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Telepharmacy & COVID-19: an Interview with Tim Youkhana

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As COVID-19 spreads across the country, it becomes important to recognize the workers on the frontlines fighting this disease. How are essential workers limiting their exposure to COVID-19? In today’s episode, Darshan Kulkarni talks with guest Timothy Youkhana about how workers are dealing with the risk factors of the pandemic, and what role telepharmacy plays in reaching patients.

Darshan: Hey, everyone. Welcome to another episode of Darshan Talks. We have a frequent guest of ours. We have Tim Youkhana. Tim, do I say your last name correctly?

Tim: You got it. You got it, Darshan. There's multiple ... It's like tomato, tomato. Youkhana, Youkhana, it doesn't matter.

Darshan: Youkhana, okay.

Tim: I'll still answer.

Darshan: Fair enough. Tim is a frequent guest. I've known him for a while. He is the person to talk to when it comes to telepharmacy.

Darshan: As some of you may know, depending on when you're listening to this, we're in the middle of the COVID-19 outbreak. Everyone's working from home as much as they can to avoid spreading, and as they say, to avoid flattening the curve.

Darshan: The perfect person to talk to right now is someone who actually has helped flatten the curve before there was a curve. In many ways, Tim is the telepharmacy hipster. He was cool before it was cool to be cool.

Tim: Yeah.

Darshan: Tim, let's ask a really basic question, which is, we've spoken about this before, but what is telepharmacy, and how is that different from telehealth or telemedicine?

Tim: I appreciate all the accolades that you gave me, Darshan. I'm blushing right now, if you can't see it.

Tim: What telepharmacy is, it's similar, in regards to the pharmacy aspect, of how telemedicine works for physicians; outpatient, inpatient treatment; psychiatric care. It's just taking that model from the telemedicine side, and integrating it into a dispensing role from a pharmacy perspective. What it allows community retail pharmacies to accomplish is essentially being able to serve a larger amount of the population in areas that might not be conducive if they were operating in a traditional setting.

Tim: Right now, as you had mentioned, depending on when anybody's listening to this, we're in the middle of a COVID-19 crisis, the pandemic that's going on all over the world really. Businesses have been scrambling, because they've been shutting down all over the place, to find ways to still not only remain important in front of their clients' perspectives, but if they're an essential business, still be able to deliver the products and services that their clients need on a day to day basis.

Tim: That's one area that telepharmacy, if you hadn't adopted it before this whole thing came up, and you're trying to find a way to be able to still stay relevant, if you're not looking into it right now, I really don't know what else would bring you to the table to start thinking, "Oh man, maybe I need to start looking into doing something like this."

Tim: God forbid something happens like this again in the future, at least you can be prepared, and your clients will be reassured that you're still going to be able to deliver them the same amount of care, if not better, because you've already been adjusted, and there's not those growing pain that kick in any time that you adopt a new process or system into your workplace.

Tim: I hope that answers, in the grand scheme, what you had asked, Darshan.

Darshan: Well, I think you're answering at a grand scheme, but one of the questions I get is that just sounds like mail order. How is this different from mail order?

Tim: You've got the brick and mortar aspect still. Telepharmacies still operate out of a physical location. It's considered an outpatient pharmacy. It's a community based pharmacy where patients can come in and out. You can have a storefront. You can do all those same things that you do in a traditional pharmacy setting. You just don't need to have a pharmacist on site.

Tim: By being able to remove that, the largest part of your payroll, you're enabled to have a couple different pharmacies in different geographic locations that would help you reach a larger population of people without having to stretch your workforce thinner and thinner, and trying to find pharmacists to be able to go in in shifts, and manage a larger team of people.

Tim: So it's not the same as mail order. Mail order, there's no actual interaction with anybody, unless it's over the phone. Mail order suppliers now, what they're doing is they're actually even providing some of these remote consultations for patients. They're doing it through MTM services and doing all that. The main difference between this-

Darshan: What's MTM services again?

Tim: ... with telepharmacy is that your patients still understand that it's owned and operated by you, the pharmacist. You're still that face of that pharmacy chain or whatever it is that you want to call it. They still have that one-on-one relationship with you, and you still have that relationship with your clients. So they still have that ability to have that human interaction whenever they need to.

Darshan: Here's a question for you, Tim. You talked about telepharmacy, and you talked about how it augments what a regular pharmacist is already doing.

Tim: Mm-hmm (affirmative).

Darshan: Obviously we get, we'll probably have to have a whole long conversation about that, because there's so much there right now, and now is the perfect time, like you said, to be using telepharmacy.

Darshan: But what happens if tomorrow I am a, I don't know, a grocery store owner, and I go, "You know what? I'm going to create a kiosk. I'm going to put a kiosk with essentially a telepharmacy video there, and someone can come talk to a pharmacist in these systems." Then I, as a grocery store, will contract with a, I don't know, mail order pharmacy and have it shipped to you.

Tim: Mm-hmm (affirmative).

Darshan: Is that the future of telepharmacy, or am I confusing mail order, or do those two things eventually meld?

Tim: It's kind of integrated together. The thing is is that the important part to ensure people are understanding is that telepharmacy doesn't mean that people are not going to be still in the background operating these centers. You're still going to have pharmacy technicians who are going to be there. You could have automation to help. If you've got a Parata machine, a Yuyama machine to help with dispensing, if you're a higher volume telepharmacy, those things can still be in place.

Tim: The benefit to it is, with a kiosk, if you're a grocery store owner, and you just want to say, "Hey, I want to have another service offering for my people that are coming in the door," I really don't want to worry about having more personnel to deal with, and all the regulations, so I'm just going to outsource it to a mail order pharmacy. That's well good.

Tim: But at the same time, there's the other aspect of having somebody that's actually physically there. Human to human interaction, even though your pharmacist might be virtual, the technicians, which are really the backbone of any community pharmacy, or even mail order pharmacy for that matter, they're there to have that ... They resolve issues right then and there.

Tim: A lot of the things that I've seen with kiosks is that the patient would have to, once the prescription comes in, it could take them about 10 to 15 minutes before they end up getting their prescription filled. They got to stay in front of this thing forever. If there's an insurance issue, that's another added step that might take a little bit longer.

Tim: The technology is available. It will take some time for it to develop. It will, just because that's the nature of the beast. But at the same token, this telepharmacy aspect allows people to not only still be able to speak to somebody one on one, but they have the ability to receive their product and their service a lot more efficiently and effectively.

Tim: If there's an issue that needs to be resolved, you've got somebody that's then and there, who can take a look at it, take care of the issue, resolve it right away. You have that customer service that, I don't care how well that mail order pharmacies work, when you have somebody that's actually there in front of you, and they're speaking to you, and they're looking you in the eye, it's a totally different feel compared to speaking to somebody over the phone.

Tim: I think I'll go right now in this atmosphere that we're dealing with a lot of virtual and all these different meetings, it's nice that we have the technology to be able to do it, but it doesn't mean that it's something that people are not going to have that urge to still want to see people and talk to them face to face.

Darshan: What I hear you saying, Tim, is that this really helps augment what already exists, and helps you scale as necessary. As opposed to hiring people, and them being on your payroll the whole time, you can bring these people on, they can help you adjust as your workflow and as the amount of people coming to your pharmacy changes. So if it's busy from 2:00 to 4:00 PM, you don't have to keep someone a hired from 8:00 AM to 5:00 PM just because of that 2:00 to 4:00 PM rush. Is that basically what you're saying?

Tim: Sure. Exactly. Just to give you some premise, and I'm going to make a plug for my company, which is Scaled Enterprise Solutions, if you don't mind.

Darshan: Please.

Tim: That's literally what we do. It's a workload balancing service providing company, where you've got prescriptions that need to get verified, you have patients that need to be consulted, you're running thin on your staffing, so what we do is we're able to provide those services for these pharmacies remotely. They send over the prescriptions to our portal. Our pharmacists can go in and verify the orders for them. It's at really low cost, and they can consult for these patients as they're coming in.

Tim: The key benefit for ... The person who stands to gain the most in this are the pharmacy owners themselves. If you're a community independent pharmacy owner, and you've got one pharmacy, and you want to expand, but you're like, "Man, I really don't feel like dealing with the headache," in regards to hiring staff, managing people, dealing with payroll. Then on top of it, I have to go in and find a pharmacist, and make sure they're doing everything accurately, and doing it in the way that I'm expecting them to be done. That's where these telepharmacies can help them.

Tim: You can reach even more people. You can leverage something like our company does to make sure that while you're at your home base, those other pharmacies and telepharmacies are covered, that the pharmacy services, by verifying and consulting, are taken care of, so it's really giving you peace of mind as a pharmacy owner to make sure that you don't have to worry about all those things, and you'll have plenty of time to be able to accomplish any goal that you need to, and oversee the whole operation as a whole.

Tim: That's, I think, the biggest thing that people need to understand is that if you have that one pharmacy, reimbursement rates are killing everybody, no matter where you're looking, whether it's in physician care or pharmacist care. Insurance companies and [PBMs 00:12:09] are getting smarter and smarter with all the data that's coming in.

Tim: So we also have to adapt as pharmacists. We have to understand that the biggest way to be able to do that is reducing your cost to fill. Your largest expenditure is payroll. By being able to find a way to be able to remove that aspect, and operate a pharmacy without having that large number hanging over each pharmacy's head with pharmacist salaries, it's something that everybody needs to really take a second look at to move forward into.

Darshan: This makes me think about what the impact of COVID is, of COVID-19, the coronavirus.

Tim: Mm-hmm (affirmative), right.

Darshan: Obviously, well, I go with my girlfriend, and I go to these pharmacies. I know, for example, that she refuses to walk into stores, because her big thing is, "I don't want to be around people, because that's how the bug is spreading." If that's true, is telepharmacy ... This is a multi-part question. Is telepharmacy the way we minimize spread of a virus, number one?

Darshan: Number two, can this be used in forums like nursing homes where, "You know what? I have a question. I want to reach to either my doctor or my pharmacist." Doctors are harder to reach sometimes, so talking to my pharmacist, but the pharmacy itself is not the right forum, because I'm over the age of 60, and I might be especially susceptible. So maybe I just need to talk to them somehow, and telepharmacy is the way to get there.

Tim: In regard to minimizing the spread of the disease itself, of the virus, what we could do is, the telepharmacy aspect of it allows you, like I said, to be able to operate multiple pharmacies without having pharmacists' labor, which is, it's far and few between, especially when you're going into remote areas.

Tim: One of the biggest things that we're seeing in a lot of these areas where there's a high number of people who are infected with this virus is that the healthcare professionals that are helping these patients, especially the pharmacists that are really on the front lines of this thing, who have the least amount of protection in place, are really the most susceptible to contracting it.

Tim: So what happens is that you have a pharmacist, and then all of a sudden, God forbid, they ended up getting the virus itself, that pharmacist is down. That pharmacy is down, because you have to have a pharmacist employed in order to be able to dispense any prescriptions. What happens if your pharmacist goes down? Then all of a sudden, you're reducing your labor pool significantly. [crosstalk 00:15:19]

Darshan: You may be shutting down your pharmacy.

Tim: Exactly. This is what we're seeing with a lot of these hospitals, where the physicians that are getting infected, all of a sudden it's an exponential rate on the opposite end of the amount of people that are able to get treated for this virus. If somebody that's in the ICU, if a physician comes down with it, all of a sudden, that physician who is usually seeing 100, 200 patients a day, if they go down, there's not another specialist who can come in and just take their spot right away. This is the same type of situation ... The hospital can still operate. They have the ability-

Darshan: [crosstalk 00:15:53] so many pharmacists out there.

Darshan: You know what the funny part is, though? I was just talking to a hospital that I have significant experience with, or have worked as a pharmacist before, and they were telling me that they are using remote systems as well.

Tim: Right. One thing that hospitals have done is they've already embedded this remote verifying service within their inpatient hospital settings. Through EPIC Rx, PipelineRx actually provides these types of remote pharmacy services where they're verifying, their consulting. If the physicians have questions, they're able to do it, especially in the off hours. So if they're overnights or something like that, and the hospital still needs a pharmacist to check orders, they're able to offload that information over to their pharmacists that are contracted with them.

Tim: What we've done with Scaled Enterprise Solutions is take that similar type of idea and embed it within the community pharmacy aspect from an independent role. If you're a independent pharmacy owner, now all of a sudden, okay, you've got the ability to scale back and offload the work over to somebody like us. We can charge a significantly lower amount compared to hiring another pharmacist, let alone trying to find a pharmacist to come in and cover any shifts for you.

Darshan: Right.

Tim: At this point in time, I reside in Illinois, the state itself is under pretty much lockdown for the most part. We're getting notifications from the state asking for volunteers in any medical or healthcare profession to be able to help address any emergency situations that might arise. What's going to happen to these community pharmacies if all of a sudden that work pool is completely saturated, and now all of a sudden it's helping with a national crisis?

Tim: Where do you go? How do you make sure that your business is staying afloat, your clients are still getting their medications as they need to? Because as much as we are focusing on this COVID-19, because it is such a serious situation, there are still people who have diabetes. There's still people who have cardiovascular issues. There's still other issues that are going on that they need that day to day medication. They need that day to day information to make sure that they're doing everything they can to control their disease that they've got long before any of this other stuff came around.

Tim: That's kind of where all of this comes from. The nursing home aspect, as you had asked before, they can leverage it as well, and be able to ... I've been working hand in hand with BestRx. What they've done is that they've actually included that teleconsult type of concept within their software programs.

Tim: So there are prescription management services that, if the nursing homes are contracted with a specific pharmacy, more times than not, those longterm care centers and community pharmacies that are providing that service to their nursing home or longterm care area, they have those teleconsult types of situations where they can call over, they can have their questions answered if they need to.

Tim: The nursing homes, the larger scale type of organizations, have begun to adopt this type of mentality. I think the biggest challenge that we've been seeing, especially from our organization, is the ability for independent pharmacy owners to begin to adapt and learn and change, and make sure that they're still maintaining their level of credibility within this type of environment.

Darshan: What I hear you saying, and Tim, please correct me if I'm wrong, is that if anything, hospitals already doing this, nursing homes already doing this. Retail pharmacies have basically fought against this the whole time, maybe not explicitly, but sort of dragged their feet on the topic.

Darshan: Corona highlights how this can actually be a profit making venture for them. If anything, COVID-19 teaches us that adoption of technology is only going to help us address the needs of our patients, address the needs of not shutting down your business. Because pharmacies are essential businesses. In the State of Pennsylvania, you're allowed to operate. But if you don't have a pharmacist to go in, well, now you have a problem.

Tim: Right.

Darshan: This might be the way you get there. The big advantage obviously is the next step of this, which is the State of Pennsylvania, again, I get emails them every so often. I could've sworn that last time I looked, they said that we don't have explicit rules barring the use of telepharmacy, which means that since we don't bar it, you're allowed to come in and operate.

Darshan: What does that mean? Does this carry over once COVID-19 is resolved? What are the opportunities that it allows? Because it's really hard to put the genie back into the bottle at the end of this, right? You can't suddenly go, "Everything we approved during is suddenly not okay anymore."

Tim: Right. I think that we see that with pretty much any law that comes through, especially in a crisis. You can't technically reel back once you open the floodgates. That's I think where a lot of state boards are starting to understand.

Tim: There's a company that's out there, it's called TelePharm, which is owned by Cardinal Health. I've worked hand in hand with them throughout this whole process. They've done an excellent job in lobbying with different state boards of pharmacy, ensuring that if there was not any specific verbiage in the rules and regulations, that they're actually requesting that verbiage to be entered in, so that people don't have that type of misnomer, like how Pennsylvania does, where, "Well, we didn't say anything about it, so you guys can take your chances, and see if there's anything that we've got."

Tim: I think that there do need to be rules that are established for the proper operation of a lot of these telepharmacies that are opening up. But I think that more and more states are starting to realize how much of a positive impact that this type of model has to their overall outcomes from the healthcare system itself.

Darshan: Two responses to that. The first question I have is something, as we were talking, I realized we probably should clarify, which is there are two types of quote unquote telepharmacy that are being discussed here. The first is verification. You take pictures of your drug so that a pharmacist in a remote location can see the prescription label, and see the drug that you're using, and then okay it. Then there's the teleconsult, which is a pharmacist in a remote location talks to the patient. Is that accurate, Tim?

Tim: It's accurate. There's two different ideologies with this. The teleconsult portion is required for any telepharmacy. If there's not a pharmacist that's on site, that capability needs to be adopted and allowed in many of the states that have embedded this telepharmacy rule and regulation within their state board of pharmacy code. The verification piece, however, that can be used in not only the telepharmacy setting, but also in a traditional community pharmacy setting itself.

Tim: Say you're a larger volume pharmacy, or say, for example, now with some of the people that we've been speaking with and pharmacy owners in the area, they've had to cut back their staff. You have to reduce your amount of labor, because you can't maintain a specific amount of distance within each other, especially in a lot of these smaller pharmacies. You can't have three, four, five people that are in this 100, 200 square foot pharmacy, just to reduce their risk of contracting any virus.

Tim: What many of them have been seeing is that, "Okay, now all of a sudden, I don't have enough staff to accommodate not only intakes of prescriptions, but filling it, dispensing it, verifying it, providing consultation, doing all the third party rejections and updates, making sure that I'm still on top of my [MTMs 00:25:03]," all of these other things that you got to make sure you're on top of.

Tim: Where do you go? The solution that you can do is offload a lot of that verification work, that rudimentary work that allows you to be able to make sure that, even if your staff does get reduced, especially in situations like this, you're still able to provide that wonderful customer service that you've known to establish yourself on as a community pharmacy.

Tim: That's a different take on it, is that there's one model that, with the verifying piece, can work in both the community setting as well as the telepharmacy, like satellite remote setting. But the consult piece is really only restricted as a need for the telepharmacy satellite remote piece itself.

Darshan: Usually, I do these for about 10, 15 minutes. We're already at almost 30 minutes. So let's finish this out with a really simple way to finish this out, which is, you mentioned that some states are doing this inappropriately, and you need to have appropriate checks and balances, appropriate rules. What are some rules you recommend, based on your experience, in terms of the types of telepharmacy that would work, that would not work, and why it matters?

Tim: Well, I'm not an attorney by any means, Darshan, so I don't want anybody to think that I'm providing legal advice.

Darshan: You reach out to me for [crosstalk 00:26:35]. That's fine.

Tim: Exactly. That's why you're around and helping everybody out with this stuff. But what I've seen allows a lot of this stuff to occur in a really, really good fashion, and might even help with establishing more pharmacies and telepharmacies in remote areas.

Tim: What I've seen in many of the states is that the requirement of having a home pharmacy first in order to open subsequent telepharmacies. What this does-

Darshan: Why is that important? Go ahead.

Tim: There's two schools of thought. I don't know if it's really that important to have a home pharmacy. Here's my argument for removing that piece of it is that by requiring that home pharmacy, you might be restricting the pharmacist who owns the pharmacy to be able to oversee multiple locations that might not require them to actually physically be over there.

Tim: The former model of the home pharmacy was based off of the pharmacy can only operate if the pharmacist is actually in place. That law has been around for over a century I'm assuming at this point in time. Many of these states haven't accommodated yet to allow for the telepharmacy technology to really take a huge adoption.

Tim: I think that by removing that requirement, and allowing pharmacies to operate only as telepharmacies, without even having that home pharmacy base itself established first, will really reduce a lot of the red tape that some of these owners are having nowadays.

Tim: From the reimbursement side, we got to make sure that our pharmacists are being as successful as they possibly can be. As part of the healthcare system, we're really the most accessible people. By reducing that access, by restricting that pharmacy to only operate as a home pharmacy with a pharmacist on site itself, minimizes the ability for us to be able to reach out even more people.

Tim: So I think that, by allowing these states, and allowing these telepharmacies to operate without that home pharmacy first established, would really help us get to that next level, especially in states that haven't thought about this telepharmacy aspect yet.

Darshan: That, to me, is a really good ending point for this. Any parting words, Tim?

Tim: I just hope that really, in all truthful and honesty, everyone is staying healthy. They're staying safe during this whole COVID thing. My heart goes out to everybody with this whole situation. Anybody who's had family members who have been impacted by this virus, all the healthcare workers, the physicians and nurses, all the pharmacists, the technicians, people that are really on the front lines and still providing that service, even the grocery store people. Nothing really can be done without everybody really pulling together and supporting everyone one at a time.

Tim: My heart goes out to all of them. My prayers and best wishes are going out to everybody to make sure that they're staying safe and healthy. That's my biggest takeaway with this whole thing.

Tim: We've also been providing remote consultations for people as well. They can go onto our website. I run a nonprofit. It's called the United Family Health Alliance. People can go on our website, which is www.theufha.org. They can book a consult from over there. Then if anybody is interested in workload balancing or verifying, you can reach out to our website, which is ses.healthcare. It's Scaled Enterprise Solutions, ses.healthcare.

Tim: Thank you again, Darshan, greatly, for having me on.

Darshan: Thanks again. Take care, guys.

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