yeah, welcome to the Central Valley.

sig