Patient Information in an Era of Change Louis A. Morris, Ph.D. Senior Vice President PRR, Inc.

Patient Information in an Era of Change

Louis A. Morris, Ph.D.

Senior Vice President

PRR, Inc.

Communications Change• Source

– from HCP to Manufacturer

• Channel– from personal and print to mass customization– internet

• Message– from health education to marketing

• Audience– from dumb terminal to active decision maker

Thesis• Redefinition of communications structure

creates new opportunities• We need new thinking

– marketing approach to patient education

• Implications for Pharmacy– public health advocates– implementers of cultural change– who pays?

Patient Info Sources: Traditional

Manufacturer

Independent

Face to Face Mass Media

ThroughHCPs

Through HCPs

Help Seeking/Reminder Ads

PublicService Ads

Patient Info Sources: Modern

Manufacturer

Independent

Face to Face Mass Mass Media Customization

1-800 #s

HCPs

DTCA

PSA/En-dorsemts

DatabaseMarketing

Infotisements

Registries

HCP/Com-mercial

HCPs - Start Kits

PublicRelations

Blending

– Starter Kits - info packages– Disease/Drug Newsletters– Registries – Clinical Experience Trials– Direct mail– Ads in direct mail pubs– Ads in patient information at Pharmacy

Blending on the Internet

• Is it independent content or an ad?• What is the Source?• Search Engine Results?• Paid Linkages?• Future Increase in Internet Use

– Multimedia Content– Faster Access, Smart Slaves, Always On less

active search, more passive use

Blending - Resch Questions

• How important is source credibility in patient information?

• How important is face-to-face?– Hi tech/Hi touch

• How does this affect pharmacy?– Pharmacist rated highest in credibility– Pharmacists viewed as most accessible– Ability to take advantage?

Why DTCA?

HCPs MCOs Pat’s

Gatekeeper + + ++

Influencer +++ + ++

Therapy Selector +++ + +

Buyer + +

User + ++

Message Evolution

• User:– “Finish all your medicine, even if you feel

better”

• Gatekeeper: – “The doctor has treatment programs that can

help”

• Influencer: – “Easy to swallow”

New Messages

• User: Medication Compliance - Will there be a rebirth?– Barrier Assessment Tools– AARDEX (MEMS Monitor) as a feedback tool

• Influencer: Quality of Life– FDA barriers– Implicit, “benefit-related” messages– symbolism

Message / Audience Interaction: Patient Information Processing

• Willingness and Ability to Learn– Motives - Message Involvement/Goals– Ability - Literacy/Self-efficacy– Opportunity - Task Constraints

• Perceived and Actual Cognitive Load– Simplification– Signals

Audience Tailoring - Stages

• Smoking Cessation:• Precontemplation, Contemplation, Preparation, Action,

Maintenance

• Abstinence at 18 mo:– Single Brochure 11.0– Individualized to Stage 18.5– Interactive feedback 25.2– Personalized (calls) 18.0

Velicer et al., 1993

Information Search ClustersFactors Ambivalent Uncertain Risk Assertively

Learners Patients Avoiders Self-Reliant n=140 n=132 n=200 n=153

InformationInvolvement .502 .069 -.275 -.160

Self-Care Orientation -.124 .575 -.483 .249

Regimen Barriers .170 1.056 -.563 -.365

Information Avoidance 1.167 -.603 -.327 -.121

Risk Aversion .239 .056 .302 -.664

Question-Asking .013 -.163 -.542 .838

New Role for Pharmacy• Message Tailoring

– New “diagnostic” tools?

• Feedback Provider (Compliance Coach)– Computer records to measure refill compliance

• Financial Barriers– Can this be provided through manufacturer– mass customization? - privacy favors Pharmacy– Pharmacist user fees?

New Role for Pharmacy (2)

• Location for services:– in pharmacy (face to face)– in central location (mass customization)

• Activity– initiator or responder to patient requests– passive or active service implementation

Health Education and Marketing• Health Education:

– combination of interventions to change behavior (info transfer)

– select by “what works”• focus on trials to establish efficacy

• Marketing– facilitating equitable exchanges (2 way flow)– select by communications goal

• focus on efficient resource use

Marketing Perspective

Health Behavior Change is more likely if:– people are involved with healthcare decisions

• educate and empower patients

– people actively plan how to comply• planning helps overcome barriers

– health professionals teach and explain treatment• people do what MDs and RPhs tell them to do

3 Inverse Relationships

Behavior Change

Low Involvement High Involvement

Persuadable (weak messages)

Ease of Adoption

Thought/Planning

Behavior Maintenance

Complex Messages

Frequency/ Reach

Behavior Change

Marketing Insights• People Change Behavior

– when it is easy– when they want to – when it serves their needs/interests

• People Maintain Behavior– when they internalize beliefs/culturally driven

• Population Interventions: Cost-effectiveness• Targeting/Relationships/Market tests

When is 7% change successful?

• Health Education– significantly better than control– depends on sample size

• Marketing– major success– define in terms of $$ made, share of market,

meeting projections

Relationship Era

Time Era Attitude20’s Production A Good Product Sells Itself

50’s Sales Creative Advertising

80’s Marketing Find a Need and Fill it

90’s Relationship Long-term Relationships

Pharmacy

• Pharmacy as Cultural Change Agents– technology, cross-(sub)cultural, dramatic events

– intercept strategies for nonsearchers– tailoring interventions

• Take advantage of relationships– database marketing

• How to make it pay?

Why Pharmacy?

• Credibility (Expertise and Trust)– Decision making - Framing

• Accessibility

• Close to the Consumer– understand people’s interest

• Existing relationships– keep info private

Segmentational Bases

• Demographics- age, gender, literacy

• Disease- severity, stage, timing

• Geographies- location, Prizm characteristics

• Psychographics- Customized AIOs, VALS

• Volume- % consumed, concurrent therapy

• Outcome- responders, compliers, QoL

• Benefits Sought- motives for therapy, info

Implications for Pharmacy

• Credibility

• Economics - little face-to-face– lost opportunity - OBRA ‘90

• New Switches– renewed call for 3rd class of drugs

• Nutrition Supplements

Historical Perspective“Let no physician teach the people about

medicines or even tell them the names of the medicines, particularly the potent ones, such a purgatives, opiates, narcotics, abortifacients, emetics or any other which are particularly dangerous: for the people may be harmed by their improper use. This under penalty of forty shilliings” - Royal College of Physicians, 1555

Why Advertise to Consumers?

DTC Promotion

PatientMD

RPh

Manufacturer

Objectives

• Why advertise to consumers?

• How is consumer marketing different?

• What role does FDA play?

• What will be the ultimate effect of DTC?

8 FDA Concerns• Reminder/Institutional

• Implied Claims

• Disclosure Adequacy

• Contextual Fair Balance

• Limits on Effectiveness

• Overall Fair Balance

• Unsubstantiated Claims

• Distractions“RID the CLOUD of DDMAC Response”

DTC Considerations• Hot, Hot, Hot

– FDA Guidance relaxes TV disclosures– $800 mil in 1997, $1.3 bil in 1998

• Multiple Media– TV, magazines, internet, professional distribution,

direct mail, outdoor

• Different Challenges and Still Learning• FDA Very Sensitivity to TV: 11 of 20 DTC ads

had an FDA letter

What Evidence Suggests: Hypotheses

• DTC increases MD visits (Pravacol)

• DTC increases patient requests for drugs

• People want risks but info may be confusing

• Physicians still don’t like it (fluid)– MCO hate DTC

• Risk information may be problematic– may also detract from benefits

• Additional disclosures may be problematic– information overload, supers have min impact

What Evidence is Needed: Too Early to Form Hypotheses

• How are TV claims interpreted?– Uses / risks / info availability

• How prices/costs/liability will change?• Impact on consumer as influencer, user • Cumulative effects (trivialization)• What is a “positive/negative” outcome?

– Eye of the beholder, consensus needed– Need research agenda

Truthfulness, Balance, Disclosure• Roth:

– 1/3 of ads lack fair balance (unclear what definition was used)

• General Concerns– Multiple streams of info (see pictures, hear/see words,

hear background)/ Limited take away (only 49% of supers are comprehended)

– Explicit and Implicit Claims– Limited internal “context-availability”

• Disclosure as a remedy?

Future of DTC

• More, More, More– Patient as central in future marketing– Marketing as part of drug development

• Mixed Media– campaigns designed to “move through process”

• Pharmacists as Implementers– passive or active role?

Audience Evolution

• Information Hungry Segment– Remains Stable for 2 Decades (about 12%)

• Heterogeneous Elderly– Multiple Meds– Aging Boomers– More willing to question HCPs– Service Directed