Dr. David Ahn discusses the latest technology for diabetes care.
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Hi, everybody. Welcome back. I'm Samantha Harris. As Dr Smith is mentioned, I have the pleasure of introducing the next speaker. Who is Dr David on? He is an endocrinologist with special interest in diabetes, and I was fortunate to have done my endocrine fellowship in training alongside him at U C. San Diego. He is now the program director of Hope Hospitals marrying Dick Allen Diabetes Center in Orange County, California. So not too far away. And he is a national expert on all things related to diabetes technology. David, we're excited here what you have to say. Great. Thank you. Um, all right. So, yeah, I just wanted to start by saying it's a huge honor to be invited to speak at scripts. Azaz. Samantha Harris was saying, You know, I've been spent 13 years in San Diego. I did my internal medicine residency training at Scripps Mercy, and I decided to pursue endocrinology during a rotation, Um, at scripts green. So I really owe a lot Thio script, So thank you for inviting me back. Mhm. Um All right, let's see. Okay. I think we're working. Okay, So my disclosures are listed here, and, um, an outline for the talk today. Um, first, we're going to start by reviewing recent developments in continuous glucose monitoring on, but I think that will probably have the first two points will probably have the most broad appeal and applicability toe practice. The second thing we'll talk about are the benefits of using connected insulin pen systems. Um, and the last thing I'll talk about is comparing and contrasting the latest automated insulin delivery systems, which are gonna be It's gonna be a little bit more focused on Type one diabetes just as a heads up. So let's start by talking about continuous glucose. Monitoring on this is a space that's definitely been blowing up in the past couple years, especially, but it has been around since about the year 2000. So I'm sure many of you are starting to get a lot more exposure to different continuous glucose monitoring systems. And the field overall is just evolving at such a rapid pace with new products. Um, that this might be a good time. Thio compare and contrast and get a better sense of the different products on the market. But the thrust behind the growth of continuous glucose monitoring is that while hemoglobin, a one C is has served us well and it's done a great job over the past 10 to 15 years, the reality is is we're realizing that a one C is very limited in the type of data that it shows. Since it's an average. As many of you know, um, just because someone's a one c is a certain number doesn't necessarily mean they're not experiencing highs or lows. And this figure is just a theoretical graph comparing three different see GM tracings continuous glucose monitoring tracings that would all have a similar a one C of about seven Ondas you can see Figure three looks great, and so when we see anyone see of a seven, you know, that's kind of what we're envisioning. Our patients have, but the reality is, is they might have something that looks closer to the Figure two, or even the figure one, where they're having scary highs and scary lows all the time. So a one C Onley really presents a limited picture of a patient's blood sugar control. And so the new thing that's becoming the standard, especially and this is on Lee made possible by continuous glucose monitoring is what we call time and range. Um, and so a consensus consensus statement was published last year, showing kind of our target ranges for time and range based on various populations. The book of what you'll be seeing in practice is really the left figure on the green bar represents Time and range, which is defined as a blood sugar spent between 70 and 1 80 mg per deciliter and for most of our patients were striving to keep them above 70% time and range, Um, all while producing hypoglycemia, so trying to keep their time spent below 70 mg per deciliter, less than 4% on their time spent in extreme hypoglycemia, which is defined as less than 54 mg per deciliter under 1%. So this kind of bar graph on the left really represents our targets. For the bulk of our patients, However, there are special risk categories to consider. So, for example, the middle figure represents on adjusted target time in range for patients that might be higher at higher risk of low blood sugars, such as older patients or patients with hypoglycemic unawareness. And in that situation, we're kind of sacrificing or trading off a little bit of we're more accepting of high blood sugar at the expense of reducing low blood sugar on gun. As you might expect in Type one diabetes, women that are pregnant, the percentages are the same greater than 70% less than 4%. But the ranges are actually different. So if you see the target range for pregnancy is to keep a blood sugar between 63 1 40. Andi. That's just to reflect pregnancy targets. So thes thes bar graphs and goals are kind of becoming more standard and more widely used, especially in our C G M patients. Now the latest released, the most recently released continuous glucose monitor, is the Freestyle Library. To, um, this came out over the summer of this year. One of the main advantages over the Freestyle Library one is that it introduces hypoglycemia and hyperglycemia alarms eso really quickly. I'll take a quick step back and do a quick, high level summary of what continuous glucose monitoring is for those that might not be aware. Eso Basically it's a device that you wear on the body, whether it's the abdomen or the upper arm, and it measures your blood sugar every five or everyone to 15 minutes. I should say no on git can transmit that reading, um, continuously to a nearby device or on demand, such as in a device such as a freestyle library. So with the freestyle liberal A system, it requires a swipe for reading. So there's a reader or a smartphone that you can use, and you would hold it over the sensor and very similar to doing a mobile payment with your smartphone. It wirelessly transmits data to your phone or reader eso. Every time you swipe with the Freestyle Lee Brae, you'll get a blood sugar reading. You'll get a direction arrow, which is obviously not available with the standard blood glucose meter, and you get a graph of the past eight hours of blood sugar. Andi, I apologize for not having pictures. That was by design, because I think for CMI we weren't able to have product photos. Eso I had to remove those, um, but one of the main advantages of the Freestyle Library to over the library one is that it introduces hypo and hyper alarms, meaning if your blood sugar is going high or going low. Um, the reader will actually display an alert to the patient, and it will say high or low, prompting the patient to swipe their blood sugar. So in the previous system, the Freestyle Library one there would be no indicator to the patients, whether they're going high or low. So that could be very dangerous for a patient who eyes unaware of their hyperglycemia because they might be going low and have no idea until the morning after when they swipe. So the freestyle library to does have that ability to alert the patient that they need to scan for, ah, high or a low. But the patient will only see the exact number once they scan. Um, In addition, the Freestyle Liberty to does have more accuracy, especially in the hypoglycemic range. So for those of you that have experimented with or regularly prescribed the library one, you might find that patients say that a lot of times it tells them that their low blood sugars, But when they do a finger stick comparison, it's maybe lower by 20 points. Um, the freestyle library, too, has much better accuracy, especially in the hypoglycemic range, so That's a huge upgrade for our patients as well. Similar to the Freestyle Library one. It's a 14 day system that requires zero calibrations. It's priced the same as a freestyle library. One S O that comes in the full price. Um, if you if you pay full price without using any coupons, the the price for two sensors or a month supply would be about $120. Um, but for non Medicare patients, um, that can use coupons. You can call the manufacturer to get a coupon that should bring it down to about $80 a month for two sensors. Andi Freestyle has announced partnerships with future pump companies such Azzam NEPAD tandem. They also have promised integrations with some smart pens. But no, no, those are available at the moment. So this is kind of a great option for patients that have to pay cash because it is the cheapest cash. Pray cash price. See GM on the market. Um, now the second system is the decks. Com G six, and many of you are familiar with Dex comes reputation. They're kind of the gold. The golden child, I guess, in the c g M realm. They have the most fully featured continuous glucose monitor, but it is priced quite a bit higher on a cash pricing basis. Eso One of the nice things about the G six and the Decks com system is that, unlike the liberal, you don't have to swipe, um t transmit data. So it's constantly measuring your blood sugar every five minutes and transmitting those numbers to a nearby smartphone or reader. Um, unlike the Liberty to it has true passive alarms. So not only will it tell the patient if they're going high or low, it will also give them their number because they always. Patients always have wireless access to all their readings without having to do a swipe, so it will tell them if they're going high or low, and it will even predict hypoglycemia 30 minutes before it occurs. So if the decks come forecast that your blood sugar is going to be dropping below a certain threshold 30 minutes in advance, it will tell the patient that we anticipate you're going to go low. Um, the decks come G six has a 10 day sensor, so you have to change it every 10 days. as opposed to the 14 days of the freestyle Liberal A, um, like the freestyle library systems. It does not require calibrations or or finger sticks. Um, but unlike the Freestyle, Liberate does accept calibration. So if you're patient eyes very concerned about the accuracy of their system, they can enter finger stick calibrations into the decks. Calm. The library does not accept any calibrations. Another great feature of the decks com that's not found in the library is that you can share up to 10 followers. You can share your blood sugar data. So this is great for Children with type one diabetes, whose parents are really concerned about low blood sugars overnight or loved ones. You know, if you have ah, elderly parents who might not be as, um, um, able to respond to their low blood sugars, you can set up alerts eso that loved ones can follow them and make sure their blood sugars are okay. Um, the decks come also shares data very readily through Apple Health and Google fit, which can be very convenient if you're combining different systems together. The third continuous glucose monitor on the market is the Medtronic Guardian Sensor, three on. This has many similar features to the decks, calm in the sense that it does have a smartphone app. It does have passive alarms. It measured blood sugar every five minutes. It can predict highs and lows ahead of time, but one major limitation of the Medtronic system is that it does require calibrations. Andi, they require 2 to 4 calibrations a day on Dwell. That's not much, and you definitely get a ton of data, a za result of doing those calibrations. Um, it's a much tougher sell to patients. Patients get really excited about not having to do any finger sticks. Eso even 2 to 4 calibrations a day could be a big ask uh, the Guardian Sensor three also has, unfortunately, a shorter way where period than even the decks come at seven days. But it does have sharing capabilities, which is great for parents and loved ones. Like I was sharing on the decks come. There is a kind of a different paradigm of continuous glucose monitoring that was made available by a new company a couple years ago. On this system is called the Sensi Onyx. Ever since this is implanted continuous glucose monitor The sensor itself is about the size of Ah, ticktock, Andi. It goes in the upper arm very similar to, like, implant on for birth control. Um, it at this time it has a 90 day lifespan so that it does require a minor procedure in office every 90 days to replace that sensor. Thea Other big thing to be aware of is you still do have to wear a transmitter on the skin over the sensor. Um, but because there's no sensor actually penetrating the skin. So all the previous three sensors I talked about has a small hair like sensor that penetrates the skin three ever since does not because the sensors actually embedded under the skin s o. The adhesive is changed every day. So unlike the other systems which have acrylic based adhesives, the sensi onyx has more of a silicone based adhesive. So to think about it, it would be like the comparison of, like, an e k g lead where it's kind of gel based S O. It's a lot gentle on the skin. So I found some patients that have really bad rash reactions toe other adhesives do fairly well with the sensi onyx ever since. Um, the other advantages that it does have vibrate Ori alarms so the transmitter will vibrate on the arm. Um, if a patient's going high or low. So for some people that don't like Thio send carry around their phone all the time, they do get that vibration on the body. Unfortunately, it does require to calibrations a day on DNA. 90 days. Um, as a frequency of of a minor surgical procedure is fairly often they do have a six month sensor plan for next year. Um, that they're awaiting FDA approval. Eso and I'm I looked into it, and I do believe that scripts does offer the Sensi onyx ever since. So if your local, they do offer it. So this is a little comparison table I made of the various see GM systems because sometimes it all becomes blended together on. But I just wanted to highlight some of the key differences. So, as you can see, the accuracy of all four are very close. Lower is better. Um, technically, the sensi onyx has the best m a r D data, but, um, it does, you know, it's a very different paradigms, so of the three that penetrate the skin. The decks. Com does have the most accuracy on bond. The other thing to keep in mind is that the smartphone column for the Freestyle Library to is listed as pending because while the Freestyle Library one allowed your smartphone to swipe the sensor, which was very convenient, the library to APP has not been yet made available. So currently, you have to use the Freestyle Library reader to take advantage of the library to. I suspect that the APP will be available at any moment. Andi, I've been told that hopefully will be before the end of the year. But when it comes to APP approvals and FDA, it can always be very variable. So at the moment you cannot use your smartphone. But hopefully that should change very soon. And for those of you that have a lot of patients using smartphones with their lib raise, what I've done personally is most of mine are staying with the library. One. Andi, I'll have them upgrade to the library to once the app is available. Um, because especially in the world of virtual care, being able to go through the smartphone is very convenient. They all have various warm up periods, Andi and the other. The last thing I'd like to highlight on this side is that the decks come G six is the only sensor that is very liberal with sharing their data on. But I think as we get into a more technologically advanced world of managing diabetes, it's really important for patients to have access to their data on different platforms. And so I like Thio. Give credit to Dex com for being very generous with their data on. Hopefully that will encourage other companies to be more generous with their data as well. Um, I did also want to call out that there is another category of continuous glucose monitoring called professional See GM, and they're very similar to their consumer based counterparts. The main difference is that these are intended as kind of like a one time use, and this is often done by clinics. So if you have a patient who doesn't necessarily need to be on the C G m all the time, maybe their insurance doesn't cover it. Or maybe the patient doesn't wanna wear one all the time. You can use a professional C G m as a one time session, and these tend to be fairly well covered by insurance as long as you're only doing them. You know a couple times a year, Um, and so these can be very useful. The most common systems there are the decks com G six pro, which is essentially a G six that you loan out to your patient for one time. Use Andan, the Freestyle Liberate Pro, which is based off of the library. One technology. Um, the main difference is that the liberal pro is always blinded, meaning that the patient does not have access to see their blood sugars in real time while they're wearing it. They don't see their numbers until they come back to see you in the office, so that could be useful in some respects. But I'm a big believer that having giving patients access to their data in real time really helps them learn how their body works and allows them to see the response of various foods activity medications. So I'm a big believer that, um, even for these professional short term trials, I think patients gain a lot from being able to see their sugars in real time on that, that's only available on the decks. Com G six Pro. Now I want to talk about insulin delivery methods and primarily in the form of connected insulin pens. Since we're talking about exciting technology, Onda what I mean by a connected insulin pen is basically a pen that has any digital component. Um, the main are the only FDA approved product right now that fits this category in the United States, Um, is made by a company called Companion Medical on Dee. Their product is called the in pen on DWhite. It is is it's a reusable pen that uses insulin cartridges. Um, that you change. So it's kind of the difference between ah, Bic pen versus a fountain pen when you're when you're thinking about ink pens. So right now, most of our patients use disposable pens, right, so they throw it out every time. But this connected insulin pen is more of like a fountain pen model, where you keep the housing system and you're just changing out the insulin cartridges. Eso it does require a separate prescription for insulin cartridges, as opposed depends but insulin. But insurance coverage is generally the same for an insulin cartridge versus an insulin pen. Um, so while there are various formats for connected insulin pen, So, for example, some companies are developing smart insulin pen caps that you can use with disposable pens so you can kind of, um, it's a lot. It's a lot easier because you don't have to prescribe a new type of insulin pen, and then the patient would basically take a pen cap and transferred from each pen to each pen s. Oh, that's another model, but those that one is not yet available on the market on. But there's a lot of hope and enthusiasm that eventually the insulin manufacturers themselves, like Lily and Novo, will build in a digital component to the disposable pence so that every disposable pen that a patient gets might have some smart pen component to it. So what these connected insulin pens do, at the very least, is that they can automatically load are sorry automatically log the dose and time that patients are taking their insulin. So, for example, right now, patients are fairly good at checking their blood sugar. Um, right, we have access to see GM data. We have access to blood glucose meter downloads. Our patients are generally willing to keep a record of their blood sugars written down, but very few patients of mine at least actually logged down their insulin dozing. So having a connected insulin pen that can automatic automatically create a dozing diary can be extremely helpful. In addition, toe monitoring insulin dose ing, they can sometimes monitor additional parameters. So, for example, the current companion medical in Pen also monitors insulin temperature. So if it detects that the insulin was exposed toe unsafe high temperatures, it will put an alert on the smartphone app. It also automatically filters out prime ING doses. So say, for example, you know, we teach our patients to do a two units squirt to make sure that the pen is primed before doing their real dose. Thean pen app actually will automatically filter that out. Using some logic, um, the in Penn will also track the duration of the current pen. So it will tell you. You know, it's been 40 days since you last change your cartridge. You might want Thio consider changing that Andi. It can also calculate on display insulin on board, which is very convenient for preventing insulin stacking. In addition, theme in pen, um, specifically does have the option for reminders as well. So it can. You can set up windows, say, for example, if it doesn't detect an insulin dose that was taken between 8 a.m. and 10 a.m. It will remind you, you know, don't forget to take a breakfast dose. So I'm trying to include some literature in in in this talkto show, the clinical evidence of all these different systems. This study was done in Europe using the Novo Pen six, which is not available yet in the United States on what this pen does is it was very simplistic. It purely tracks the dozing history and creates a dose diary. This study looked at 94 patients with type one diabetes who were also using a C G M. Um, and basically they had five visits over the span of 220 days. And what the what the clinicians did at each visit is they would download the dozing history and compare it with their continuous glucose monitoring history. And they had software that would basically look for missed. Boulis is, so the software would see you know, when did the continuous glucose monitoring data show a spike in blood sugar without a corresponding insulin dose? And that would suggest that, hey, your patient probably took a probably took a meal without remembering to dose their insulin. Andi. This would prompt the clinician to be able to discuss that with the patient and see if there were, you know, tricks or tips that they could use to help increase their frequency of remembering toe take their insulin on. But this study showed that was after the study completed was completed. Their time in range had, um, increased by 1.9 hours per day and their time spent in severe hypoglycemia reduced by 0.3 hours per day. And the frequency of missed Boulis is decreased by almost half. So there's that study kind of showed that being ableto have a dose record automatically created by the smart insulin pen on deck. Um, pairing it to data enabled clinicians to help their patients be a little bit more consistent with behaviors that we know would help improve blood sugar control. Another really neat feature that insulin smart insulin pens can introduce Onda, the current currently available in pen by companion Medical does have this feature is a bullish calculator. Eso. We're all probably fairly familiar with how bullets calculators work. They basically help factor in your carb ratio. Um, your correction factor Insulin on board the patient or provider would put that in. And then when the patient is about to eat a meal, all they do is have to type in their blood sugar and their carbs, and it will spit out a recommended dose on DSO. Having a bullish calculator on the APP can be really helpful for patients who aren't that good at doing the mental math A. Z You know, many of our patients, even the ones that are good at mental math, tend to use what I call kind of the magic wand method. When they're coming up with their insulin dozing eso they'll, you know, they kind of use arbitrary measurements in their head. They just kind of look at the plate and say, I think that's eight units. Um, so having a bullet calculator can help create a more systematic approach. Onda bullets, calculator, APS that air well designed, um, such as this one, in my opinion, allows for extra features, such as having different settings for different times of day. So, for example, you can have a different carb ratio and correction factor for breakfast, lunch and dinner on day. One really neat thing is that since the smart insulin pen is transmitting the dozing history, the APP can also factor in insulin on board eso that it reduces the risk of insulin stacking. So if a patient takes a dose for their lunch at noon, and then two hours later, their blood sugar is still high. Um, the APP will tell them how money what percent of that original dose they took at noon is still working toe. Help them prevent, um, insulin stacking and prevent overdosing for their correction dose two hours later. Um, the other neat thing about this insulin bullets calculator app in particular is that it does have different methods of suggesting doses to patients. So what I was just describing and what we generally think about is one eyes the method using carb ratios right? That's what we teach most of our Type one patients, but it also has an option for fixed dozing. So so say, for your type two patients. You want them to take eight units with every breakfast, 10 units with every lunch and 12 units with every dinner. Um, that fix those calculator will help the patient automatically remember how much they're supposed to take. Um, similarly, it can also do meal estimations. So you, as the clinician can program it to say. For a small card meal, give eight units for a medium card meal. Give 12 units for a large card meal. Give 16 units so that when the patient just pick small, medium large, um, it will automatically spit out the corresponding dose. So these bullets calculators are really, um, empowered by insulin. Smart insulin tends to be more fully featured. Um, continuing the theme of insulin delivery. I just wanted to give a quick highlight of the of the insulin pumps that are available right now. Eso One is the insulin omni pod on, but this is a patch pump that you wear. It's the only insulin pump that doesn't have to being, um, it does have a new updated receiver or PDM controller that looks like a smartphone. Um, it and that PDM is ableto deliver Thio give delivery settings and view history from the pump. Unfortunately, at this point, you cannot use your own personal smartphone to do that. But that's something that's planned for the future. Um, and they're targeting, um three introduction of their hybrid closed loop for spring of 2021. Sorry, that should say 2021 for next year. So that's kind of a current generation insulin pump. Now, I wanted to spend the last portion of my talk, um, talking quickly about automated insulin delivery. And what this is is basically insulin pumps that can use automation to help optimize blood sugar control. And the reason why this is so important is that we're just not doing our job yet in terms of getting patients the control that they need. So this data was published in 2019, and it represents data from the type one diabetes exchange. Um, and this is just two figures marking out patients blood sugar control from earlier. I think the first set of data in red is from 2010 around 2010, and then the Blue curve is representing about 2016 to 2018 data. So, as you can see, despite all our advances in technology. Um, all our advances in insulin, all our advances in continuous glucose monitoring. If anything, our overall control of type one diabetes has actually gotten worse by some measurements. But definitely there's not a clear argument that we've gotten better. Um, eso definitely our blood sugar performance and type one diabetes is still lacking, and I really I'm not going to go be able to go too deep into the automated insulin delivery section due to time, but that's by design. But I would like to kind of highlight the importance of, um, what the's the promise of these automated insulin delivery systems. And that's the really regarding the mental burden of diabetes. So we all manage diabetes. Um, and I had someone explain this analogy, and I thought it was really helpful for me in my fellowship to better understand what it's like living with Type one diabetes. I was listening to a patient explained, managing my type one diabetes is very similar to driving a car, and in that sense, it's that the day to day decisions the minute by minute decisions that you make are fairly mundane, right, managing medications, managing your activity, managing your eating. It's not too complicated, and I think us as clinicians. Its's easy for us to oversimplify. It's like, Hey, it's not that hard to do these things. But the reality is so is that unlike driving a car that we dio people with type one diabetes when they drive their car, they can never leave the car, so their hands are basically chained to their steering wheel. They're having to make these mundane decisions every minute of their life bond. It's that fatigue that sets in, right? So, for example, for me, it's like I don't mind driving an hour at a time, But when I have to drive for longer than an hour just becomes very tedious. And I think that illustration really helped me realize how frustrating it could be for our patients with type one diabetes that have to make these decisions every minute, Um, for the rest of their lives. And I think that's why thes automated insulin delivery systems, which are also known as closed loops, can be extremely valuable by introducing automation for our patients. And I think their current products that are on the market right now, such as the tandem t slim. With control like you that introduces some degree of automation to our patients, it could be very useful. Um, Medtronic also has a system, um, called the 7. 70 g that introduces some automation to our patients. Um and, um, and I'd like to provide these resource is for those of you that are interested in learning more about automated insulin delivery and all the latest developments and continuous glucose monitoring and insulin delivery. So the first three our websites that are resource is, um the fourth is a Facebook group that I moderate full disclosure, but it does have a pretty active group of about 500 people. The last time I checked of all different C. D E s or D C. E. S s Andi endocrinologists who are just discussing the latest and diabetes technology. Um, so I apologize for being quite fast in that last section, but I figured the first two topics we're going to be the most high yield. Andi, I'm happy to answer any questions about automated insulin delivery as well. Um, in this question and answer period. Thank you, David. That was really great. We do have a few questions that have come in. Um, the first question is, can you test anything to the cost in terms of C G. M, especially with Medicare and the Medicaid population? Yeah, that's a great question. So this is where it can be really tricky, because the cash pricing doesn't necessarily translate to what a patient pays. So, for example, the cash pricing, the ongoing cash pricing of a library system, as I have stated, is about $120 a month. For if you had to pay purely cash and for a Decks com system, it would be about 400 to $500 a month. Pure cash. However, both of those systems are covered by Medicare on DSO. If a patient has really good Medicare coverage on, then it might be that both end up being the same price. Ondas, I stated before, um, the siege The decks come does have more features, so it's kind of tricky, um, knowing which system to apply for, because due to being Medicare, you have to go through hardware benefit so it's a little bit more complicated. You have to fill out to see, you know, a certificate of medical necessity so, unfortunately, can be a little bit of a hassle. So it it really helps to have a good staff that's trained, helped process the paperwork. So I guess the long story short is on Medicare or Medical. There are many scenarios where the price of both might be the same to each patient because it's covered by Medicare. Um, but but the cash price is much different. So if you have a patient that might end up, are very likely will end up paying cash, and the library can be a much more affordable option. One thing I should say is that Medicare guidelines cover see GM for only certain types of patients. So the official guidance is, uh, patients have to be taking insulin more than three times three or more times a day. Um, and they have to be checking their blood sugar four times a day. Um, but I will say that the proof that you have to show like the period that they have to be checking their sugar four times a day is not necessarily that long. So you can have your patient follow the requirements, you know, for a period of time to get that covered properly. Okay. Thank you. That's very helpful. Also, do you have any experience in using any of the diabetes technology in the inpatient setting? Including, you know, Dex, com Libya or even things such as the control like you feature on tandem, which Irma was interested in knowing about? Yeah. So I personally we we as a hospital system have not yet implemented See GM in our hospital. We, like many of you, are we have a policy where patients can continue their outpatient devices if they would like, but we don't have yet. Um Ah, Pilot. Where we used GM in the hospital. I know scripts does have one. I spoke with someone there who was telling me about the pilot that was done there on DSO scripts. You know, definitely scripts has been a leader in that, um but but we have not yet personally done it, but we do expect this to become more widely adopted very quickly. Um, see, GM in the hospital has been granted kind of a special status due to cove in 19. Um, so a lot of hospitals now are in the process of starting to introduce. See gm in the hospital. So I expect in the next year this will become a lot more widespread. We at Khobar hoping toe implement a pilot in early 2021. Okay, thank you. And there was some questions about the resource is that you put up on the slide. But we should have access to the slides, um, to the program later on. So those of you who missed it, my last question is, um with all this technology the c g m, the in pens, all these different things Do you ever feel like it's becoming too complicated and that sometimes less is more? And how do you sort of decide? You know, when technology is appropriate? Yeah, it's a good question. I think, you know, given my reputation as being kind of the tech guy and, you know, being, um e think e think that's a really important point that you are a panel are attending, might have brought up. I try to temper my enthusiasm and my excitement for technology to really understand where my patients are at. And I think that the best clinicians are able thio kind of understand their patients needs before their own desires. Um, I do think that it can be extremely useful and worthwhile to go through the hurdle of training patients. So, for example, with control like you and the 7. 70 g, I've had some patients that you know aren't very tech savvy, but it was worth the hassle because the added benefit of control is just extremely beneficial. Um, that being said, I also have a patient who I was hopeful, would do well on the control like you, But But she just did not, You know, the technology, like you were saying, even putting on the decks come to her was just very confusing and very frustrating. So I think we kind of just there's It's definitely a situation where more is not always better. I do think the right technology, you know, as technology gets better, it can be more widely usable, right? So think of like an iPhone versus a BlackBerry. I think the iPhone was well designed to be usable by most people, including those that are not tech savvy, and that's just better designed. So hopefully, as our technology gets better, the design will improve and, um, the usability of these devices will improve. But it is true that thes thes gadgets are not the best for every patient. Great. Thank you so much. That was really, really informative. It was really nice having you here. Yeah, Thank you for having me off course.
