Pharma gets into the 'digital workflow' of physicians

According to market research from Epocrates, while 99% of physicians use digital devices of any sort, 88% use smartphones, 75% use tablets, and 68% use all three.

In the early days of electronic health records (EHR) and e-prescribing systems—a scant 3—5 years ago—most considered these new electronic tools to represent an end in themselves. Namely, it was widely accepted that these systems would improve physicians’ working lives by allowing them to easily access patient health records; automate many office tasks; and improve the prescribing process through accurate, informed decisionmaking.

Today, thanks to a confluence of factors—accelerating growth in EHR and e-prescribing systems adoptions, rapid expansion of the richly layered information that can be found in many of these systems, and growth in the use of all types of mobile devices to access them (laptop computers, tablets and smartphones)—these systems are increasingly being viewed as not just an end in themselves, but as a means to a much greater end. Collectively, the improved “digital workflow” capabilities that are now available for today’s e-enabled physicians provide a bold new paradigm for enriching the doctor-patient relationship, improving drug adherence and clinical outcomes for patients, and reducing overall healthcare costs.

This explosion in the so-called EHR channel has created new opportunities for drug manufacturers and their brand teams. While many pharma companies are only beginning to explore the opportunities and have yet to fully embrace this new information outlet, parallel efforts by early pioneers have been helping to define some ad hoc rules of engagement for how messaging sponsored by drug makers should—and should not—be embedded within the doctor’s digital workflow, and what the industry’s self-imposed limits should be.

“Forward-looking advertising agencies and media buyers should be saying to pharma brand teams, ‘You have your print strategy, you have your Web strategy, you have your mobile strategy; okay, now what is your EHR strategy and how do you plan to get your sales reps knowledgeable and viewing the EHRs as an important way to make sure their brand services are within arm’s reach when the doctor is prescribing?’”, says Edward Fotsch, MD, CEO of PDR Network (Montvale, NJ).

This is more possible than ever, as a growing number of pharmaceutical sales reps are using iPads or similar tablets. “Today’s technology options let sales reps build on their personal relationships, but enhance the offering with the ability to share with prescribers product information on an engaging Web-based platform that can be easily accessed from the doctor’s office or home,” says George Esgro, vice president of US commercial sales at Quintiles (Parsippany, NJ). “During a Web-based session, reps can often get 15 to 20 minutes of engagement time from the physician, instead of the usual two or three minutes.”

EHR systems, oriented mostly toward the workflow of healthcare providers in hospital or clinical settings, are rapidly being linked together with e-prescribing; the next step—bringing in drug information, whether branded or not—is an opportunity area for pharma, systems vendors say. “When actionable, sponsored content from drug makers surfaces at the moment that the doctor is evaluating competing therapeutic options, it provides an important, additional level of information,” says Lawrence Susnow, MD, president of NewCrop LLC (Houston, TX), a developer of e-prescribing systems. “The goal is not to try to influence the prescribing process, but rather to support the doctor’s own decisionmaking—and that’s an important distinction that is sometimes lost on skeptics.”

“Since doctors have had to completely change their practices to adapt to their new digital workflow, pharma companies also need to totally rethink the way they do things to take advantage of this new channel,” adds Peter Kaufman, MD, chief medical officer of DrFirst (Rockville, MD), a maker of e-prescribing systems that are available both as standalone systems and currently embedded with more than 200 EHR vendors.

“We look at EHR systems as building a foundation, and by layering in strategic content from various pharma industry stakeholders, we can continue to add value to really leverage the digital workflows in ways that can improve patient outcomes,” says Jake Boos, chief operating officer, coordinated care solutions, for PatientPoint (Orlando, FL), a provider of patient- and physician-engagement solutions that was acquired by Healthy Advice Networks last February.

The digital omnivore

Today, the face-to-face interaction of a physician and a patient has a third component: a digial device. According to a 2012 survey of physicians by Epocrates, Inc. (San Mateo, CA), 97% use a computer in the workplace; 78% use a smartphone professionally (68% at least once daily for professional purposes); and 34% use a tablet professionally (27% at least once daily for professional purposes). Typical uses include accessing clinical and drug data, looking up disease or treatment guidelines, accessing clinical notes, reviewing lab data, examining diagnostic images, accessing formulary information, contacting manufacturers, and carrying out electronic prescribing. Epocrates has coined the phrase “digital omnivore” to refer to physicians who use all three types of mobile computing devices.

According to Epocrates, among doctors who use tablets, Apple’s iPad is dominant (being used by 81% of physicians), followed by tablets based on the Android operating system (just 9% of physicians). Today, 34% of physicians report using a tablet professionally, but 75% of surveyed physicians expect to be using a tablet within the next year. While the use of smartphones for professional purposes is on the rise among physicians, and many healthcare-related resources can now be accessed through these handheld devices, most experts agree that these handy gadgets will never fully replace the tablet or laptop in clinical settings, mostly because of small screen real estate. Still, these devices give physicians convenient access to top-line information or a glimpse into patients’ charts or prescription details.

With the growing use of three different types of digital devices, physicians are spending more time online than ever before, at all times of the day and night. And according to the Epocrates report, 85% of physicians agree that mobile devices are likely to lead to better medical decisionmaking, and 72% agreed that mobile devices can significantly enhance their productivity.

The combination of various government incentives for EHR adoption, coupled with financial penalties for non-adoption, has changed the game for physicians, and today, EHR and e-prescribing systems are used by roughly half of all prescribers, with 80% adoption projected over the next few years. “The current drivers have effectively taken 10 to 20 years of adoption-uptake time and crammed it into just two or three years,” says Fotsch of PDR Network.

And, despite the rapid growth in EHR use, further growth is assured. “We’re still on the steep side of the growth curve,” says Kaufman of DrFirst. “With only about a half-billion prescriptions per year handled electronically in the US (out of a total four billion written per year), we’ve still got tremendous room for growth, and this provides numerous opportunities in the years to come for pharma companies looking for ways to reach e-enabled prescribers.”

“All brand teams should be asking themselves, if I have a dollar, will I spend it trying to reach the masses, or targeting my main audience who I know will be most receptive to my information? The mobile channel offers pharma marketers a targeted means to do just that, and if they do it right, they have an opportunity to re-invigorate the pharma-physician relationship,” says Adam Budish, SVP, sales, at Epocrates. “Three out of four physicians say that they have changed a prescribing decision based on Epocrates information. For that degree of influence to happen with a brand, a pharma company needs to do more than just show up.” He adds, “It needs to be strategic about the value it provides to prescribers.”

Fig. 1. Source: OneKey Digital, SK&A Information

Exploiting the EHR channel

Just where do doctors obtain drug information as they’re making prescribing decisions? FDA has a variety of databases, including the Orange Book, and [email protected], which provide the approved label information, drug alerts and therapeutic equivalencies. But private-sector publishers have long worked at compilations (in hardcopy form or online) that include the label information, along with medical journal literature, edited summaries of recent research, patient education materials (in multiple languages) and other useful resources.

“Manufacturers are looking to healthcare information suppliers—such as PDR Network, Medscape (from WebMD), MD Consult (Elsevier), JAMAevidence (AMA/McGraw-Hill), DynaMed (EBSCO Publishing), Epocrates and others—to be the change agents they need to help synthesize the explosion of raw data,” says Peter Harbin of IMS. “Intermediary information providers have a big role to play in synthesizing the vast volumes of information that are available, and to provide content that is instantly understandable and points the way forward. The goal is to have users say, I know what this means and I know what to do with it.”

From the healthcare provider perspective, these resources are commonly known as “clinical decision support” (CDS), and to Harbin’s list can be added First Databank (a unit of Hearst Business Media), Medi-Span from Wolters Kluwer, Truven Health (the former Thomson Reuters business), and at least 30 or so other vendors. Black Book Rankings (Clearwater, FL), a market research firm, analyzed 42 CDS vendors in its 2012 survey. Some of these are tailored to point-of-care decisionmaking; some are more for hospital or clinical administration, including e-prescribing (which dips into another area of healthcare IT, computerized physician order entry, or CPOE).

Some of the publishers or database aggregators include drug pricing and formulary status—stepping away from a strictly medical orientation and into the commercial world of drug buying and selling. Epocrates, PDR Network and WebMD, to name three, explicitly allow manufacturers to buy advertising in their information services. And, in a case of the camel’s body following his nose into the tent, some information vendors are allowing manufacturers to place coupon offers in conjunction with the prescribing information—a service that many physicians like to present to their patients, but one that insurers and pharmacy benefit managers strongly dislike. Another valuable offering for many physicians is the ability to order drug samples through their EHR.

“The challenge for brand teams, in this fractured marketplace with so many different EHR and e-prescribing systems available, is, how do I get any scale at all trying to reach prescribers?” says Fotsch of PDR Network. By sponsoring messages in any of the PDR Network products, brand teams are able to reach more than 100,000 prescribers (through PDR’s many EHR- and e-prescribing-related partnerships). “With that critical mass, we are able to approach drug makers and say, what additional information resources or services can we provide for your brand that will distinguish you or make doctors aware of useful information you may have, at the moment they need it most?”

In line with this trend, Physicians Interactive (Marlborough, MA), a multichannel marketing services company for manufacturers, recently launched eCoupon, an automated voucher and coupon distribution solution for healthcare providers. The company has partnered with EHR vendor Allscripts (Chicago) to integrate the eCoupons functionality into Allscripts’ standalone ePrescribe electronic prescribing software, so that coupon availability becomes apparent right in the existing workflow of the physician. Allscripts, by one measure, is the No. 1 EHR system in the US, according to a survey performed by SK&A, a Cegedim Company, last summer (Fig. 1).

Rules of engagement

To make the most of the opportunities presented by the EHR channel, branded drug teams, intermediary information companies, and designers of EHR and e-prescribing systems must observe the rules of the road to address two important issues. First, they must ensure good content—not ads, but useful information that can assist physicians in their diagnostic and prescribing efforts. And second, they must present and embed the information, and structure the user interface, in the most streamlined and logical way possible. “If the interruption slows down the physicians or seems to be needlessly intrusive or too blatantly commercial or self-serving, they will reject it (or, if possible, turn off the functionality in their system),” says Kaufman of DrFirst.

“We tenaciously protect the concept of a pristine, unobstructed digital workflow, so we work hard on the programming end to reduce the clutter on-screen and minimize the number of clicks required, and to think strategically about the best place for a given piece of information to pop up,” adds Susnow of NewCrop.

At DrFirst, a team of doctors and pharmacists must approve of any branded content that is slated to be integrated into its e-prescribing system, says Fay Hung of DrFirst. “Plain and simple, the branded messaging is not supposed to aim to influence the prescribing choice, but to support and inform the prescribing decision as it’s being made by the physician,” she adds. “And we give users a lot of freedom to set up and turn off alerts, so they can still be in control of the information flow they need most and don’t get ‘alert fatigue.’”

Another variation on having a promotional presence in EHR systems is to engage the physician through television (which can also be set up as a streaming feed to laptops or smartphones). PatientPoint also offers the PracticeWire platform, which provides a constant feed of breaking healthcare-related news and research updates from journals, along with appropriate, sponsored content from drug makers, on digital screens that are mounted in the back-office setting, for physicians and other clinicians to view when they are between patients. The PracticeWire functionality is also available as a free mobile app for the iPhone and iPod Touch devices, which lets physicians access a constantly updated stream of health content, including research, advice, product safety recalls and FDA-issued boxed warnings for drug labels, from leading medical journals and news feeds.

A similar service from PatientPoint engages patients: The Care Coordination and Check-in gives patients an iPad based platform, so that they can complete all of their forms electronically when checking in for their appointment. This not only serves to capture all of the information electronically (eliminating the need for office personnel to transcribe or scan paper forms), but helps to immediately highlight gaps in care, by identifying, for instance, that the patient is overdue for a mammogram, colonoscopy or medication refill. This insight automatically surfaces within the doctor’s EHR system, and this can help to focus the conversations between provider and patients once inside the examination room. “Physicians are overwhelmed, and there are many conversations they should be having with patients but are not,” says Boos. “The platform can be leveraged to tee up a more productive conversation between the doctor and the patient during their limited time together.”

Fig. 2. Source: Wolters Kluwer

While a growing number of third-party healthcare information providers are working with pharma companies to leverage the opportunities of the EHR channel, others, such as First Databank (FDB; South San Francisco, CA), are not. “As an independent publisher of drug information, we take our role as an impartial source for credible information about drugs very seriously,” says Patrick Lupinetti, SVP and editorial director at FDP. “In the complex and highly competitive pharmaceutical marketplace, where discretionary professional judgments about drug classification and evaluation can have multimillion-dollar financial consequences, it is critical that we maintain our reputation for objectivity.” Even so, FDB counts pharma marketers, and website businesses that do accept advertising, among its hundreds of clients.

To those who would say that the richness of today’s database offerings, as impartial as they can be, precludes pharma marketing messages, here’s one startling counterpoint: In its 2011 annual Point of Care Survey, Wolters Kluwer Health found that general Web searches on Google or Yahoo! outpaced dedicated healthcare content publishers by four percentage points for “frequent” online queries (Fig. 2). Presumably, physicians wouldn’t start a search for, say, hypertension, on Google if equally valued information was available and accessible through an EHR’s drug database.

A more recent survey, just published by SK&A Information, shows that social media “transactions” have quintupled since 2009 among HCPs surveyed. Exchanges on blogs, and posts or comments to LinkedIn and Twitter, dominate the channels used (SK&A is monitoring only publicly accessible sites, so password-protected communications on Facebook or elsewhere are not counted). SK&A futher analyzes the data to categorize “observers,” “socializers,” “specialists” and “thought leaders” based on the linkages among their exchanges and references to public data like PubMed. “Thought leaders” identified thereby could become an online version of the highly valued Key Opinion Leader quality, says SK&A, which is refining its analysis. At the same time, there are other online efforts, such as Klout.com (which has acquired some notoriety for its “Klout” score that ranks individuals’ influence through social media).

In the eyes of EHR access proponents though, that statistic might simply be a snapshot of a situation rapidly fading into the past. “More and more, doctors are coming to expect that their EHR is going to tell them everything they need to know,” says Fotsch of PDR Network. “Today, pharma companies that are able to provide complete, high-quality informational offerings that surface at the appropriate spot within the doctor’s digital workflow are able to enjoy a first-mover competitive advantage,” he continues. “While this is not yet mainstream today, within the next 18 months, if you’re not there, you’ll be conspicuously absent, and if your information does not surface at the right time at the point of care, doctors will assume it doesn’t exist.”