I think definitely the patients that want something more convenient. They don't want a disruption in their daily workflow. They don't want to have to take extra time off of their Workday just to find time to, meet with a pharmacist or even their primary care providers.

Welcome to a virtual view where we talk about telehealth, healthcare and everything in between.

today I have the pleasure with speaking with Stephanie Hislobb from aluminate health. Who's going to speak with us a little bit more about telepharmacy So Stephanie, I want to give a chance just for you to be able to share a little bit about your background and how you got started. Intella. With the audience

thank you for having me. So I originally graduated from Franklin college with a degree in chemistry and right after graduation, I went on to Purdue to obtain my pharm D right after college, I had a job with a retail pharmacy, and I worked in retail pharmacy for about a year and a half before I transitioned into. The little pharmacies. And I worked in hospital pharmacy for about seven and a half years. And what interested me in telehealth was I actually started subscribing to some healthcare tech magazines to see what was going on in the trend and in the market. And that really interested me. So I actually went back to school in 2018 to earn an MBA from Butler university. And I graduated in August of 2020. So the last semester and a half of my education was all online. But I actually met a classmate of mine who was an intern for aluminate health and she actually connected me. With the company. And at the time he didn't have a role for me. But about six to eight months later, he reached out and said, Hey, I have an opportunity for you. So I actually just joined the company in October of 21. So I've been with the company. For almost about six months now.

Great, Stephanie, thank you. And congratulations on your recent graduation with your MBA. And it's cool to hear, just being, what initially sparked your interest in telehealth is just seeing some of the emerging trends and really that leading you into this particular application with telehealth. Especially telepharmacy, we've been able to see the utilization of it increase a lot during the public health emergency, where a lot of waivers that existed for the first time. And now that we've had for a couple of years, we've been able to see really how telepharmacy works for the first time on a very large scale. But for some of our audience who maybe is a little bit. To the concept. Do you mind just sharing what a brief definition of a telepharmacy visit?

Yeah. There are a couple of different options for telepharmacy. Some of you might think of telepharmacy in the sense of a retail pharmacy where the new trend now, even before the pandemic was to have a pharmacist offsite in a remote location. Verifying prescriptions that technicians were filling and they were verifying those through images that were sent to them. And then they would provide patient education remotely when patients would pick up their medicines. our company provides a telepharmacy service, where it's patient facing. Virtually. So with our visit, we actually meet with the patient virtually through video chat and we set up a few different interviews with them. So the first one is what we call a comprehensive medication review, where we spend some time going over all of the patient's medications going over maybe struggles that they have with their medicines, whether it's. Side effects that they're experiencing, which is preventing them from actually taking their medicines and adhering to their medication regimen. Sometimes it's a cost issue where maybe insurance isn't covering the medicine or they're not covering it fully. So they have a high copay. Or sometimes the patients just feel overwhelmed in general and they don't want to take all of these medicines. So in that first initial interview that we have with our patients, we go over all their medications that they're taking. And we talk to them about kind of their goals of care, are they having issues with any of those things that I just mentioned? And if so, how can we make their medication? Regimen more manageable. So they are taking their medications and they are treating their disease states. So that's our first initial console. And then after we speak with the patient, then we would go back to the provider and make recommendations on any therapy changes to make their medication regimen a little bit more manageable for. And then every month we reach out to the patient through our platform and we just ask them, are you having any new side effects? Do you have any medication questions? Just so we always are keeping constant contact with the patient and addressing any issues as they come about. And they're not just piling up until the next visit. So then every quarter we offer another. Video interview again, video consult, but it's more condensed. And we still go over all the medications and any new medicines that were started or medicines that have been discontinued. And we just offer our services and have patients reach out to us at any point in time. If they start a new medicine or they have questions in general, they can contact us.

What I hear through what you're sharing there is, it really just gives patients significantly more access to being able to consult with a pharmacist, with all of the different questions that they may have for their medications, where. If you're only in an in-person option, you're really having to travel onsite and consult with those pharmacists there, versus being able to do that conveniently and easily from the comfort of your own home or another location. As well as being able to have that pharmacist interact with your provider as well with a self-management. And so for some of the patients when it comes to telepharmacy and we talk about this with tele-health a lot is when you're putting a patient in a telehealth program it's also about, it being a fit for the patient too. So what types of patients do you feel like benefit the most from being able to engage in these telepharmacy services?

I think definitely the patients that want something more convenient. They don't want a disruption in their daily workflow. They don't want to have to take extra time off of their Workday just to find time to, meet with a pharmacist or even their primary care providers. So patients that have. Wanting something more convenient patients that actually have the resources to utilize our platform is very important. So you need internet connection to utilize our services. So I know some patients are limited with that resource, so this might not be the best type of service to provide for those patients. Also, the patients that have a high digital literacy. I know sometimes apps, even for myself, can be very confusing and frustrating. And then I just give up and I don't want to use it. So patients that really not necessarily are tech savvy, but they. Can, find their way around a platform. But some patients just don't want that kind of virtual interaction. They want that in-person interaction. And so patients that want that in-person interaction, this might not be the best option. we can provide some level of in-person interaction through video connection. And it's not just through mobile messaging. You have that option to visualize who you're speaking to. So you can put a face and a voice with, with the person.

Absolutely. Yeah. Being able to have conveniently access, those resources is always going to be a huge and important factor when engaging with telehealth services. And I should've clarified this earlier. But I meant to ask with your telepharmacy services. Do you also prescribe medications through those telepharmacy services?

We do not know. We do not prove we don't have pharmacists in Indiana. Do not have prescribing past. So we always have to go to the provider and get those changes authorized by the provider. So basically the pharmacist is acting as the liaison between the patient and the provider to say, okay, Cameron's having trouble with his medication regiment. And based on my interview with him, here's what I recommend to make it a little bit more manageable. And then the doctor has to come back and say, yes, I agree. Or no, I don't, we're going to keep it the same, but some states do recognize pharmacists as providers and give them, prescribing powers. Unfortunately Indiana is not one of those states right now.

By chance, do you know what that may look like in the states of Ohio, Michigan, or Illinois?

That I don't know. Unfortunately with tele-health and, authorizing pharmacists to provide care across state lines, that's just an ongoing topic of regulations and what the states are allowing, and it's a state by state basis. In the state of Indiana, during the pandemic, when we saw the need for telepharmacy services, You know, the state board of pharmacy and the government adapted pretty quickly and authorized emergency licensures essentially to give pharmacists the power, to provide services across state lines. But those are temporary. And they're ongoing. So they constantly have to reevaluate the need and whether or not they're going to allow this as an ongoing surface.

Right. And we'll see, with the policy landscape as it is right now. Consistently things are changing and, we are starting to see some tele-health services that are having some permanent revisions that will last after the public health emergency. But with that, time will tell and we'll see, where some of those things shake out from a state and kind of federal level as well. I wanted to loop back. What you were sharing a little bit of, the pharmacist is really serving as the liaison between the provider and the patient. How do you feel that model really helps to cover some gaps that patients may face without being able to have that pharmacist liaison?

Yeah. It's really nice that we're able to connect with our patients and really take the time to interview our patients. I don't know if you've been in retail pharmacies at all or you just pick up your medicine through the drive-through, but pharmacists are very busy and taking on many tasks. So sometimes, unfortunately we don't always have. The time needed to really sit down with patients, interview them, see what's going on to really hone in on what is the problem? Why aren't you taking your medicines? So providing a service virtually. Where patients can make their appointment with us at a convenient time for them, we're able to sit down and really figure out what's going on and find a better treatment plan for them. So providing those patients with that kind of extra care. It was really preventing, maybe medication non-adherence, which could lead to, extra doctor visits or even ER, visits that could eventually lead to hospitalizations or rehospitalizations when patients just feel overwhelmed and just don't want to take their medicine. So we are trying to prevent that. Bye, providing the service, taking the extra time to really figure out what's going on and making sure that patients understand, okay, you're on this medicine for this reason and you need to take it. And if you're experiencing side effects or you're feeling overwhelmed because you're on 10 other medicines, let's figure out that. Medication treatment plan for you. And let's talk to your doctor. Let's see if your doctor is willing to make those changes, to make this easier for you.

Yeah. So there's a cost if a patient is not clear on what exactly they're taking the meds. For the frequency, the dosage, as well as, not being Nat adherent to the medication that they're taking. So I guess how does that, so you already talk through a little bit. You know how that costs the patient. So potentially, readmissions, poor management of the condition that they're trying to treat. How does that kind of pan out as far as like a monetary standpoint what is the cost of not adherence or drug confusion?

Yeah. With the recent research I've done actually 2.7 million us. Little admissions occur each year due to sub optimal medication therapy. And then 213 billion of total us healthcare spending is considered wasteful and avoidable with 50% of that being attributed to medication, not adherence. So that is a lot of money that is unnecessarily spent because patients are not adhering to their medications. For a variety of reasons. And those reasons can range from side-effects to just not understanding why they're taking it to a cost issue. Insurance isn't covering it, or they just don't have the funds. And sometimes patients just don't want to take 10 to 15 medicines. It can be hard to remember to take medicines. And it's not just for elderly patients, younger patients forget to take their medicines. So it is a very costly medication non-adherence for sure.

Yeah, and I can this is probably. This isn't a great example, but I have a hard time even remembering to take a daily multivitamins, let alone having to manage multiple prescriptions, understanding the dosage, understanding how many pills of this. Do I need to take let alone the cost, like you said, there may be certain specialty drugs that have a huge amount that the patient is really having to pay in order to be able to take those medications which can become a huge barrier. That's both a huge financial cost to the patient, but also even just a cost to the medical system as a whole. Cause as you said, The patient can't take some of those medications they may need, they may be admitted into the hospital more frequently than if they were able to, get those drugs be able to take them consistently and getting them at a affordable price. And being able to have kind of that pharmacist liaison really helped the patient. Navigate some of those issues. It was a huge benefit to them, especially when they're not having to constantly go in person to meet with someone, to talk through some of those things. Drug confusion and not inherence can. Bring significant costs to the healthcare system, not only to the patient as well. So really? How does a telepharmacy program kind of fit into a value based care?

Okay. So telepharmacy services provide benefits to all stakeholders involved in that value based care model. Speaking of so we're able to provide quality patient care and improve overall health outcomes by reducing the overall healthcare costs associated with medication non-adherence and hospitalizations and rehospitalizations. So for patients, they see the value in telepharmacy services by having additional support from their pharmacists without having to feel like they have to go into a retail pharmacy to ask those questions. We also ensure that patients understand their medication regimens. Experiencing any side effects or cost barriers to obtain their medications, thus improving their overall health outcomes. Providers actually see benefit by having an additional layer of support through pharmacists on their team. By allowing us on their team, we're able to provide that. Medication support with evidence-based medication recommendations solutions for medicines that aren't covered by a patient's insurance, or maybe the patient has affordability issues and we can find. Patient assistant programs or drug companies and just relieving the overall burden placed on providers to do it all on their own. So we take over the responsibility of all the medication questions that are related to patient care, and then insurance companies see major value. With reduced healthcare spending for patients who have access to pharmacists through telepharmacy services because we are the ones that are proactively identifying issues with medication regimens and we're encouraging medication adherence. By doing this, we are preventing excessive. As to the doctors and possible hospitalizations, rehospitalizations and anything that goes along with medication nonadherence.

That's a great holistic overview uh, You know how the telepharmacy services can come alongside organizations that are looking to reduce the cost of the care that they're providing and provide higher quality care for the patients that they're working with as well. And that there's a benefit kind of from multiple sides of the healthcare system, whether you. A provider who's getting some additional assistance from a pharmacist that's helping walk through and provide this additional education for your patient. Or whether you be, an insurer and you're looking for ways that you can help reduce total medical costs that your, covered lives are really experiencing. We talked about costs, talked about value based care. One thing that we haven't talked about specifically yet is poly-pharmacy risk and really how, a telepharmacy program could help reduce some of the negative side effects that a patient may experience when they are taking several drugs that may have 12 or more active ingredients.

Yeah, so with telepharmacy services. We know that it's really easy for patients to be prescribed multiple medications, especially if they're seeing multiple providers. Let's say they're not only just seeing their primary care doctor, but they're also seeing specialists because they have asthma. So they're seeing a pulmonologist or they have diabetes. So they're seeing an endocrinologist. So unless those providers are aware of all the medications. These patients are taking there might be a disconnect in understanding, okay, what are the active medications these patients are taking? And let's make sure that I'm not duplicating any sort of medication therapy. Other times it's solely patient confusion. They are started on a new medicine, but maybe at the next doctor visit the doctor actually increases their dose because they're not achieving the optimal care with that current. But then the patient doesn't stop taking the lower dose. They're duplicating their dose, they're taking the lower and the higher dose. So then that creates more problems for the patient. So when we have our initial comprehensive review with our patients, we're getting a list of all their medications. And at that point, I see, is there a duplication in therapy or are you taking a lot more medicines than what you need to? Some patients I know a lot of patients do this is they keep old medicines and they don't get rid of them. And one drug class that is a common offender of this is antibiotics. So some patients will hang on to their antibiotic in case they get sick again. And we don't want that. So we want to make sure that patients aren't hanging on to old medicines cause medications do expire. And it's just not safe to have those medications just in the home, for anybody to use or get ahold of. So we really focus on making sure that the patient's active medication list is safe. It doesn't have any duplications in therapy and if they do, then we need to really hone in on why. Taking those medicines.

Yeah. And that gets really important when you're taking multiple medications for a variety of different reasons. And, to your point If a patient is seeing multiple specialists, unless that patient is making sure that every detail when they're going to see the other doctor is correct. And I know if you're taking multiple medications, that's difficult to track. Make sure that, You're clearly communicating to the provider that you're seeing. This is the drug that I'm taking. This is the dosage that I'm taking currently. And making sure that your provider has that updated information that just easy for, as you said, suddenly you're taking a higher dosage and then you're still taking a lower dosage of even the same medication, just because there was some information that may have not been shared among some of those provider groups. Four to a patients in their defense, they're not medically trained. How would they know? That's something that they don't know if there's certain drug interactions that may happen if you take one medication with another medication. And if that information isn't shared from the patient to the provider that, can cause some issues. So being able to have. A third party who's looking and catching those things from the outside of, okay. You were prescribed a new medication. This was the dosage. You told me at one point that you were taking this making those adjustments, whenever some of those changes come up, so you don't run into those issues. Long-term feel through our conversation, Stephanie, it really does seem biggest gap that's being filled through telepharmacy services is the potential for a lack of information being shared among multiple providers or from the patient who isn't medically trained. Understand exactly what they're taking and why they're taking it and really helping to educate that patient on what those particular medications are being used to treat. And how do you make sure that you're taking them appropriately? Like you said, not stockpiling old medications that then you take when you're not supposed to be taking them or they're expired. And so it really does seem that telepharmacy really sits in of really addressing those gaps of education and misinformed.

Yeah, absolutely. And also just dedicating that time to spend with the patient to sit down. Like I said, retail, pharmacies, doctors, other providers just don't have the time. To sit down and really listen to their patients because they've got other patients that are waiting to be seen as well. So no fault to them, it's just, they're limited in what they can actually provide in their 20 to 30 minute time slot that there are a lot of, for each patient. So just allowing that additional time to really sit down and talk with the patient and understand their concerns.

Absolutely. We've talked about, a lot of benefits for telepharmacy with each service. I think one thing is always identifying if there's any particular risks that are involved with telepharmacy. And I know that especially with the. Opioid epidemic. And a lot of those issues that have come just through, being able to prescribe patients medication, and some concerns that individuals may have of, will telepharmacy perhaps make that even more accessible or more of an issue in the future. What are, some of the. That you could see that could come with telepharmacy and how do you help mitigate some of the.

So the first one that comes to my mind are just cyber attacks in general. So cyber attacks are on the rise, especially with healthcare organizations being the main target. So ensuring that your telepharmacy organization takes all the measures to have a secure connection, especially if your employees are utilizing their own personal device. To provide the services you, and with health care, it's very important to keep all that information private and secure. So that is a major risk with telepharmacy and telehealth in general. Another risk is, again, I think I mentioned this before, but the availability of resources with internet connection, not everybody has that access. That is a risk with providing telehealth and telepharmacy services is some patients that really need it. Especially the patients in rural areas that have just, a lack of access to providers. They might not have the resources to utilize the services. So that's unfortunate, but. That's a risk with the telepharmacy and telehealth services. And then again, the digital literacy patients, really not understanding how to use the platform, or maybe they just don't want to use, a tele-health telepharmacy platform and they want that in-person visit. So those are some of the risks associated with telehealth in general, there are ways around those. But yeah.

No, that makes sense. And a lot of those risks, as you said, are risks that a lot of telehealth programs face and look to mitigate. With some of the restrictions that we talked about specific to telepharmacy and being able to have, some of that prescribing power when it comes to being able to provide telepharmacy services some individuals may be concerned on, Do some of those regulations and restrictions look like when it comes to the prescribing pack power and telepharmacy, if we saw some of those issues with the opioid epidemic, with, a lot of addiction that happened through prescribing patients opiates in an in-person visit and concerns individuals may have of, would we see something like that happen then? You know, Regulations or restrictions around telepharmacy services. Aren't the same as they are in person, how would you go about addressing that concerns specific to telepharmacy I know in Indiana we don't, have that power here. But maybe in other states where you've seen where they do have the power to do that, how are telepharmacy programs guarding against that?

Yeah. I'm not really familiar with the, what the prescribing power looks like in those states, but I would imagine it's within their scope of practice, I would think that some things like opioids would be off limits and more so maybe medications for chronic diseases such as diabetes. Hypertension thyroid disease. But I would think that even if pharmacists were allowed to prescribe opioids, they would still have. Regulations of, how many day supply can they prescribe and what are we using this for? And, just they enacted that law here recently where, certain prescribers can prescribe opioids. But only for a certain day supply, unless you were like an oncologist or pain management doctor, of course you can prescribe 30 days, but here in the state of Indiana and I believe it's a seven day max for primary care docs because they don't want to over-prescribe and definitely as a pharmacist, those regulations and restrictions and guidelines would probably. Aligned with what providers are actually mandated to follow if not stricter. So as a pharmacist, I can say I would not feel prescribing opioids. I would probably refer them to their PCP or, a pain management doctor.

That's a great point. Cause I think, with. The concerns that may come up with tele-health services of, can the services be regulated the same as they would for an in-person. Like you're saying a lot of the standards are going to stay the same. There's not going to be like a, kind of a wild west of telepharmacy where you can prescribe whatever you want whenever you want. A lot of those restrictions will look very similar and, there's a lot that we have learned through the opioid epidemic and how to monitor and to your point. It's only certain providers can even provide for more than a seven day supply. And so with that, there is still a lot of regulation that would exist within telepharmacy services. Regardless if multiple states started allowing. Pharmacists to be able to prescribe via telehealth. And thank you for answering that. I know that can be a sticky subject. But I'm really seeing that a lot of those Regulations will exist and it will still be a safe way for patients to receive care for pharmacy services as well. So that we talked a little bit about the restrictions. So I want to look at the future. What do you feel like is the future of telepharmacy service?

Yeah, I think more and more organizations will start implementing these services. I think definitely during the pandemic, every healthcare organization had to find creative and innovative ways to improve efficiencies, especially when we started noticing staffing shortages, we can only do so many things as time allows. And so implementing some of these AI powered services to. Risk stratify patients and identify the ones that actually need to be prioritized first and seen first and taken care of first taking, I guess you would say the guesswork out of it. Really streamlining processes and procedures to again, Overcome those challenges that we didn't foresee with staffing. But just overall in general, I think organizations are seeing the benefits of having some sort of tele-health telepharmacy services integrated into their current workflow. So I don't think that telepharmacy. Telehealth services are going to decrease in the future. I think if anything, they're going to keep increasing and you'll see more and more organizations implementing those. You're going to see more and more startups like my company, developing new things new services that will really improve patient care and just the overall goal of, improving health outcomes, reducing healthcare costs. And making sure patients are aware of, their health and their medications and just taking, more initiative to manage their own healthcare.

Absolutely. The telepharmacy landscape looks very bright in the future. And I think as you said, as organizations become more and more aware of the benefits and what can be offered through telepharmacy I see a lot of organizations really spending time to develop these services so they can create those better value services for their patients and reduce, their overall costs as well. And so Stephanie this wraps up our time today. And so I just want to thank you for taking some time to come out and speak with us today. And for any of you who are interested Stephanie's information will be included. And so you can learn more about her and her organization. But Stephanie just want to thank you for your time. And we hope to talk to you again soon.

Yeah. Thank you again for having me. It was a pleasure being here.

Thank you for listening to a virtual view. You can find more information about today's episode in the show notes below. If you would like to support our podcast, please rate and review us on your favorite podcast player. Do you have any questions or topics you'd like us to discuss? If so, contact us at info at UMTRC dot org or through the form found in the show notes. Also, we'd like to give a special thanks to our editor. Finally a special thanks to the health resources and service administration. Also known as HERSA. Our podcast series of virtual view is sponsored in part by hearses telehealth resource center program, which is under hers is office of the administrator and the office for the advancement of tele. The content and conclusions of this podcast are those of Cameron hilt of the UMTRC and should not be construed as the official policy of, or the position of nor should any endorsements be inferred by HERSA, HHS, or the U S government. Thanks for listening and have a great day.