University Place

Good afternoon. I'd like to welcome you to the Better With Age series put on by the UW-Health Division of Geriatrics. My name's Marje Murray, and I'm the director of geriatric services. And it is my great pleasure to introduce Professor Joe Zorek from the School of Pharmacy to talk to us today about maximizing your medications. Well, thank you guys for coming. Very much appreciate it. Marje invited me to talk about medication use and safe medication use, and so I've prepared a talk that'll be about 45 minutes, mostly focused on the big picture, so common errors that happen in the medication use process and how to avoid those things when you're a patient trying to navigate what's a pretty complex medication use system. Little bit, very quickly, about myself. I'm a licensed pharmacist. I got my pharmacy degree from the University of Illinois in 2011. That's a Doctor of Pharmacy degree. I did two years of specialized training, postdoctorate training at Texas Tech University. And that was in Amarillo, Texas, where I focused, most of my clinical focus was on older adults. I got experience researching and doing research on team-based health care. So geriatric care and teamwork within the health system, they're very closely related. And, as you can see from my current position at the University of Wisconsin, I'm doing a lot of the same things. So at the School of Pharmacy, I teach in our geriatric pharmacotherapy course. That's teaching pharmacy students, so future pharmacists, how to help older adults use medication safely and effectively. I also teach a course called Pathways in Pharmacy Practice, which isn't necessarily that related to here, so we'll gloss over that. And as a pharmacist working in academia, one of the things I do in my division, all of us who are pharmacists in my division practice, and so I spend some time each week at Dean Health. How about a show of hands? Does anybody see a provider at Dean? Okay, so we have some people in the audience. And Dean is committed, very renewed commitment, to leveraging the expertise of pharmacists to help reduce medication risks in the whole population. And what I do there is I work to help lower those risks in older adults. So, as you can see, I have quite a bit of experience, and I hope that this is an engaging talk for you, and I hope that we can generate some good questions at the end. So I just very quickly would like to acknowledge two people. Dr. Amy Blaszczyk from Texas Tech, a colleague of mine, she shared some material that helped me shape these slides. And I'd also like to thank Dr. Walsh. How about a show of hands as well? Who was here for Dr. Walsh's talk last month? Okay, well, that's actually, oh, there we go. Yeah, excellent. And so Dr. Walsh was kind enough to share her slides, and since she focused on medications, and I was asked to focus on medications, it's very helpful to see those slides to make sure what I'm talking about is a different angle. And so you'll see that today we're not gonna talk about some of the same things that you did last month. We're gonna have a little bit different spin on today's presentation. The overarching goals are really to share with you some common medication-related problems and to help you avoid them. Beyond that, if we have some time, I'm hoping to talk about how pharmacists are trying really hard, in the community setting especially, to move away from just checking that your drug is safe and giving it to you to actually sitting down with you, working with you just like other health care providers do, again, focused on making sure your meds are safe. And I'm gonna hope at the end of this that you will be inclined to connect with your pharmacist wherever you pick up your meds and ask them questions to help maximize your medication therapy. So the first thing I wanna do is talk about some common medication-related problems. Several years ago, about 15 years ago, the Institute of Medicine published a very nice report that has started a snowball effect within health care towards safety, and a focus on safe use of medications in particular was one of those foci. The types of errors they identified you see on the screen here. I'm gonna talk today about the medication focused ones. So errors in dosing or methods, we'll talk about those two. Pharmacists like to separate those things. Dosing errors and methods errors, we'll talk about those separately. Inappropriate care is another topic that we'll single out. Has anyone heard of the prescribing cascade? Okay, so I'm glad you're shaking your head no 'cause we're gonna talk a little bit about that today, and this is something that would fall into that category of inappropriate care. Inadequate monitoring or follow-up. I was talking to some of you before we started, and you shared that many of you are taking some dangerous drugs. Warfarin was an example that came up. We'll talk about the importance of monitoring drug therapy and what role pharmacists can play to help you do that. And this is the big one, this failure in communication. This is a multi-system problem. There's a lot of communication that has to take place around your medications. Your prescriber, there might be a nurse practitioner or a nurse. You might be prescribed a medication related to pain, and you might be working with a physical therpaist, for example. And then ultimately pharmacy gets looped in too, and oftentimes pharmacy gets looped in in a way that isn't very good for us to keep open lines of communication, and that leads to a lot of medication errors. So that same Institute of Medication published five years after that initial report a specific report focused on medication errors. Oftentimes, health care providers talk about items dealing with health care in a way that's not very conducive to regular, everyday people, and so I wanna make sure we're on the same page as far as terminology goes, and I wanted to share this diagram to help get us on the same page. So when I talk about a medication error, you'll notice that this is the biggest bubble in the diagram. These are errors within medication use that may or may not lead to harm, okay. When it does lead to harm, that's when we classify that kind of medication error as an adverse drug event. And so what this leaves out, though, so now that we know medication errors are anything dealing with medication use. Adverse drug events are the ones where if you take the drug and it leads to injury and hurts you, that's an adverse drug event, but what that leaves out are just regular old side effects. Can I see a show of hands of anyone who's experienced the side effect from medication? Yeah, so a lot of us have, right? A side effect, for the purposes of our talk, we will refer to that as something that happens due to the medication that doesn't harm you. Okay. So we have medication errors, adverse drug events, and then side effects. What do you guys think of this picture? (audience murmuring) Yeah, it's pretty gross, right? This was, when I was a resident, I worked on a medical team. One of the physicians I worked with was an infectious disease specialist. So linezolid, that's an antibiotic. And one day in clinic, Dr. Khasawneh came up and said, "Can you please take a look at this patient? "I think we have an adverse drug event happening." And so I went in the room, and the patient stuck out his tongue, and I said, "Oh! "Oh my goodness. "That certainly look like something's going on." And I wanted to share this. We ended up writing this up and publishing it to share with our colleagues around the country, and I thought I'd share it today 'cause I think it's a good example of the difference between an error, an adverse drug event, and a side effect. And so this is certainly a disconcerting event, but it didn't necessarily hurt the patient, so, from our perspective, we would call this a side effect. It's a rare one, and it's very interesting but a side effect, not an adverse drug event, 'cause it didn't cause harm. Does anyone recognize Dennis Quaid? Star of many interesting and fun films. So Dennis Quaid, as the image shows, has become a very strong advocate for patient safety. Does anyone know why? Show of hands? Okay, just one person. That's really good. I'm glad this will be some new information related to dosing errors. So that first error I really wanna focus on is dosing, getting the right amount of drug into your body. So Dennis Quaid and his wife gave birth to twins in 2007. And they were in the hospital, and they were about, I think, 10 or 11 days old when they experienced a dosing error that almost took both of their lives. And has anyone heard of heparin? Okay, yeah, a lot of head shaking. So most people have experienced use of some kind of blood thinner we'll call it. So heparin is a blood thinner, and it comes in very different doses, and the vials, when you see them, they're very similar. One of them is a really, really low dose, and it's used to keep, if you've ever had an IV, sometimes they will put a little bit of heparin in there to keep your IV line from clotting or clogging up. But, then, if you're having, before the talk someone was sharing with me that they experienced a pulmonary embolism, and that's like a clot that goes to your lungs, and it can be very, very catastrophic. If you're experiencing a clot like that and the physicians on the medical team wants to bust that clot or break that clot up, one of the drugs they could potentially use is high dose heparin. So what happened with Dennis Quaid's twins is the vials look very similar, and on accident the high dose was given to clear those lines, and it was a thousandfold overdose, so that's an enormous overdose. So, thankfully, the twins survived, but this sort of sparked Dennis Quaid and his wife to start a foundation and dedicate some money and resources to helping minimize medication errors, or medical errors, dosing being one of the big ones. One more story related to dosing errors involves an individual named Betsy Lehman, and Betsy, unfortunately, died from her dosing error. So Betsy was a 39-year-old mother of two who was diagnosed with breast cancer and was undergoing chemotherapy in order to help take care of the cancer. So she, you may well know that chemotherapeutic agents, these sort of cancer drugs, they're very toxic 'cause they have to destroy the cancer, but in the process they can destroy normal cells as well, and so the dosing has to be really, really on point. And what happened in Betsy's case, unfortunately, she received a fourfold dosing error, overdose, and this, unfortunately, led to her death. And in the process, there's another center and foundation in her name formed to help reduce these dosing errors. And I share these dosing examples with you because at the end of today I want you to feel empowered. I want you to feel like you can take charge of your medications, and one of the things you can do is make sure that your dosing is right, and that's something that's within your power. You, your caregivers, and your providers can work collaboratively to make sure those kinds of dosing errors don't take place. The other error is a methods error, and you can see from the slide that there are lots of ways people can stick with you a needle, and I'm sure you've experienced many of these, right? So drugs are designed to be delivered in, specific drugs, for example, are intended to be delivered in your muscle. Has anyone received a flu shot recently? Flu season's coming up. You're gonna get another stick in your deltoid muscle, and it's intended to go into your muscle tissue. Other drugs are also intended to go in your muscle and not into your vein or into you subcutaneous or your underneath the skin tissue. And there's a very common error that happens and has been happening for a long time. I'll share with you a case where a woman had an allergic reaction to shellfish. Do we have any food allergies in the room? No? That's actually really good. I actually, myself, have food allergies, so this is something I'm very concerned about. So she had an allergic reacon to shellfish, and one of the treatments is to give epinephrine or like an EpiPen. You probably have heard that or seen that advertised on TV. Well, unfortunately, this woman received the epinephrine not into her muscle tissue, but accidentally somebody put it into her vein. So it went into her vein, and so instead of staying local in the muscle and slowly getting absorbed, it went right into her circulation, and what resulted from that error was a heart attack. And so, fortunately, she lived through the situation, but I just wanted to share these stories to highlight that these errors are really important for you to pay attention to. I mentioned the prescribing cascade to several of you when we were chatting beforehand, and I wanna walk through this very quickly. I know you saw this last month. This is a little bit different spin and, again, why I emphasize the difference between an adverse drug event and a side effect. So, those of you who have experienced a side effect... Many people who have experienced side effects, they go to their doctor or their nurse practitioner or their physician assistant, and they'll tell them about, "Oh, I'm experiencing a side effect," and it happens sometimes that the prescriber gives them another medication to sort of treat the side effect. And so the common, and you can see this is like a stepwise scenario because oftentimes it can lead to several medications being on your list, and I know some of you are taking upwards of, I think 19 was the number that was the highest in the room when we were chatting. That's a lot of medications, and it's worth your time and effort to work with a pharmacist or your physician to figure out which ones do you need, which ones may be secondary to this scenario that we could eliminate. But the classic example is someone who has arthritis, and I know many of you probably have experienced some arthritis, and they're treating it with Tylenol, and it's not working, so the doctor will say, "Why don't we try something a little bit stronger? "How about some naproxen "or some other kind of NSAID?" Have you guys heard of NSAIDs before? Okay, so we're all pretty familiar. These are a lot of over-the-counter. Did you know that NSAIDs can cause your blood pressure to go up? Yeah, so the reason this is frequently used in this example is because if the provider isn't aware of that sort of common side effect of NSAID use and you use like ibuprofen or naproxen to handle the pain, the arthritis pain, your blood pressure might go up, and the provider might think, "Well, this patient needs blood pressure meds." It's a very common, logical thought if you think about it. And so maybe they give you a water pill. How about a show of hands? Who's taking a water pill in the room? Such a common medication, right? You may know that water pills oftentimes can lead to gout. Has anyone heard that before? So now you've done the NSAID, you've had high blood pressure, they've given you a water pill. Now you're developing gout, and they give you an anti-gout medication. What we train our pharmacy students to do at the University of Wisconsin and elsewhere is really to hone in on proper medication use, avoiding this kind of inappropriate care, so disrupting this prescribing cascade before it starts. So you should be aware of that and talk to your providers about that. I know we have one guest who really wanted to talk about the University of Wisconsin today, and I think this might be my only slide. So does anyone recognize that building? (audience murmuring) It's the WARF building, the Wisconsin Alumni Research Foundation. I have an arrow. You can't see it in the picture, but do you know what building is where that arrow is? -

audience

Hospital. Yeah, someone said hospital. That's a really great guess. It's actually the School of Pharmacy, so where I work. On a daily basis, I'm reminded of the importance of not only the University of Wisconsin and WARF but the importance of proper use of warfarin and other medications. And... I wanna emphasize for you that these meds, most of you are well aware, just like the chemotherapeutic agents, the cancer drugs, they have a very, we call that a narrow window, therapeutic index is what the technical term is. But you have to stay within this very narrow range, and if you go above it, so if you get too much drug, and you're outside of the range, really bad things can happen. And so because I didn't wanna scare you, I left off, I was thinking about adding some really graphic images of the consequences of warfarin overdose, but I decided to go with something a little more light. I'm glad you appreciated that. So within this inadequate monitoring thing. Pharmacy has become, a lot of pharmacists now are trained and they're working in non-dispensing roles. Some of you may have interface with them where they're working a lot like physicians or nurse practitioners where they're meeting with you in clinic. Most of that started with warfarin, which is another reason I love being at the University of Wisconsin because there's such a rich history that ties into pharmacy practice and what pharmacists are trying to do to help you use your medications more effectively. So a lot of pharmacists will do this monitoring for physicians or on behalf of other people on the medical team because of their training. One other area of inadequate monitoring that I wanna bring your attention to is adherence. This is a huge monitoring issue. If I say adherence, can I see a show of hands of who knows what I'm talking about here? Okay, so good. So only a little, only a few of us. So you might be surprised to know that when you are, as a population, physician or a nurse practitioner or a PA writes a prescription. Only roughly one in three people, two out of three people fill that prescription. So 1/3 of all prescriptions where people have a condition that needs to be treated, 1/3 of those people are just not filling the med. So they're not taking the med, right? That's called non-adherence, right? So taking the meds as directed is called adherence. This is also a really key critical thing for the health care system because, as you can see in the bottom right in sort of the dark orange, 1/3, so another 33% of medication-related hospital admissions, which are horrendous. If any of you have been in the hospital, you know you don't want to be there, right? 1/3 of medication-related admissions are because people simply aren't taking their meds the way that they're supposed to. And one reason they're not doing that is because as a health care system, the physician, the pharmacist, the nurse, we haven't quite figured out how best to help monitor your medications. And I'm gonna share at the end some ideas that pharmacy has to correct that matter. I love this picture. You probably recognize, I see some heads nodding. C. Everett Koop, probably the most famous surgeon general in U.S. history. He had this quote that we like to emphasize in the world of pharmacy that "drugs don't work in patients who don't take them," and that's just the most common sense quote and thought, and it hits at this adherence issue. And one of the reasons that C. Everett Koop was so interested in adherence is because the government, taxpayer dollars, so your hard earned money, you've paid into the system your whole career, your whole lives, your whole working lives. A lot of that money goes to fund research and drug development so that we get new drugs, and so it's incredibly expensive, and it's a huge investment of society, for Amerians. And so we put billions of dollars into developing a handful of drugs, right? But then it's maddening because people won't take them. And so this is why I think this has become an issue. It was an issue for C. Everett Koop back in the 80s. It remains an issue right now in health care. So take your meds. I'll give you a second. Can everybody read that? It doesn't look like it came through very well. I thought I'd introduce some levity into the talk. So it reads, this is a pharmacist standing behind the counter checking a patient out at the pharmacy, and it's in quotes. The pharmacist is saying, "The $39.95 is for the prescription, sir, "and the $7 surcharge is a little something "for our handwriting expert." (audience laughs) So that's sort of a cheap joke to play off of this notion that physicians and other health care providers have horrible handwriting, right? But it's a joke. There's one more little joke for you related. So we have two ladies over coffee or tea and one says, "I've lost faith in my doctor. "My pharmacist can read his prescriptions." (audience laughs) So that's the funny sort of angle on it, but I don't wanna leave it at that. I wanna emphasize how important this communication failure can be for your health. In the 90s, this is also another really famous case that's taught in pharmacy schools and medical schools. A gentleman by the name of Ramon Vasquez went to the doctor, or went to the hospital and was given a prescription for, he was having angina, some chest pain. The doctor wrote this med. And I'm gonna challenge you to raise your hand if you think you can read that. -

audience

Zenadril. Zenadril, that's a great guess. Zestril might be another guess. Plendil. -

audience

Plendil. Plendil's a good guess. So the doctor wrote this, and I don't see it in here, but he wrote this for Isordil, so that's an I-S, Isordil. Isordil is a nitrate, and people take it kind of like nitroglycerin. Some of you may have seen this drug where you put it, if you're having chest pain, you put a little tablet under your tongue, and it quickly opens up those blood vessels and helps relieve the pain. So that's what that drug was designed for. And instead the pharmacist filled it for Plendil, and Plendil is the brand name for a generic drug called felodipine. Felodipine, some of you may have taken in your lives. It's a blood pressure med. It's called a calcium channel blocker. And dosed 20 milligrams every six hours is an incredible overdose, So, unfortunately, Mr. Vasquez, like Betsy Lehman before him, died from this failure of communication. And it's important for the world of pharmacy because this was the, I believe this was the first case where the pharmacist was held equally responsible in terms of liability, and I think the monetary compensation was somewhere around half a million dollars. 250 went to the physician, 250 to the pharmacist. So I like to stress this with my students because it demonstrates that we as a profession, your pharmacist really has a professional duty to not take short cuts, to make sure that you're getting the right med, and so I would encourage you to hold pharmacists' feet to the fire. Make sure they do their job. We'll do this quickly. Here's another example. Anyone have any guesses on these? -

audience

Looks like Coumadin. Okay, I heard Coumadin twice. Has anyone heard of the drug Avandia? Diabetes med. Okay. I don't even know what the right answer is to be honest with you. It could be either one because the names match if you're quickly reading it, and the doses actually match. A lot of times pharmacists sort of deduce which drug their prescriber has written for by what doses are along side of it, so it becomes very dangerous when you get overlap on the name and the doses. Fortunately, there was an act of Congress in 2009. You've all probably heard about The American Recovery and Reinvestment Act, tied to the economic downturn and all of that. A piece of that legislation was devoted to tackling this failure of communication. And in the health care world, they call this health information technology. How do we use technology to get rid of some of these errors that are happening? The acronym for this section of the act is called HITECH. And so over the course of 10 years starting in 2009, the government is devoting huge sums of money to promote and advance the incorporation of more computer systems, smart computer systems, to help get rid of some of these errors. Simultaneously, they're introducing better and more technologies to facilitate electronic prescribing. Let's get rid of those written prescriptions. Does anyone still receive written prescriptions? Okay. Couple of hands. I would encourage you strongly to talk to your prescriber and potentially try to work with a group that has kind of advanced a little bit technologically 'cause it's very important, and you'll see here from the impact why it's important. So between 2008 and 2012, there was a humongous uptake in the number of electronic prescriptions. Simultaneously, the number of electronic health record, that's what that EHR stands for, the number of electronic health record vendors skyrocketed. You guys are familiar with this place right? -

audience

Epic. - Yeah, it's Epic. So another local huge player in the health care industry. So here in Madison we have access to some really huge influential players in the health care industry, which is another great reason to be involved with UW Health like Marje has set this up for you. So that's Epic. Epic's one of the most successful EHR companies in, really, the world. And here's the upside. So when hospitals use electronic health records, there's enormous reduction in medication errors. So you see the range. Some studies have found almost 100% reduction in medication errors. When community pharmacies use electronic prescribing, you see a sevenfold decrease in error rates. That's enormous. Those are huge, huge improvements to the system. That doesn't mean, though, that that's the be-all, end-all to tackle this communication issue. It's always gonna come down to that one-on-one contact between you and your prescriber, between the pharmacist and you, between the pharmacist and the prescriber when it comes to this kind of medication safety. So some colleagues of mine at Dean, we did a study. We were worried that some patients, they were seeing their doctor. And Dean is a wonderful health care entity if you're involved in it. Very modern, electronic records, the whole shebang. We got concerned in the pharmacy department that some patients were seeing their doctors and their doctors were saying, "You can stop drug A. "Let's just use warfarin since we've gone down that route. "You can stop taking your warfarin." And then the doctor goes into the electronic record, completes a discontinuation or a stop medication order. But then the patient goes to the pharmacy, and the pharmacy says, "You still have refills on your warfarin." "Do you need that?" And the patient says, "I think so. "If I have refills, surely I need it." And they were dispensing the meds even though the doctors had said stop taking it. And so we did a very small study that got published in the Journal of the American Pharmacists Association just recently that demonstrated that, we just looked at five categories of meds. And within just those five categories, we found a 3% rate when the doctor discontinued it, those patients still filled them, so we're working on implementing systems there to correct this. So the message I'm trying to send is even though we've got electronic records, we've got access to some technology, it's still on you to make sure you're taking charge of your situation and you're helping make sure that when the pharmacist says, "Do you need a refill on your warfarin?" if you're not sure, I'm gonna strongly encourage you to say, "You know what? "I don't really know. "Can you please figure it out?" And then let them figure it out for you. So we've talked about definitions, med errors, adverse drug events, side effects. I hope we're on the same page there. And then we've highlighted some key medication errors that I hope you'll be able to avoid in the future. Dosing, method, inappropriate care, inadequate monitoring, and then this key one, this failure of communication. So let's talk about some tips, some things you can actually do and that we, at the School of Pharmacy, we teach our students when you're working with patients, you've got to do these things. Get them going. You got to empower them. That word empowerment I've used several times, and it's not a coincidence. This diagram here is from the current website for the current surgeon general of the United States. And he happens to be the second youngest. He's a very young man. I think he's my age, 30-something. 38, I think. This is their diagram. This is called the National Prevention Plan. This is the big picture, what the government wants to do to prevent people from getting sick and utilizing lots of health care resources and to reduce errors and that kind of thing. One of the key pieces, and I don't know if you can read that, it's to empower people. Another one is to focus clinical and community services on prevention. So from a pharmacist's perspective, when I see this, I think, "I wanna empower my patients "to prevent medication-related problems," and that, for me, is a very clear message that I hope you can take with you today. Did anybody study Latin as a kid? I don't even know if I have this correct. I pulled this off the web. This is one of the oldest recorded use of this phrase, knowledge is power. Comes from Ancient Islam, actually. I was reading a little bit about this. In the 600s, 600 AD. In English-speaking culture, this was used going all the way back to the 800s. So this concept of knowledge is power, I want you to take that with you today and feel empowered. The first thing you need to know to be powerful in this system is that you have to know your mediations. So I want you to raise your hand if this has ever happened to you. Your doctor or a nurse or a pharmacist says, "Can you tell me about your drug, your lisinopril?" And you say, "Isthat the blue one?" (audience laughs) I can't tell you how frequently we experience that on the pharmacy side. People simply don't know, or one person in a household really takes charge, and they know. So when I was a resident, one of my big projects was working with older adults to help reduce their medication errors, and it was very frequent that older gentleman would come in to the clinic, and we'd meet and talk, and they would say, "Can you call my wife? "She manages the meds." Okay, I'm here to tell you, as a man or a woman, if that's your perspective, that's got to change. You have to know your own meds 'cause you're the one who's gonna be in charge of keeping yourself safe. So here are the key questions that any time you talk to your doctor, any time someone's gonna give you a new medication, either they're gonna write a new prescription, or you're gonna pick it up from the pharmacy, these are the questions I think you should ask and you should know. What's the name of the med? What is it supposed to do? Does anybody take a medication here they don't even know why? Can you raise your hands? I hope we can capture this on camera. Lots of people take meds they don't even know why, right? It's very, very common. So we need to know why we're taking the med and what it's called. Beyond that, you should know what the common side effects are because if you experience a side effect and you know it might be a side effect, something that's not gonna harm you, then you'll know, let's just go talk to the doctor, tell him I'm experiencing a side effect 'cause I was sort of primed to look out for this. Some people experience a side effect and what do you think they do? They just stop. I've actually done this myself. I hate to admit it as a pharmacist. I've done it myself. I'm not gonna take it. So if you know the side effects and you have it, you won't be afraid of the drug. You'll know that it's a common thing that happens with this drug. You go talk to the pharmacist. You go talk to the doctor. Try to correct it. When you go there, if the doctor tries to give you another med to treat the side effect, what should you tell him? (audience murmuring) No, thank you. Let's find a med that works that doesn't cause this side effect. There's lots and lots of meds, and your pharmacist can help you with that. How do you know if the medicine's working? If you have blood pressure, you could monitor your blood pressure. If you have diabetes, you should be familiar with what an A1C is, right? If you're taking warfarin, you should know what an INR is. These aren't obscure terms that should be left just to the providers. You should know. Some other questions. What if it's a bad reaction? In other words, what if I'm having something that's causing injury? Seek immediate attention. And when do I start or stop this? Lot of medications are meant to be taken for the rest of your life. Others are meant to be taken for a short period of time. If you have arthritis and they give you naproxen or ibuprofen or some kind of NSAID, do you think you should take that for the rest of your life every day? (audience murmuring) Probably not unless it's under the guidance and supervision of a health care provider, right? Some additional questions, and I'm gonna speed up a little bit just to get to the next section. Can you take this med safely with your other medications? This is something pharmacists are doing on a regular daily basis, checking for drug-drug interactions. You should know those answers, and you should ask your providers. Lifestyle changes, that's a key thing. How do you take the medication? Does anybody crush their medications in here? Lot of people do. It's very common. Some medications can't be crushed. You should know that you can't crush your meds if you plan to crush it, okay. What kind foods should you avoid? Alcohol, that kind of thing. The next thing I'm gonna strongly encourage you to do if you haven't done this already is create a medication list. Does anybody have a list? Okay. Lot of people keep it in their wallet or their purse. I would encourage you to create one on a word processing program like Microsoft Word, something that you could print out 50 copies, and I would encourage you to get everything on that list. So, as a pharmacist, when people say, "What's a drug? "Is an over-the-counter thing I buy, is that a drug? "Is an herbal a drug? "Is a vitamin a drug?" the answer is absolutely yes. Anything you put in your mouth that you think is gonna help you in some way or have some kind of effect, I want you to think of that like a medicine that you have to tell everyone about 'cause a lot of them interfere with one another. So I want you to print out 50 copies of that list, and I literally want you to give it to everyone you know. Okay, give it to your, how many people see multiple doctors? Every doctor, every single visit, bring your list and say, "This is my updated list," 'cause I guarantee you some of them don't know all of the meds you're taking. Has anyone received an offer for a $25 coupon to transfer their prescription somewhere from one pharmacy to another? It's very common, and my advice to you is not to do that, to use one pharmacy, okay, because if you use one pharmacy, then you can start to get to know one pharmacist. That person could become your guide, your coach, as it relates to the medicines. So say no to coupons and say yes to safety. And this is really critical if you see multiple physicians. Take your medications. I couldn't help but put that picture back up. The last tip I wanna provide for you, and this is uncomfortable for some people because, you know, as humans, and we're Americans, American culture, we have an inclination to want to please people, right? So if your doctor's been telling you for several visits you need to take that medication, you need to take that medication, and you go to your next visit but you haven't been taking your medication, and the doctor says, "Did you take that medication?" some people, I've experienced this myself, will say, "Oh, yeah, yeah, yeah. "I've taken that." All right. That's a huge issue in this communication error. Whatever you're doing, it's totally your choice. This will empower you, make you feel like you're in charge of your meds. If you don't wanna take a certain med, you should tell your doctor. Tell them, "I don't wanna take this. "What else can we do?" But it's important that they know exactly what you're doing so that they can help you the best. So no fibbing, okay? So to summarize that, we really focused on you taking charge, taking ownership, and don't feel afraid being honest and direct. If you don't understand something, if the pharmacist, I know a lot of you have experienced this, I've experienced this, where you go to the pharmacy, and you get your med, and the pharmacist says, "Do you have any questions?" and they clearly are so busy they don't wanna talk to you. And I would encourage you, and we train our students to do the same thing. Say to that pharmacist, "You know, I do have lots of questions. "I actually have my medication list. "Can you please review the whole thing?" And it's their professional obligation. They will do it. So I like this diagram a lot, and I use it in a lot of different talks 'cause it shows the breach, sort of broken communication, that happens, and this is primarily for pharmacists at community pharmacies. Lot of them are detached from what your doctors and your nurse practitioners and your PAs are actually doing so they don't know, and this is a big problem for pharmacy because pharmacy really wants to help you, but we need to be looped in. We have to figure out how to close this loop. A really promising service that pharmacists across the country are promoting is something called medication therapy management intended to close this loop. Has anyone heard of this term before? Oh, absolutely. So if you haven't heard of this, I'm so glad I've decided to bring it up. So medication therapy management, this is the definition that you could pull off of the American Pharmacist Association website, is "a term used to describe a broad range "of health care services provided by pharmacists." And I like that they put this in here, "to take ownership of their expertise of medication use." They've created this diagram that we share with our students, we share with other people of all the different things pharmacists are doing that qualify for MTM. I'm just gonna focus on the box that's highlighted. That's the medication therapy reviews. In this situation, you actually set up an appointment with your pharmacist. Has anyone done this before? Okay, good. One person. All of you should do this in the next month. Go to your pharmacist and say, "Do you do MTM? "I wanna schedule an appointment with you." And they will schedule it for you. The targets are all of these errors, trying to avoid all of these errors we've addressed throughout the talk, adherence, side effects, sub-optimal dosing, whether that's are you being underdosed or are you being overdosed, a lack of monitoring, duplications in therapy, and potential drug interactions. Lot of researchers in pharmacy like myself have been looking at MTM. Is it effective? Here's one study. This is Dr. Doucette out of the University of Iowa, and he's one of the leaders in MTM, in researching MTM. And what he found, this is a community pharmacy where they're communicating over fax. They were able to improve 50% of the recommendations they made were accepted by their provider, trying to close that loop, so they made a big impact on Medicaid patients' use of medications. The key areas that they made that impact on were in patients who were receiving unnecessary drug therapy. If you take a lot of meds and you don't like it, go to your pharmacist and say, "Can you review my meds? "I'd like to see if I'm taking any unnecessary drugs." Okay, that was a key thing they found. Adherence, people weren't taking their meds. And then effectiveness. What they found here was that some patients were taking the wrong drug. Some patients were taking doses that were simply too low to have the desired effect, so you're taking a pill, it's not doing anything for you except for annoying you. Another researcher out of the University of Illinois, Chicago is Dr. Dan Touchette. He looked at this a little bit more systematically. In the medical community, we love to do randomized controlled trials. Everything. Best evidence comes through there. And this study involved a lot of different institutions. They interfaced with close to 400 elderly patients, and they identified a ton of medication-related problems. Again, they sent recommendations to the physicians via fax, and 30% of those were accepted. The big issues that they found were... wrong drug. Again, if you're gonna take meds, you should be on the right one, right? That's a no-brainer. They found adverse reactions to meds as the second highest problem. They found that the patient was getting the wrong drug for their particular disease or that they were having, yep, getting the wrong drug there, and then the next one was that the patient was getting, again, this says underdosing or overdosing. Your pharmacist, I promise you, is highly trained and educated to help you maximize your meds. And he's one of the most underutilized resources in the whole health care system, and so use him. So they were closing the loop with a fax machine. That seems a little bit outdated doesn't it? Absolutely. In Wisconsin, again another plug for this amazing state for health care and for pharmacy in particular. There's a state organization called the Pharmacy Society of Wisconsin, which I'm a proud member of, and they have made huge advances in MTM. They created a program called the Wisconsin Pharmacy Quality Collaborative to help facilitate patients getting the service. They created an electronic platform. We talked about the importance of that electronic platform. They used some of the resources from this big grant they received to help create an electronic platform. And then they trained pharmacists and pharmacies on how to best do MTM. The pharmacists go through a lot of training to get certified and to identify, prioritize, and help resolve all of these medication-related problems we've talked about today. This is a pretty impressive map. The program started, they won the award in 2012, and it just finished just a couple of months ago. And in that time period, they were able to enroll pharmacists and pharmacies. They were able to accredit, this is accredited pharmacies, in almost every county in Wisconsin. They've delivered 50,000 MTM services to patients. A huge bulk of that were Medicaid patients. So if you haven't heard of WPQC or MTM, my takeaway message is go talk to your pharmacist about that. They know how to do it, and they can help you. And this here just talks about sometimes health care providers don't really, they step on each other's toes, and it's an issue. Within MTM and this new initiative, which has been a lot of support in the state from our physician colleagues and our prescriber colleagues, and this is just some evidence of that support. So I think one of the best things the state of Wisconsin has ever done to close this loop is this WPQC model. And if you talk to Marje, I can get her to share with you some of the resources, some of the brochures, et cetera. So... Pharmacists can help you, and they're underutilized. Go get some help from them. Make sure when you talk to one that it's a WPQC certified pharmacy and WPQC trained pharmacist, and then take some brochures before you leave. So we've talked about a lot of things. I hope you leave this discussion, this sort of lecture-based talk, I hope you leave here feeling empowered, feeling like you've taken away something about what medication-related problems are, how you can avoid them. And I hope you now know what MTM is and what you can expect from your pharmacist. And with that, I'd love to take some questions if you have some. (audience applause)