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Talking Intentional Automation in Specialty Pharmacy Referrals with Tennr | NASP Specialty Pharmacy Podcast · Pharmacy Podcast Network

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  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy Podcast Network.
• 0:25
  Speaker 2: You're listening to the NASP Specialty Pharmacy Podcast, a collaboration
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  Speaker 2: between the National Association of Specialty Pharmacy and the Pharmacy
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  Speaker 2: Podcast Network. Each episode dives deep into trends, challenges, innovations,
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  Speaker 2: and patient centric practices shaping the future of this dynamic
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  Speaker 2: and rapidly evolving industry. Whether you're a pharmacist or healthcare provider,
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  Speaker 2: patient advocate, or industry leader, you'll hear expert insights, real
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  Speaker 2: world evidence, and thought provoking discussion that highlights all that
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  Speaker 2: makes specialty pharmacy special.
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  Speaker 3: In support of NAP's mission to empower specialty pharmacy stakeholders
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  Speaker 3: to advance the standard of patient care, NASP supports a
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  Speaker 3: free market healthcare system in which all specialty pharmacies compete
• 1:10
  Speaker 3: on the same fare and level playing field, because that
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  Speaker 3: is in the best interest of the patients we collectively serve.
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  Speaker 3: NASP is committed to working with all stakeholders and policymakers
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  Speaker 3: to ensure that all patients have access to the life
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  Speaker 3: saving medications they need and the high touch patient care
• 1:25
  Speaker 3: and support services they deserve from the pharmacy of their choosing.
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  Speaker 4: Hello, my name Isshila Arkkeett, and I am the President
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  Speaker 4: and CEO of the National Association of Specialty Pharmacy. I
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  Speaker 4: am delighted to welcome my special guest, Trey Alterman to
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  Speaker 4: this episode of the NASP podcast. Trey Holterman is the
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  Speaker 4: CEO and co founder of Tenor, a referral automation platform
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  Speaker 4: built for healthcare operators. Trey studied computer science with a
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  Speaker 4: focus on machine learning at Stanford. Prior to founding Tenor,
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  Speaker 4: he focused on applying his research in the health technology
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  Speaker 4: world at health iq and Strava. Trey is an expert
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  Speaker 4: in healthcare operations, machine learning research, and how to snip
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  Speaker 4: out false promises when it comes to AI. Trey, thanks
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  Speaker 4: so much for joining me today.
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  Speaker 5: Oh thank you for having me, Sheila.
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  Speaker 4: All right, let's dive right in. You graduated from Stanford University,
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  Speaker 4: went straight to Strava, and now you're the CEO and
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  Speaker 4: co founder of Tenor, one of the fastest growing healthcare
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  Speaker 4: startups out there. In just a year and a half,
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  Speaker 4: Tenner went from an eighteen million Series A raise, which
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  Speaker 4: is pretty impressive from the start to a series C
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  Speaker 4: raise of one hundred and one million dollars with a
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  Speaker 4: six hundred and five million dollar evaluation. Not too chevy.
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  Speaker 4: So tell us a little bit about who you are,
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  Speaker 4: how Tenner was born, and what exactly is your company?
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  Speaker 4: Does that cause this growth?
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  Speaker 5: Yeah, well thanks, thank you for intro. I mean it
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  Speaker 5: is they say the best benefit of fundraises is that
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  Speaker 5: it gives people some way to kind of just growth,
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  Speaker 5: and it's good for employees and good for you know,
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  Speaker 5: my parents to can be convinced that I have a job,
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  Speaker 5: I mean, but hopeful me. Of course, you would actually
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  Speaker 5: wish that you you would be you wouldn't fundraise so much,
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  Speaker 5: or you would you know, you'd grow profitably or something
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  Speaker 5: like this. But you know, look, but I mean, behind
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  Speaker 5: the scenes, like we have taken sort of a maniacal
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  Speaker 5: focus on how do you get more patients from provider
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  Speaker 5: A into supplier or dispenser B or provider B, and
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  Speaker 5: just have been maniacally focused on that referral relationship and
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  Speaker 5: then the ongoing handling of the patient and all the
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  Speaker 5: sort of paperwork associated. That's why I often call ourselves
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  Speaker 5: an automation platform and it turns out it's incredibly expensive
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  Speaker 5: to fill to to build the technology required to do
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  Speaker 5: some of these things, incredibly expensive to build, you know,
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  Speaker 5: the models required to do the stuff intentionally, and then
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  Speaker 5: you also have to build out a team that really
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  Speaker 5: knows how to deploy it and is also experts and
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  Speaker 5: is able to sort of get into the sort of
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  Speaker 5: nothing gouts to the business and figure out, you know,
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  Speaker 5: how to drive really impressive outcomes. So you know, a
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  Speaker 5: lot of that stuff just does you know, take upfront investment,
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  Speaker 5: and at each stage when we have sort of aible
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  Speaker 5: to invest that we've been able to drive those outcomes
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  Speaker 5: for customers and feed more growth and kind of do
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  Speaker 5: it on a larger scale each time.
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  Speaker 4: Basically, so you're not marketing Tenor as first and foremost
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  Speaker 4: an AI company, But there's no sort of of companies
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  Speaker 4: today touting automation and AI AI in both specialty pharmacy
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  Speaker 4: and healthcare in general. Left and right, we're seeing tech
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  Speaker 4: companies promised to solve inefficiencies. From mere perspective, how should
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  Speaker 4: the industry be thinking even critically about this new wave
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  Speaker 4: of automation and AI in what's actually going to move
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  Speaker 4: the needle for specialty pharmacies. And to add to that question, tree,
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  Speaker 4: what sets ten are apart from the crowd?
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  Speaker 5: Yeah, mantor well this there's this idea, right of there's
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  Speaker 5: so many much noise in people wanting to go and
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  Speaker 5: build like one off AI or automation projects and so
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  Speaker 5: much of sort of like the zeitgeist. I guess in
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  Speaker 5: the in the tech and health careacter section of the
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  Speaker 5: world is like, oh man, there's all this work and
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  Speaker 5: we should just be automating. We should automate this, automate that.
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  Speaker 5: And I think our stance on this is it's way
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  Speaker 5: less interesting like automating work for automating work's sake is
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  Speaker 5: one it fails most of the time. From like a
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  Speaker 5: project management standpoint, I just wrote this piece about the
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  Speaker 5: MIT study where about the MT study that came out
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  Speaker 5: saying ninety five percent of enterprise IT custom projects fail.
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  Speaker 5: And actually, what the only thing I had to add
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  Speaker 5: to the conversation is that actually ninety one percent of
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  Speaker 5: enterprise IT projects with or without nondeterministic language models what
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  Speaker 5: people call prou as AI, fails too. So basically, anytime
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  Speaker 5: you're trying to just one off automate a big process,
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  Speaker 5: you're going to run into a big challenge if you're
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  Speaker 5: doing it, especially for the first time. So our focus
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  Speaker 5: is always about how do you just solve a fundamental
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  Speaker 5: problem in a business. Because if you can just say, look,
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  Speaker 5: we can see themount of patients that you're sent, We
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  Speaker 5: see themount of patients that you convert, We see themunt
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  Speaker 5: of the denials that you that you're you're receiving, and
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  Speaker 5: we also see the ft efficiency that you have. You
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  Speaker 5: can put up a scoreboard and you can literally just
• 6:12
  Speaker 5: rank yourself against that scoreboard and say, you know, how
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  Speaker 5: did we do in improving conversions? How did we do
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  Speaker 5: in in driving down denials by fixing the front end
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  Speaker 5: of the of the process and bringing in a new
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  Speaker 5: and better process. And if you just are obsessed with
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  Speaker 5: the automation side of it, you will like, you know,
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  Speaker 5: it's like, well, how much you're willing to give are
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  Speaker 5: you willing to automate you know, ten people's jobs? But
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  Speaker 5: your denials go up five percent? Like probably not right?
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  Speaker 5: And so I think if you don't have those those
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  Speaker 5: sort of benchmarks in mind and really sort of like
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  Speaker 5: an approach to handle all of that stuff, you're just
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  Speaker 5: going to be kind of screwed. So that's the sort
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  Speaker 5: of the problem focus or the sort of outcome focus
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  Speaker 5: that we carried in the business. You know. Beyond that though,
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  Speaker 5: the sort of not calling ourselves an a platform, even
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  Speaker 5: though we've got a pretty big team we send a
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  Speaker 5: ton of money building and fine tuning our own models.
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  Speaker 5: That's really more out of the fact that, like, you know,
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  Speaker 5: these language models are one small piece of the solution,
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  Speaker 5: but so much of what we've built, of what we've
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  Speaker 5: built and continue to build, you know, is enabled by
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  Speaker 5: a lot of this technology, but doesn't actually rely on
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  Speaker 5: it in certain cases. Right, So I think it just
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  Speaker 5: gets lost in this sort of fog of people thinking
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  Speaker 5: that there's some panacea, like one size fits all. We're
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  Speaker 5: just going to throw a bunch of chat GBT API
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  Speaker 5: calls at this problem and we're going to be, you know,
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  Speaker 5: in the Holy Land. It's just not the case. It's
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  Speaker 5: just not reality. You've got to be super purpose built
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  Speaker 5: for the problems that you're solving. You've got to have
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  Speaker 5: a great way to measure it. And so that's why
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  Speaker 5: we don't let people say AI as a company for
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  Speaker 5: that exact purpose.
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  Speaker 4: So in specialty pharmacy, making benefits checks and test claims
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  Speaker 4: air tight. So the right NBC is dispensed and reimbursement
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  Speaker 4: is predictable is crucial. Can you walk us through how
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  Speaker 4: Tenor is effective in tackling these industry specific and really
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  Speaker 4: specially pharmacy specific problems by describing what tangible business outcomes
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  Speaker 4: especialty pharmacy customer of yours could expect six months to
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  Speaker 4: a year after adopting the platform.
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  Speaker 5: Yeah, totally. So there are like the reason why it
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  Speaker 5: is a super exciting opportunity. There's a super exciting opportunity
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  Speaker 5: for technology. You know, in this space, especially pharmacy, there's
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  Speaker 5: all sorts of nondeterministic, very very sort of like judgmental
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  Speaker 5: decisions that need to be made around medical necessity, around
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  Speaker 5: step therapy adherents, around guidelines posted by payers, and if
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  Speaker 5: you want to sort of orchestrate this very very optimal
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  Speaker 5: pre dispensing pre servicing process where you can actually make
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  Speaker 5: sure you understand are we selecting the right NBC for
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  Speaker 5: us and for the patient. Make sure you understand you
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  Speaker 5: know the patient responsibility. Make sure you understand if you're
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  Speaker 5: going to be successful for an authorization and if it's
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  Speaker 5: even needed ahead of time, there are all sorts of
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  Speaker 5: moments in those processes that require really like the judgment
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  Speaker 5: of an expert, and that those like finite little moments
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  Speaker 5: of judgment are where we've built these models that are
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  Speaker 5: just very very good at making certain decisions that move
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  Speaker 5: along the process really swimmingly, so that people can do
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  Speaker 5: a lot more with a lot less and they can
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  Speaker 5: make much better decisions than maybe a more you know,
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  Speaker 5: more your medium employee. And so why are we able
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  Speaker 5: to do that just because you just really focus on,
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  Speaker 5: like what is the decision being made at this particular step.
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  Speaker 5: So something that's super simple, like you know, uh, the
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  Speaker 5: payer selection, right, it's the amount of mistakes that get
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  Speaker 5: made on first pass prior ops by not actually making
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  Speaker 5: sure that they're selecting the right plan or the right
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  Speaker 5: benefit for the simple reason of there's a bunch of
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  Speaker 5: judgment calls they have to make and they have to
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  Speaker 5: like go through a payer umbrella search to figure out
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  Speaker 5: which payer does this plan actually belong to. So we
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  Speaker 5: built out this massive payer engine that can take in
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  Speaker 5: those sort of plans prefix codes, PO box indicators, address
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  Speaker 5: of the patient to actually discern which payer and which
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  Speaker 5: guidelines that plan is most appropriate. To actually sort of
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  Speaker 5: try to adhere to. So there's all I guess said,
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  Speaker 5: just give me a couple of examples, because because you
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  Speaker 5: brought it up. But there's all sorts of moments like
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  Speaker 5: this in a in a you know, servicing workflow where
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  Speaker 5: you have to qualify the patient. You know, if you
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  Speaker 5: had to figure out if if the if the patient's
• 10:20
  Speaker 5: meeting three forty B criteria eligibility, and so there's all
• 10:23
  Speaker 5: these little like tricks and judgment calls that unfortunately you
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  Speaker 5: can't make if then rules about and language models that
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  Speaker 5: are very specifically guardrailed have just been super productive for
• 10:34
  Speaker 5: us and deploying solutions for that. So and then to
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  Speaker 5: the second part of your question, of course, there is
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  Speaker 5: again like that scorecard, it's all about what are we
• 10:44
  Speaker 5: seeing on conversions? Are we converting more patients in? What
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  Speaker 5: are we seeing on margin optimization and of course denial avoidance.
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  Speaker 5: Are we making sure that we're maximizing the value of
• 10:51
  Speaker 5: each referral that we're receiving. And then of course in
• 10:53
  Speaker 5: the back end, what is the ft efficiency and very
• 10:56
  Speaker 5: clearly measuring what is the throughput in the output of
• 10:59
  Speaker 5: patients her you know, our admin teams on both intake
• 11:04
  Speaker 5: RCM and just buying large operations. So that's those are
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  Speaker 5: really our scorecards. That's really how we think about our
• 11:10
  Speaker 5: scorecard for the actual measurement about six months later. It
• 11:15
  Speaker 5: totally varies based on you know, the type of like
• 11:19
  Speaker 5: the sort of before and after photo, but pretty dramatic
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  Speaker 5: in terms of what you can do from a tonal reduction,
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  Speaker 5: margin optimization improvement and just upfront off denial avoidance, and
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  Speaker 5: then conversion is also very very dependent on you know,
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  Speaker 5: the center location, the center, the options for that patient
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  Speaker 5: and sort of the things you can do there. But
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  Speaker 5: you know, you're often seeing pretty significant double digit percentage
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  Speaker 5: growth in conversion lifts by fixing these processes, contacting patients
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  Speaker 5: same day, coming to them with full patient responsibility and
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  Speaker 5: understanding of the best options for them and knowing what
• 11:52
  Speaker 5: the next steps are going to be in their process.
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  Speaker 5: So that's kind of how we think about the measurement side.
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  Speaker 5: Chila to your second half of the question.
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  Speaker 4: So one of the unique challenges for a specialty pharmacy
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  Speaker 4: provider is the expensive inventory sitting on the shelf. Can
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  Speaker 4: you talk more about this challenge and how tenor impacts
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  Speaker 4: the bottom line by getting these medicines off the shelves quicker.
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  Speaker 5: Yeah, So I mean that question obviously can be you know,
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  Speaker 5: can can go pretty darned deep, and so I'll try
• 12:18
  Speaker 5: to not go take it too far. But like you know, fundamentally, right,
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  Speaker 5: what we want to look at is driving down sort
• 12:28
  Speaker 5: of the amount of lag time between hey, we've received
• 12:31
  Speaker 5: a script and that drug has been dispensed, where everybody
• 12:35
  Speaker 5: sort of wants this right. The patient wants it, the
• 12:36
  Speaker 5: provider wants it, and the pharmacy wants it. And so
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  Speaker 5: for us, it's really a time game. It's how quickly
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  Speaker 5: can you get the patient through all the steps of
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  Speaker 5: the process and then engage them so that they can
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  Speaker 5: actually go and dispense. There's of course other optimizations like
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  Speaker 5: making sure that you know, any any patient coming that
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  Speaker 5: is three forty that whose script is three forty be eligible.
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  Speaker 5: We're making sure that we are you know, decrementing and
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  Speaker 5: and keeping all of our systems up to date so
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  Speaker 5: that we are you know, not restocking with sort of
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  Speaker 5: the right the wrong fee schedules and things of that nature.
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  Speaker 5: And then there's like I sort of alluded to earlier,
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  Speaker 5: there's all sorts of margin optimization games you can play
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  Speaker 5: by being very very smart about sort of nec selection
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  Speaker 5: and about really frankly, making sure that you understand the
• 13:24
  Speaker 5: documentation of the payer and what their requirements are so
• 13:27
  Speaker 5: that you can do it right the first time, make
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  Speaker 5: the right selection the first time, and get the patient,
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  Speaker 5: you know, on a therapy that's going to work for
• 13:34
  Speaker 5: them as quickly as possible. I mean, that's the main
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  Speaker 5: way that I think about inventory margin optimization, and of.
• 13:40
  Speaker 4: Course just speed looking ahead, where do you see the
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  Speaker 4: biggest shifts happening in specialty pharmacy over the next five years,
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  Speaker 4: and how does tennor plan to meet these shifts?
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  Speaker 5: You know? I think I try to stay obviously in
• 13:56
  Speaker 5: my sort of circle of competence, so I always like
• 13:58
  Speaker 5: to focus on the the sort of technology patient experience,
• 14:02
  Speaker 5: and maybe less on predict trying to forecast, you know,
• 14:05
  Speaker 5: where regulatory industry go honestly should I'll probably put the
• 14:08
  Speaker 5: I'll put the uh, I'll put the industry side of
• 14:11
  Speaker 5: it back to you because I'd love curious to hear
• 14:12
  Speaker 5: your thoughts. But from the sort of technology standpoint, I
• 14:15
  Speaker 5: think what you're going to see is that a lot
• 14:18
  Speaker 5: of activities that specialty pharmacies would you know, would love
• 14:23
  Speaker 5: to do in you know, maybe a healthy reimbursement rate environment,
• 14:26
  Speaker 5: or you know, maybe it used to do and labor
• 14:30
  Speaker 5: has gotten too expensive, will come back, a lot of
• 14:34
  Speaker 5: additional sort of patient checkings, a lot of patient engagement,
• 14:36
  Speaker 5: a lot of adherence checkings, a lot of explanations. I
• 14:38
  Speaker 5: think the cost of sort of the friendly nudge, the
• 14:41
  Speaker 5: cost of the sort of educated patient engagement is going
• 14:44
  Speaker 5: to go down dramatically. And I'm not one of these
• 14:46
  Speaker 5: people that thinks, like, you know, uh, these models or
• 14:49
  Speaker 5: AI is going out raise somebody's kids or something like this,
• 14:51
  Speaker 5: it's gonna be so good. But I do think it's
• 14:53
  Speaker 5: going to be able to basically nudge along a lot
• 14:56
  Speaker 5: of patients that are confused, experiencing sort of you know, uh,
• 15:02
  Speaker 5: surprise symptoms that they don't want to see, and and
• 15:07
  Speaker 5: just sort of like nudge patients along to a point
• 15:09
  Speaker 5: that you're going to see I think, better adherence, better conversion,
• 15:13
  Speaker 5: and just overall a better provider patients experience when people
• 15:18
  Speaker 5: go to get on the specialty pharmaceuticals.
• 15:21
  Speaker 4: Right, And I think you made a very a very
• 15:23
  Speaker 4: interesting point where the costs of providing those services right
• 15:26
  Speaker 4: that I think make special de pharmacy so special may
• 15:30
  Speaker 4: go down, the value does not, right, there is so
• 15:34
  Speaker 4: much value in all of that, that care coordination and
• 15:37
  Speaker 4: that patient centric care that's delivered. And I think, you know,
• 15:40
  Speaker 4: over the next five years, I think we have to
• 15:42
  Speaker 4: do a better job right of speaking in a louder
• 15:45
  Speaker 4: voice about the value that special de pharmacy brings as
• 15:48
  Speaker 4: a healthcare provider.
• 15:50
  Speaker 5: Yeah, sheel, absolutely. I mean, look, I think that is
• 15:52
  Speaker 5: like I think that is, you know, so much of
• 15:55
  Speaker 5: the healthcare journey, you know, continues on with with that
• 15:59
  Speaker 5: pharmacy relationship. And so if you know, if you can
• 16:05
  Speaker 5: do ten times the amount of you know, educational engagement,
• 16:08
  Speaker 5: if you can follow up more often, if you can
• 16:10
  Speaker 5: like you know, continue helping the patient, spend more time
• 16:12
  Speaker 5: on that and less time on some of the you know,
• 16:14
  Speaker 5: sort of ridiculous administrative things, and that cost goes way down.
• 16:18
  Speaker 5: For doing that, You're just going to see way better
• 16:20
  Speaker 5: adher and everybody's gonna win.
• 16:22
  Speaker 3: Really.
• 16:22
  Speaker 5: I think that is like a not sort of fictional
• 16:26
  Speaker 5: projection of sort of where the patient engagement experience is
• 16:29
  Speaker 5: going to go. There's just going to be a lot
• 16:31
  Speaker 5: more of it. It's going to be a lot more thoughtful,
• 16:34
  Speaker 5: and uh, there's gonna be a lot of intelligent systems
• 16:37
  Speaker 5: like guiding the patient you know, through that journey.
• 16:40
  Speaker 4: That would be awesome, right, because then I think these
• 16:42
  Speaker 4: care plans can be really personalized and tailored to that
• 16:45
  Speaker 4: individual because you know, even if you had ten people
• 16:48
  Speaker 4: with the same disease, right, let's say, I don't know
• 16:50
  Speaker 4: rhumatroid arthritis, They're all going to respond differently. They're all
• 16:53
  Speaker 4: going to do different things, They're going to have a
• 16:55
  Speaker 4: different experience, right, based on what makes them them. And
• 16:57
  Speaker 4: if you could, you could spend more time tailoring to
• 17:00
  Speaker 4: get them to be compliant and adherent and get you know,
• 17:03
  Speaker 4: the optimal results from these therapies.
• 17:05
  Speaker 5: I think that's key, oh totally. And I think people
• 17:09
  Speaker 5: have this idea that's like, oh, it's just going to
• 17:10
  Speaker 5: be you know, some you know bot that's going to
• 17:15
  Speaker 5: go rogue trying to explain these things. I think the
• 17:18
  Speaker 5: I think it's actually not gonna be the case. I
• 17:19
  Speaker 5: think you're gonna have a lot of basically you know,
• 17:21
  Speaker 5: of your best humans able to sort of review and
• 17:23
  Speaker 5: approve the types of engagements that are going to go
• 17:25
  Speaker 5: out to patients and patients are just gonna be like, whoa,
• 17:27
  Speaker 5: this is like a super relevant to me and super helpful.
• 17:31
  Speaker 5: So that's like where I'm very excited and get super bolish.
• 17:34
  Speaker 5: So yeah, I agree, I'm curious Sheila. By the way,
• 17:37
  Speaker 5: I would love to hear like, what do you think
• 17:38
  Speaker 5: the major industry developments are for the next five years
• 17:41
  Speaker 5: to be aware of?
• 17:43
  Speaker 4: Yeah, you know, I think it's like selling gene therapies, right, continue,
• 17:46
  Speaker 4: what is the role that specialty pharmacy is going to
• 17:48
  Speaker 4: play in that? And I think a lot of it
• 17:50
  Speaker 4: is because maybe the initial administration, right, they may help
• 17:54
  Speaker 4: be a conduit right to to you know, get authorization
• 17:59
  Speaker 4: for that therapy and do the benefits investigation and kind
• 18:01
  Speaker 4: of help you know, coordinate. But I think a lot
• 18:03
  Speaker 4: of these are going to be administered in centers of excellence.
• 18:06
  Speaker 4: But it's just not a one and done right, even
• 18:08
  Speaker 4: though that maybe what the therapy says. But there's so
• 18:10
  Speaker 4: much monitoring that I think is going to have to
• 18:12
  Speaker 4: go on, Like, you know, number one, how does the
• 18:14
  Speaker 4: patient do on it? What's the durability of response? Do
• 18:17
  Speaker 4: they need to be supported with other therapies or care coordination?
• 18:21
  Speaker 5: Right?
• 18:21
  Speaker 4: How do we take what we're going to learn from
• 18:23
  Speaker 4: these folks, right as this continues to evolve and then
• 18:26
  Speaker 4: apply it, you know to a bigger patient population, and
• 18:30
  Speaker 4: you know, how do we afford all this? So I
• 18:33
  Speaker 4: think specialty pharmacy, I think is going to continue to evolve.
• 18:36
  Speaker 4: But I think that you know, at its core what
• 18:39
  Speaker 4: it does best, it'll continue to do best, but just
• 18:41
  Speaker 4: probably under different circumstances, right or applying it to different
• 18:45
  Speaker 4: therapies or different scenarios or settings. But I think the
• 18:50
  Speaker 4: foundation is there.
• 18:52
  Speaker 5: Yeah, yeah, no, and totally. I mean that's basically where
• 18:55
  Speaker 5: I see like a big, long term and super interesting
• 18:57
  Speaker 5: opportunities just in generals, Like every new drug is always
• 19:01
  Speaker 5: going to require somebody to be there to guide the
• 19:03
  Speaker 5: patient through it. And I think it's just going to
• 19:04
  Speaker 5: get that. Technology is just going to get so so
• 19:06
  Speaker 5: so good that you're just going to see so much
• 19:09
  Speaker 5: leverage to pharmacies being able to do more of.
• 19:11
  Speaker 4: That work absolutely right, And like if we don't know
• 19:14
  Speaker 4: how long some of these responses are going to last,
• 19:16
  Speaker 4: like what will be the indicator right to jump in
• 19:18
  Speaker 4: and kind of get that patient either back on track
• 19:21
  Speaker 4: or you know, onto something else. If if that response
• 19:24
  Speaker 4: is waning for whatever reason, right before it becomes a
• 19:28
  Speaker 4: much more dire situation. Well awesome, yeah, oh my gosh,
• 19:35
  Speaker 4: all right, well, thank you so much Trey for chatting
• 19:37
  Speaker 4: with me and for sharing this valuable information.
• 19:40
  Speaker 5: Thank you so much for having me guys, it was
• 19:42
  Speaker 5: much pleasure.
• 19:43
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• 19:46
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• 20:05
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