Saturday morning coffee [September 23 2017]

It is better to be hated for what you are than to be loved for what you are not.” ― André Gide

So much happens each and every week, and 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…

Itreigned supreme at the box office for a second week in a row, bringing its total domestic gross to nearly $220 million. Not bad for a movie I will never see. I’ve never understood the human psyche that drives people to want to be scared. The world is scary enough already, and it’s free.

Speaking of movies, earlier this week my wife and I threw our hard-earned money at American Assassin. It wasn’t a bad movie, but it’s probably not something you’d want to pay full price for either. Michael Keaton is one of the co-stars. He plays an ex-Navy Seal that’s now used by the CIA to train covert spies, i.e. assassins. I swear there was one point in the movie where his character was going off the deep end a bit and all I could think was Beetlejuice.

Los Angeles Times: “A state pharmacy inspector made a surprising discovery last year while conducting a routine records review at a Westside facility that compounded drugs for patients at UCLA medical centers…More than 1,000 IV bags of sterile medications for heart patients and others with serious health issues had been made with expired and potentially dangerous ingredients, according to state Board of Pharmacy records.” Oops. The list of expired items included monosodium glutamate monohydrate (MSG) and monosodium aspartate monohydrate (MSA), clopidogrel, mexiletine, and estradiol. The dates on those drugs ranged from November 2015 to September 2016, a month before the inspection. While there is no excuse for using expired medications, it’s likely that no harm would come from it. In fact, the FDA has recently started to question the expiration date practice of drug manufacturers.

Looks like a theme park ride, although I doubt the people on the station platform were having much fun:

I was in San Diego last weekend to celebrate my daughter’s birthday. While there, we visited a local mall where Amazon was showcasing the Smart Life Roadshow. Basically a trailer with all kinds of smart appliances connected to the Amazon Alexa. It was pretty cool. I have both an Amazon Alexa and a Google Home. The Alexa resides in my living room and the Google Home in my kitchen. They are similar in many ways, but I prefer the Google Home. My wife, on the other hand, seems to use Alexa more. Just goes to show that there’s a place for all these smart devices. The only thing I find creepy is that they are always listening.

My wife drives a 2017 Dodge Charger. Nice car. During our trip to San Diego, I had an opportunity to spend a lot of time behind the wheel using Android Auto, which is built into the Charger. Super nice setup. With my phone connected to the car, I was able to do all the things I normally do on my phone via voice control: navigation, look for places to eat or get gas, ask questions, play music via Google Music or Spotify, and so on. Not to mention I was able to use the giant touchscreen in the middle of the dash to do the same. It was cool. Something I’ll definitely look for when I finally decide to replace my truck.

I found myself using the term eutectic at work this week. “A eutectic mixture is defined as a mixture of two or more components which usually do not interact to form a new chemical compound but, which at certain ratios, inhibit the crystallization process of one another resulting in a system having a lower melting point than either of the components [1]. Eutectic mixtures, can be formed between Active Pharmaceutical Ingredients (APIs), between APIs and excipient or between excipient; thereby providing a vast scope for its applications in pharmaceutical industry. Eutectic mixture formation is usually, governed by following factors: (a) the components must be miscible in liquid state and mostly immiscible in solid state [1], (b) Intimate contact between eutectic forming materials is necessary for contact induced melting point depression [2], (c) the components should have chemical groups that can interact to form physical bonds such has intermolecular hydrogen bonding etc., (d) the molecules which are in accordance to modified VantHoff’s equation can form eutectic mixtures [3].” (source: Journal of Developing Drugs)

Anyone remember Hostess Zingers? I was having a conversation with one of my colleagues this week, and she told me that she had never heard of a Zinger. Those little raspberry cakes of gold are a solid childhood memory for me. Are they no longer a thing? Does that mean I’ve outlived my usefulness because I’m out of touch? Heck no! It means I need to buy her a box of Zingers.

Engadget: “Researchers at BYU have introduced a non-interfering solution: A nanofoam cushioning that measures impacts in real-time… The foam can be inserted in helmets and padding to track collisions via electrical signals and wirelessly send the data to tablets and devices held by coaching staff on the sidelines. It’s designed to operate quickly, too, informing coaches how hard a player has been hit — and whether they’re at risk of a concussion and should be pulled off the field.” – Pretty cool.

And just for the heck of it, let us all watch how balls of steel are made….

Have a great weekend, everyone.

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It’s time to disrupt pharmacist order verification

Several years ago there was a debate over the long-time practice of having pharmacists review all medication orders prior to administration; referred to as nearly universal prospective order review (NUPOR).(1) At the heart of the debate was whether or not such a process was still relevant in the changing face of healthcare, i.e. do pharmacist really need to see every single medication order prior to that medication being administered to a patient?(2)

The argument in favor of universal medication order review is obvious: ensure complete, accurate orders. The argument against universal medication order review is that it’s expensive, time-consuming, and unnecessary in most instances. My own personal belief is that the practice is antiquated and should be changed.

The introduction of electronic health records (EHRs) has changed the medication order entry landscape. No longer do pharmacists interpret and enter orders from hand-written orders on paper faxed to the pharmacy. Those days are mostly behind us. These days, medication orders are generated electronically from pre-defined, pre-built entries in the EHR. Providers simply check a box and bam, order entered. Or as one pharmacist put it in a discussion forum recently “I mean an order set that has been checked by pharmacy, checked by a physician, checked by nursing, approved by P&T / Medical Ethics ….how many times do we need to verify it?”. I feel the same way.

In the rare case that no checkbox is available, today’s EHRs are intelligent enough to provide directions for the user. Not to mention that a majority of medication orders processed in a hospital are simple, routine, and require no critical thought. It is the exception rather than the rule to see an order that requires any deep thought or intervention.

There are those that argue that taking pharmacists out of the order verification role is dangerous, but nothing could be further from the truth. Having pharmacists verify orders is retroactive, at best. What percentage of orders require a pharmacist’s intervention? 10%? 5%? Hard to say, but the percentage is small.(3) The same pharmacist mentioned above said it best: “I did a cursory look and for one month out of 150,000 orders verified, only 5,000 had an intervention performed on them. So 3% of the time we are actually doing something significant enough to warrant an intervention.” So current best practice has pharmacists — a highly trained, expensive professional — looking at 100% of orders in an attempt to find the 3% that have problems. Seems kind of silly.

I often look to the model used in poison control centers for support of my opinion. Non-pharmacists screen calls at poison control centers. If the call can be handled via a well-thought-out algorithm, then it’s handled. If not, the call is escalated to a pharmacist. In other words, pharmacists are only getting the calls that require their particular brand of expertise. That’s poison control! Think about it.

The days of having a pharmacist look at each and every medication order entered into an EHR are over. It’s an antiquated process that’s long overdue for an overhaul. The time has come for healthcare systems to make better use of their personnel.

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  1. People love their acronyms. I’ve always called it “order verification”.
  2. The answer is obviously no, pharmacists do not need to review every single medication order before that medication is given to a patient. But, people like to argue.
  3. I’ve said many times that a monkey could do my job. While my comments are flippant, the sentiment rings true. I could train an intelligent teenager to do 80% of my job in a couple of short weeks. On a side note, I’ve never had a single person challenge me regarding my monkey comment. Seems odd, don’t you think? I mean, it’s insulting.

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Sutter Health partners with Qventus for real-time analytics

FierceHealthcare: “That’s what led them to invest in a new platform that went beyond algorithms and software to emphasize the data’s tangible impact on clinician workflow and hospital operations… Although Sutter Health has worked with the company [Qventus] on several other initiatives targeting patient throughput, the pharmacy pilot is the system’s first significant foray into leveraging real-time or near-real-time analytics to influence care decisions. Beyond the machine learning platform, Sutter was drawn to the workflow specialists dispatched by the company to follow pharmacy care teams in order to better understand the ideal format to deliver data-driven insights.” – Sutter is a big organization. They have the resources and the desire to do some pretty amazing things. I’ve had the opportunity to speak with them on a few occasions and found them open to things outside the traditional pharmacy box. That’s truly rare in pharmacy these days.

Sutter is planning to target cost and quality using the Qventus AI-based software platform. I’m not familiar with Qventus. I went to their website, but things were vague. Unfortunately, that’s not uncommon. I find a lot of technology vendors lack good information about their products on their own websites. Strange but true.

AI-based platforms are the future of pharmacy. We simply spend too much time looking for needles in haystacks. Imagine: no more “monitoring sheets”, no more time spent by pharmacists rummaging through every chart looking for that one thing out of place, improved antibiotic stewardship, directed therapy based on patient condition and need, optimized pharmacotherapy, improved inventory management, decreased waste, and so on and so forth. The possibilities are endless.

Let’s hope that Sutter shares their experience with the rest of the world so that we can all learn from their initiative.

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Saturday morning coffee [September 16 2017]

Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?” — Matthew 7:3 (NIV)

So much happens each and every week, and 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…

It’ was #1 at the box office last weekend, bringing in more than $120 million. Expect it to stay there for at least one more weekend. I won’t be seeing it any time soon. Not my kind of movie. Expect more scary movies to hit the box office as we approach Halloween.  

Deadline Hollywood: “It’s an age-old excuse, but, yes, blame this summer’s box office depression on too many tired tentpoles that underperformed. That’s what happens in a product-driven business.” – I feel like this is true. Some of this year’s franchise movies weren’t very good, i.e. Pirates of the Caribbean: Dead Men Tell No Tales, Alien: Covenant, and Transformers: The Last Knight to name a few.  

The FDA recently released a safety alert calling for “separating the dosing of sodium polystyrene sulfonate from other orally administered medicines by at least 3 hours…  A study found that sodium polystyrene sulfonate binds to many commonly prescribed oral medicines, decreasing the absorption and therefore effectiveness of those oral medicines.”. Sodium polystyrene sulfonate (SPS) is commonly used to treat hyperkalemia — a potassium level that’s too high. It’s kind of an odd alert as I would have thought this was common sense. It’s a freaking binding agent that preferentially exchanges sodium ions for other ions for Pete’s sake!

MedicalXpress: “In recent years, researchers have identified substances in coffee that could help quash the risk of developing Type 2 diabetes. But few of these have been tested in animals. Now in study appearing in ACS’ Journal of Natural Products, scientists report that one of these previously untested compounds [cafestol ] appears to improve cell function and insulin sensitivity in laboratory mice.” – It’s coffee time! Coffee, coffee, coffee, coffee…

Bloomberg: “Here’s a fact you have to write down to believe: Over the past 10 years, during which the world has adopted smartphones and social media, sales of fountain pens have risen… Retail sales, in particular, have grown consistently. In 2016 they were up 2.1 percent from the year before, making fountain pens a $1 billion market, according to a report by Euromonitor International.” — I enjoy using fountain pens, and have several. My most recent acquisition is a Pilot Vanishing Point. Neat pen. Retractable nib. 

Jalopnik: “Tesla briefly sold a 60 and 60D trim level of its Model S and Model X vehicles. These models had 75 kWh battery packs installed, but were software limited to have less range to artificially create a more affordable entry-level tier for buyers….With category four Hurricane Irma headed straight for Florida, Tesla unlocked the full capacity of 60 and 60D model owners in Florida to give them about a 30 mile range boost while evacuating.” – Tesla is getting a lot of praise for doing this. On the surface that makes sense, but why would you put an artificial limit on the car straight off the production line. Can you imagine if Chevy or Ford said, “here’s our new V6. It gets 30 miles per gallon, but we tune it down to 22 miles per gallon unless you pay us more”. Think about it.

Xiaomi announces the Mi Mix 2 and Mi Note 3, a better bezel-less flagship and mid-ranger for the end of 2017. With the price of smartphones at or above $1000, it’s time to search for an alternative. 

Looks like Google is ready to drop the curtain on the Pixel 2. “Google hasn’t yet sent out invitations to its next event, but it is beginning to tease it. After sightings of a billboard in Boston suggested that we “ask more of our phone,” Google has thrown up a homepage for the entire world with the same notion — the Pixel 2s are coming.” (source: Android Central). I have to admit, the Pixel and Pixel XL just didn’t do it for me. My wife and daughter both carry the Pixel XL. Meh.

Healthcare IT News: “AMA demands EHR overhaul, calls them ‘poorly designed and implemented’…Latest study confirms typing and clicking consume more than half the workday for doctors.” – Ya think?

Ars Technica: “The situation at Cooley Dickinson is not unique; patients nationwide are being potentially misled about the quality of their care. According to data collected by the [Wall Street] Journal, hundreds of hospitals with federal safety violations continue to boast accreditation and a “Gold Seal of Approval” from the Joint Commission, a nonprofit that the government relies on to accredit almost 80 percent of US hospitals.” – This really isn’t a surprise. The Joint Commission is a joke. They give hospitals tons of warning prior to their “inspections”. And of course, they do a superficial job of looking around. I think they should just pop in without warning and do a deep dive. I could certainly tell them where to look. 

I watched a slew of college football games last weekend. A couple of minor surprises, like Oklahoma over Ohio State — for which I am eternally grateful — and how much trouble Washington State had with Boise State. The PAC-12 looks pretty solid as does the SEC, as usual. Looking forward to watching a few this weekend as well: USC vs. Texas and Louisville vs. Clemson, for starters.

As far as NFL games from last weekend, I didn’t watch a single one. That’s the first time that I can remember that I didn’t sit down on a Sunday and watch the NFL. You want to know something? I don’t really miss it.

I gotta’ go to work now. Have a great weekend, everyone.

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IV workflow management systems and workarounds

A large portion of the most recent issue of the ISMP Medication Safety Alert is dedicated to IV workflow management systems (IVWFM) and errors caused by workarounds. There are a few head-scratchers in the list to be sure. There are even some that had me speculating their authenticity, i.e. too wacky to believe.

Data submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP) have repeatedly shown that manual verification of intravenous (IV) admixture ingredients by pharmacy personnel who prepare solutions and pharmacists who inspect the final products is not particularly effective in detecting and correcting errors.” You can take this to the bank! Rule #1: people are people. They make mistakes and do crazy things sometimes. Rule #2: no amount of technology will eliminate rule #1.

However, as with any new technology that introduces an element of change, we want you to know about the workarounds and errors we have learned about with WFMS and why they may be happening so you can be as prepared as possible to address the when you assess or implement this technology. Some of these workarounds or errors are common to many other forms of healthcare technology.”

This is no doubt true as I’ve witnessed workarounds with pharmacy technology on many occasions.The sad truth of the matter is that no amount of technology will prevent people from finding workarounds. Just like no amount of manual processes and double checking will prevent workarounds. Unfortunately, these workarounds can lead to mistakes, which is what we are ultimately trying to prevent.

Typically, it is a combination of well-defined processes with appropriate technology that creates the safest environment. It’s also the best way to prevent workarounds. That and opening a can of whoop ass on people that don’t follow the rules; figuratively speaking, of course.

Here are some of the potential workarounds and errors identified by ISMP, many of which are similar to those seen with bar-code medication administration (BCMA):

Inability to scan the barcode — This is a common problem with any bar-code scanning process, i.e. BCMA, etc. Barcodes are far from perfect and will never be 100% scannable.

Reluctance to scan the barcode — Human nature. Go figure.

Scanning just one vial — i.e. scanning a “representative vial” when using more than one vial during CSP prep. Happens all the time.

Using a decoy for scanning or image capture — the old barcode-in-the-pocket scam.

Using the syringe pull-back method — hard to imagine that this is still going on in pharmacies across the country. It should be banned. Any facility caught using the syringe pull-back method should be fined heavily and mocked openly for their laziness.

Blurry or missing digital images — I’ve experienced this personally. Here are some images from one popular IVWFM system that were given to me. Can you tell, without any doubt, what the volumes are in these syringes? [If anyone has any sample images, I would love to see them]

Lapses in technique. “Use of WFMS touch screens can lead to touch contamination, especially when handling hazardous drugs. This and other lapses in hazardous drug handling and aseptic technique are not easily captured by the WFMS and may go unnoticed.” — No doubt a problem. Regardless of what technology you add to your process, proper technique in the hood is a must.

Interference with the scale. “ISMP has received a report about a WFMS with gravimetric technology for which the scale would not work in a laminar airflow workbench/biological safety cabinet due to vibration. Every time the pharmacy technician needed to weigh a product, he or she had to turn off the hood [what the heck!].” — not all gravimetric solutions are equal. There are at least two IVWFM systems on the market that do a great job with their gravimetrics. There is at least one that doesn’t. Any facility considering this technology should make sure to do their homework.

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A “no-mistakes sponge system” — bar-coded sponges in the OR

While not directly related to pharmacy, the SurgiCount Safety-Sponge System is kinda’ cool. The system uses low-tech barcode technology to prevent surgical sponges from being left behind in patients. Simple yet effective.

The system uses sterile bar-coded sponges and a computer tablet loaded with proprietary software to ensure that all sponges are tracked. After approximately 11 million surgical procedures over the last five years, which involved the use of more than 200 million sponges, the system boasts zero sponges left behind.” source: MLive

The lowly barcode gets a bum wrap sometimes. It’s far from perfect, but overall I believe the use of barcodes has improved safety throughout the healthcare environment. I remember just a few short years ago when barcode scanning was uncommon. Now, not so much. “Overall, 92.6% of hospitals have barcode-assisted medication administration (BCMA) systems to verify patient identity and electronically check doses administered by nurses (Table 2). Over the past 13 years, the percentage of hospitals having BCMA has increased from 1.5% in 2002.“(1) I get calls in the pharmacy from nurses refusing to administer medication because they’re unable to scan the medication barcode. We’ve come a long way.

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(1) Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2016. American Journal of Health-System Pharmacy. 2017;74(17):1336-1352. doi:10.2146/ajhp170228.

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Pearson Medical Technologies introduces m:Print Version 3.9.1

This came through one of my Google Alerts this morning.

Life Pulse Health Magazine: “Pearson Medical Technologies’ [PMT] … m:Print Version 3.9.1 has been updated to use Microsoft SQL Server 2012/2014 for more efficiency and advanced performance. Each packaging run can now automatically generate a unique lot number. Most importantly, Pearson Medical has added a bar code constructing module which allows users to add more than one drug information into a bar code… in addition to the release of a new version of m:Print , we have selected Medi-Span to provide the drug database for use within m:Print.”

m:Print is a great stand-alone option for pharmacies looking to print bar code labels for vials, ampules, syringes, IV bags, etc. The system is well liked by many. In fact, PMT has OEM’d m:Print for other companies as their bar code printing solution. So if you have an inventory management system from another company and m:Print looks familiar, that’s probably because it’s the same software, minus some minor UI tweaks.

I personally like m:Print, mostly due to its flexibility. It offers the ability to use virtually any printer or label type. You can customize labels just about any way you see fit, including the use of 2D and/or linear bar codes.

I had the opportunity to get a sneak peak of m:Print version 3.9.1 prior to its release. Overall, there are some nice improvements. Chances are, if you liked the system before, you’re probably going to like it even better now.

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Disclaimer: as a consultant, I’ve done work for PMT and with companies that have partnered with PMT.

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Nonadherence to diabetes medications costly

This is follow-up commentary to an article I Tweeted about earlier this week.

JCP: “[Express Scripts] found that patients who were adherent to oral diabetes drugs had 235 fewer emergency department visits and 50 fewer inpatient hospitalizations per 1000 patients, resulting in an average of $500 saved per patients and a total decrease of $210 million in health care spending in 2016…Patients who were nonadherent were found to have 1.3 times higher medical costs and 4% higher total health care costs compared with adherent patients, a difference of $11,176 vs $10,683, respectively.” – No surprise. Poor control of chronic diseases like diabetes can lead to lots of complications, including admission to a hospital for advanced care.

Nonadherence to medication is tricky. Proposed solutions to the problem are many. Actual solutions to the problem are few. The issue is that there’s no one-size-fits-all approach to the problem. People behave like people. Some will do a great job managing their disease, while others won’t. The more complicated the disease management, the more likely that adherence will slip. And management of patients with diabetes can get very complicated.

The difficulty comes when multiple healthcare providers are involved. There are often multiple medications, complicated administration regimens, and so on. I witnessed this firsthand while caring for my mom during the last year of her life. She was a complicated patient, and her medication regimen changed frequently depending on the physician seen and which area of the disease was the focus of treatment; the old whack-a-mole approach to medicine. With that said, my mother was a best case scenario. Her ability to manage her medications was inspiration. However, even as a pharmacist I found it difficult to keep track of what was going on at times. There were times when I would re-sort and organize her weekly medications three times in a ten day period. Crazy.

My opinion is that adherence strategies are still in their infancy. There are simply too many variable when it comes to patients take their medications correctly. The most important thing, in my opinion, is getting people to take a stake in their own disease management. That should be the primary goal. The rest is window dressing at this point.

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Has adoption of IV Workflow Management Systems in hospital pharmacies slowed?

Pharmacy Purchasing & Products (PP&P) puts out a survey each year called The State of Pharmacy Automation (SOPA). The 2017 PP&P SOPA is out and available for your reading pleasure.

The PP&P SOPA survey covers many automation, technology, and practice trends. One item that I look at each year with great interest is the reported IV workflow management system (IVWFMS) adoption rate. I’ve written about IVWFMS many times. I even went as far as to do a podcast dedicated to them back in 2015.*

While reviewing the 2017 SOPA numbers, I was surprised to see that this year’s survey shows no gain in adoption of IVWMS over last year. They appear to be stalled at approximately 19%, same as last year (see graph from PP&P 2017 SOPA below).

While informative, it’s important to take these survey results with a grain of salt. Response rates are incredibly low, for one thing. Results can also be skewed based on participants, i.e. it may not be the same pharmacies responding year over year. This makes it difficult to draw direct comparisons from one year to the next. 

Regardless, I was still surprised to see the flattened curve. I expected to see a sharp uptake. Most facilities I go into these days are using, or in the process of implementing, an IVWFMS of some kind. It’s becoming less common to find a facility not using one of these systems, especially in larger facilities where they seem to be slowly becoming best practice.  

One other item worth mentioning is my belief that last year’s survey overestimated the number of facilities using IVWFMS. So if last year was really 12-15%, perhaps this year’s result is an improvement. That’s purely speculation on my part. I have nothing concrete to back it up other than my sense of the market. Through no fault of PP&P, I feel like these surveys are a poor representation of what’s really going on in the real world.

Other takeaways from this year’s survey:

  • Larger hospitals are adopting IVWFMS faster than smaller hospitals. No surprise here. If you’re a hospital with more than 400 beds and you haven’t implemented one of these systems, you’re wrong and should be embarrassed by your lack of action. “Ninety-nine percent of the failures come from people who have the habit of making excuses.” ~ George Washington Carver. Simple as that.
  • DoseEdge by Baxter is the #1 system in use. Again, no surprise. This corresponds to what I see in the wild. Baxter has been in the game for a while. DoseEdge is definitely the first system that comes to mind when talking about IV room technology. Pharmacy Keeper by MedKeeper at #2 is a bit of a surprise. I have yet to go into a pharmacy that is using it. It’s a less functional system than say DoseEdge or BD Cato, but it’s also less expensive and easier to install, implement, and maintain. I personally believe pharmacies should be looking at systems with proven gravimetrics, but that’s just me. Pick your own poison.
  • DoseEdge by Baxter is the #1 system under consideration for new implementations. BD Cato comes in at #2 by a small margin. DoseEdge at #1 surprises me a bit. Most facilities I go into these days have BD Cato at the top of their list of possibles, and for good reason. BD Cato has a lot to offer, especially now that they are part of CareFusion. Perhaps the survey is a bit behind what I’m seeing out in the wild. Impossible to say.

That’s it. I’m not sure that the raw numbers presented in the survey are helpful, but the information in the SOPA survey goes way beyond the numbers. For instance, the SOPA may introduce pharmacies to vendors and technologies that they’ve never heard of before. I encourage everyone to read through the PP&P 2017 SOPA. Who knows, you might find something new and exciting in there. I’ve been doing this for many years, but I still get surprised from time to time. 

I can’t explain the SOPA survey results, but overall it feels to me that adoption of IVWFMS is still on the rise.

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*Looking back through some of my old posts — and the podcast — it’s amazing how little this landscape has changed.

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Saturday morning coffee [September 2 2017]

Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?” — Matthew 7:3 (NIV)

So much happens each and every week, and 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 Hitman’s Bodyguard was #1 at the box office last weekend, making it two in a row. It’s a decent movie. Not as funny as one might think, or hope. My wife and I both thought the same thing, Ryan Reynolds playing Deadpool without the costume.

Speaking of movies, this Summer hasn’t been kind to the Hollywood bottom line. From the New York Post: “Heading into the next-to-last weekend of the summer movie season, the US box office was running 13.4 percent below last summer, according to comScore.” Take it from someone that likes watching movies on the big screen, this summer has indeed been lackluster. The Mummy wasn’t very good. Transformers 5 was bad. Planet of the Apes was too dark and depressing. Atomic Blonde had some awesome fight scenes, but was otherwise meh. Dark Tower made me look at my watch and wonder “how long is this thing”. And the above mentioned Hitman’s Bodyguard was just ok. Wonder Woman was the cream of the crop, leaps and bounds better than any other movie this summer. It makes me desperate for Justice League.

Lest we forget just how powerful Mother Nature can be, Houston, Tx is literally under water following Hurricane Harvey.

Alabama is sitting pretty at #1 in this year’s first preseason Top 25. And there they will sit until someone knocks them off. I think it’s going to be a great year for college football. As for the NFL, not so much. I’ve lost almost all interest in the NFL. I haven’t watched a single pre-season quarter.

The NSAS Flickr site has some pretty cool images from the eclipse.

It appears that “banana bags” are no longer the treatment of choice for management of alcohol-associated vitamin and electrolyte deficiencies. Go figure. The practice of using banana bags has been called into question secondary to time to infuse, cost:benefit, etc. “Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke’s encephalopathy, we suggest abandoning the banana bag [in favor of different therapy].” — Flannery A, Adkins D, Cook A. Unpeeling the Evidence for the Banana Bag. Critical Care Medicine. 2016;44(8):1545-1552. doi:10.1097/ccm.0000000000001659.

Calcium Gluconate is the calcium salt of gluconic acid, an oxidation product of glucose. It’s commonly used in healthcare, even more so now that Calcium Chloride is hard to get. The 10% solution, pictured below, is supersaturated and stabilized by the addition of calcium saccharate tetrahydrate. The problem is that supersaturated solutions are prone to precipitation. I was basically unaware of the problem until I found this bottle. I Tweeted about it and received multiple responses indicating that “it happens all the time”. In my 20 years, I don’t recall ever seeing this before. Some propose that it’s the warm California weather that prevents it from happening. Maybe.

In the wake of what went down in Charlottesville, some groups were kicked off the internet. For example, Cloudflare Inc., an internet security service, cut ties with the neo-Nazi website the Daily Stormer. While everyone seems to agree that these people are aholes, I think we’re getting into some pretty dangerous territory. Even Cloudflare’s CEO, Matthew Prince thinks so, and he’s the one who pulled the plug on Daily Stormer. According to Prince he “Literally… woke up in a bad mood and decided someone shouldn’t be allowed on the internet. No one should have that power”. He’s right, no one should have that power. Everyone believes in the right to free speech and having their own opinion until someone else’s opinion doesn’t agree with their own. At that point rational thought goes right out the window. Whether I disagree with Daily Stormer’s views is irrelevant. I have no idea what their views are. I’ve never been to their site. I am not a neo-Nazi nor do I believe in their cause, at all. Until the Charlottesville incident I had never even heard of them. However, that’s not the point. What if someone woke up one day and decided I shouldn’t be allowed on the internet because of my views? That’s some scary stuff right there. Think about it.

There’s an interesting article at Ars Technica about the slippery slope we’re on with internet censorship.  

Android Authority: “The official Android 8.0 release is here: Android Oreo officially arrived Monday August 21 during the solar eclipse. The over-the-air (OTA) update began rolling out immediately to supported Pixel and Nexus devices and factory images were posted on the Android Developers’ site the same day.” – Android 8.0 – Orea – will include the following new features: Picture-in-picture, Notification dots, simplified autofill framework to simplify how users set up a new device and synchronize passwords, system optimizations and background limits, auto-sizing textview, adaptive icons, shortcut pinning, and a few things under the hood that are over my head. My wife’s Pixel XL received the update a couple of days ago. I’m jealous. 

The Essential Phone is finally available, sort of.  While I appreciate the engineering that went into the device — and it is beautiful — the reviews have all said the same thing, it’s a beautiful phone that’s not quite up to par in certain key areas.  Not to mention, the company has suffered from shipping problems and at least one email slip up. As much as I link new toys, there’s just nothing there to entice me.

IFA 2017 is going on in Berlin as we speak. I love reading about all the cool stuff that shows up at IFA each and every year. In years where I’m thinking about buying a new laptop — like this year — I typically wait to see what drops at IFA before making a decision.

The Samsung Note 8 was recently announced. My Note 5 was the best smartphone on the market when I bought it, and it still kicks butt. From what I’ve seen and read, the Note 8 is better in almost every way, with a couple of minor exceptions. It looks like Samsung has the best smartphone on the planet, again. For your reading pleasure: 10 Reasons you’ll love the Note 8

Chrome Unboxed: Chrome Tip To Help Those Who Use Lots Of Tabs: “Take your files app, for instance: you can hold CTRL and select multiple items or hold SHIFT and select a range of items with just a couple clicks….That’s right, you can hold CTRL and select multiple tabs. After this, you can grab any of the selected tabs and move them around as a group. Likewise, if you click one tab, hold SHIFT, and then click another tab, all the tabs between are selected and can be moved as a group.” – I’m a longtime user of Chrome and had never heard of this tip before. Very useful. 

Speaking of Chromebooks, I’m thinking about giving them another try. Even after my recent failure, I’m still drawn to them. This time around it’ll be either a Samsung Chromebook Plus or Asus Chromebook Flip C302, I think.The Samsung Chromebook Plus has the edge, but the stupid thing doesn’t have a backlit keyboard. Then again, I’ll wait until IFA is over before making any decisions. 

I continue to be amazed by the quality of images captured by smartphones. The image below was taken with my two-year old Samsung Galaxy Note 5 while out walking my dogs. 

Have a great weekend, everyone.

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