Monday, May 26, 2014

Tobor to the Rescue? Home Medication Dispensers

When I was a child, there was a movie -- or maybe a tv show -- with a friendly robot named Tobor.  Tobor soon became an imaginary friend for the neighborhood children, and conveniently, someone we could blame when we forgot to close a door or knocked something over.  "Tobor did it!"

Fast forward many years and last week, during a meeting at my Area Agency on Aging, I learned the AAA had entered into a contract with a company that makes home medication dispensers to provide the devices at a modest cost to clients in the county.  "Tobor for the Boomer Generation!"

The device, about the size of a blender or coffee machine, can be pre-loaded with a large number of doses of different kinds of medications with different dispensing schedules, and with recorded messages such as "Drink with water."  The machine signals the client to take the revealed dose, and continues the signal until the medication is removed.  It can also be programmed to contact a family member about a missed dose.  Of course, there are limits to the utility of any automated device, as the client must still have the capacity to follow the directions and not simply discard the dose. 

It will be interesting to see, over time, whether (and which kind of ) Tobors are effective innovations with long-range satisfaction and utility.  I do seem to have a lot of ignored contraptions on my own kitchen counter.

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There is a prevalent “Catch 22” here in Texas regarding medicine boxes. Let’s begin with the confusion in terminology: Home Health is often used in Long Term Care Insurance policies to mean custodial care in the home. However, “Home Health” agencies in Texas are in business to get Medicare money, so one has to instead use “private duty” or some other nomenclature to describe the custodial aspect of the desired care. Home Health agencies have the RN’s, and “private duty” agencies do not. The State requires that medication “boxes” be filled by an RN, so the “private duty” agencies cannot provide that service. What is someone to do if there is no family member around to “fill” the medication box, whether it be Todor or the old-fashioned kind? Do you think pharmacies would do it if the private duty aide brought the box and all the medications to the pharmacists? If permitted to do this service, will pharmacies respond to the need? Will this become a new niche for at-home service ---- a circuit riding Todor box filler that meets the State’s requirements or pharmacies that do it?
Missouri required an RN to load a medication box. Thankfully my mother’s “private duty” service DID employ an RN to come each Monday to fill it. The aide would place each dose in a small paper cup and give the cup to my mother. If this arrangement had not worked, it would have meant a 3-year acceleration into the nursing home for her. That would have been a real shame --- admittance into a nursing home JUST because of the medication box. I don’t think Texas is where it needs to be yet. There may be other states out there with a similar “Catch 22.” Todor may be a great solution, especially if doses can be programmed and loaded for a long term, but the box still has to be loaded per State regulation.

Posted by: Jennifer Young | May 26, 2014 5:04:11 AM

The Missouri Law, cited by Jennifer Young, is an example of the reactive legislation that tends to impede commonsensical resolutions to our nation’s healthcare challenges. Medication management is a huge problem for elderly persons with mild (or more) cognitive impairment. It’s also a problem that cries out for a technological solution.

The challenge is that technology solutions have been unimaginatively incremental instead of addressing the overall problem. Most medication management systems require pre-dosing and they simply deliver the medication packet at the required time. Filling dosing cups is boring and repetitive and the possibility for error is rampant. Nurses are regularly dismissed from employment for errors which might be avoided with a different system.

The Philips Dispenser and similar devices still require manual filling of the correct medicines into dosing cups or containers. The most promising technological solution that I’ve found to the challenge of medication management is the OnSiteRx device (see It is still more costly than desirable, and there is a need to expand the number of medications supported as the pharmaceutical industry expands its product offerings, but the concepts of the device show what is possible if the will is there to improve medication dispensing accuracy, to increase physician flexibility, and to reduce error prone human interventions.

Healthcare has lagged other industries in the development of technological solutions for everyday needs. For instance, the financial services industry introduced automated teller machines (ATMs) in the 1980s, thirty years ago, while a simple automated dispensing machine is only now beginning to surface on the decision radar of many long term care providers. The first ATM is said to have been introduced in 1969, so it took fifteen to twenty years for ATMs to become prevalent.

Only now, today, is it proposed to replace human staffing at bank branches with more flexible ATMs that allow remote video access to a bank officer. If that same time frame applies to such a simple healthcare application as medication management then it is likely to be midcentury before automation begins to dramatically change healthcare delivery in America.

Posted by: Jack Cumming | May 26, 2014 9:34:26 AM

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