The Information Diet

IN A WORLD OVERFLOWING WITH INFORMATION, most people—including doctors—learn to ignore all but a tiny fraction of the unsolicited material sent their way. Most of the time, that's a good strategy. People could not be productive if they paid attention to every scrap of information they see. Unfortunately, pharmaceutical companies, like most other providers of medical information, assume that doctors consume all the information they receive. So they send as much as possible. If the doctors can't use the data now, pharma seems to think, they dutifully file it away and utilize it when necessary.

In fact, doctors are at least as selective as anyone else. Our qualitative and ethnographic research, which includes thousands of physician interviews and hundreds of hours spent observing their behavior, suggests that doctors look for certain types of information in particular formats at particular times. Most of the rest they ignore. In the best of cases, it becomes casual professional reading when they have a spare moment. So if the pharmaceutical industry provides important information in the wrong place or in the wrong format, physicians miss it. If the industry wants its information to be more valuable to doctors, it needs to think about how doctors will be using it, and where and when they expect to find it.

Prescription for effective communication

The first big lesson: Physicians do not think about undifferentiated information. They are concerned about certain kinds of information that they require in different amounts, in different forms, and with different frequencies and timing.

When questioned in depth on the topic, physicians report that they think about two major types of information: point-of-care and clinical updates.

Point-of-Care information offers physicians immediate answers to questions arising when they treat a particular patient. For example, physicians might want to know whether patients taking other drugs can safely take a particular medication. Sometimes, physicians see patients presenting clinical conditions that they have rarely—or in some cases never—previously encountered. Younger, less experienced physicians need this type of point-of-care information most often. But novel medical conditions come up for everyone in the hospital emergency room, and even in the treatment room at a private doctor's office. And when they do, the physician is expected to do something about the situation right away, often without the opportunity to consult a colleague or start a time-consuming information search.

Updates provide doctors and other prescribers with new information about medications. In particular, doctors need specific information about side effects and contraindications. In addition, physicians want to receive guidelines about the treatment of particular conditions from their specialty's accrediting organization (e.g., the American Academy of Pediatrics).

Even though doctors may want and need both of these types of information, the similarities stop there. Each type of information needs to be delivered in a different but appropriate way.

Info Pyramids

Point-of-Care

In general, doctors need point-of-care information when a new situation arises, and they want immediate access to it. This information is pulled (perhaps from a database) by the doctor rather than "pushed" in e-mail or other media by the information provider.

These situations require the greatest timeliness in two different senses of the term. First, the information provided must be up-to-date. For example, the database by Epocrates provides physicians and other prescribers with information about which products appear on the formularies of various plans under the Medicare Modernization Act (Part D). This information was available as soon as Part D took effect. That is, it was ready in a timely manner for practitioners who needed help right away.

Second, when a physician decides that a particular drug is appropriate for treatment, he or she needs to find out quickly if the drug is on the formulary. The up-to-date information must also be available with a minimal investment of the practitioner's time.

To be timely in this second sense, the information must appear in the right format and be consistent with the way doctors think. When doctors think about medications, they go through a set of steps in a certain order (e.g., indications, then efficacy, then side effects, then interactions), so it is important to provide information in that order. Once a good format is established, information providers should stick with it. Doctors tell us they value consistency. For time-critical information, or even Part D formulary data, doctors want the information presented the same way, in the same place, so they know where to look for it. If information providers do not follow this formatting rule, doctors can miss critical information, waste valuable time looking for it, or both.

Very often, physicians want to be provided with information only in the depth and detail that is required for them to take the next right action. In the Part D example, physicians don't want to know why a particular drug was included on the formulary or whether it has been recently added. They want to find out, quickly and easily, whether a particular drug will be covered by this patient's plan or not.

UpToDate, a popular information service available in both computer and PDA versions, provides exactly enough disease information to determine what signs and symptoms to look for, what tests to run, and what treatment to provide. In-depth information about the reasons for these actions is not provided, on the assumption that physicians will seek out this information from other sources, such as textbooks, medical journals, etc., when time permits.

The form factor—the choice of media—also plays an important role. For example, information that a physician might use to treat the patient he or she is currently seeing should be presented in a form that the physician can access at the hospital bedside, in the treatment room, or while on the cell phone. For this type of information, the PDA has gained widespread popularity. In fact, several directors of information technology at major medical schools have told us that each medical student is provided with a PDA, which comes pre-loaded with the software that the student needs to support such point-of-care decisions. When a doctor wants to do a thorough literature search on a treatment area, he or she typically will sit down at the desktop computer. Interestingly, hard copy (e.g., medical journals) still plays a significant role; physicians report that they often carry journals to make good use of down time between patients.

Not surprisingly, doctors give source credibility significant weight when determining what information sources to consult for particular purposes. Much of the credibility they assign to a particular source derives from what they see other physicians in their community employing. In certain medical settings, for example, it is considered virtually mandatory to have read the latest issue of The New England Journal of Medicine. To be of value to the practitioner, a point-of-care information source must be unbiased. Company-funded sources that advertise their own products or, worse, exclude products of other pharmaceutical manufacturers, tend to be rejected by physicians, due to the bias in information selection.

Updates

Unlike point-of-care information, clinical updates need to be pushed by the provider instead of "pulled" by the physicians who need the information. Doctors have no way of knowing when new developments occur, and thus no reason to go searching for them. In fact, important updates must stand out against the backdrop of other kinds of information, including promotions, which physicians receive on a daily basis.

Since the update does not refer to a specific patient under treatment at the moment, timeliness is less significant than for point-of-care information. Even so, some updates are more urgent than others. A doctor wants to know immediately when a drug is being recalled due to lethal side effects, for example. Such updates should reach a doctor within a day, so that he can begin to cull his or her files for patients taking the medication.

The availability of a new drug should be brought to the doctor's attention before patients learn of it from other sources, such as the Internet. Changes in overall guidelines concerning the treatment of a disease, the requirements for vaccination of pediatric patients, etc., are less time-critical.

Due to the wide variety of updates, standardizing format is generally less of a concern. Some special forms of updates, such as the discovery of new risks of a drug available on the market, have been given their own distinct, high-profile format. The "Dear Doctor" letters issued by pharmaceutical companies, for example, have a format that is unique and attention grabbing.

It is difficult to issue a blanket pronouncement about the appropriate depth and detail of updates. A notice that a drug has been withdrawn from the market, for example, provides only a statement that the drug has been pulled and information as to why. On the other hand, updates concerning the availability of a new drug—or the approval of a new indication—require, by government regulation, that manufacturers provide more information about the appropriate use, side effects, and contraindications of the medication.

Updates concerning new treatment standards or diseases typically provide the most depth and detail. For example, if new target levels are set for lowering blood pressure or cholesterol, or a new protocol is established for the initial treatment of a particular type of cancer, the new developments must be presented in substantial depth and detail.

The form factors—or media—employed to deliver an update vary according to the type of update being delivered. Withdrawals or new risk factors typically will require a rather formal form factor. The US mail is still employed in such cases. Updates concerning the availability of a new drug or indication typically will be delivered via a number of media. Pharmaceutical sales representatives usually provide the greatest immediacy, depth, and detail. However, such launch details typically are accompanied by seminars and direct-to-consumer advertisements. Updates in treatment guidelines typically go out in hard copy—newsletters, for instance—so that physicians can study them and file them for convenient reference in the future.

Source credibility is as important with updates as with point-of-care information. But it tends to be a more complicated topic, which can be touched on only briefly here. Doctors generally regard as credible any update that announces the withdrawal of a drug or lists new risks associated with it. Updates concerning the availability of a new drug, on the other hand, which typically are provided by the pharmaceutical manufacturer and are replete with promotional claims, tend to be regarded with skepticism. Because updates concerning changes in overall treatment guidelines are typically issued by respected medical societies, most physicians take them seriously.

A Look Ahead

To effectively communicate with increasingly sophisticated doctors, pharma must rapidly get over the idea that flinging undifferentiated information at physicians will have an impact. What has no value will be ignored. Companies must carefully study how different kinds of physicians consume and utilize information in particular situations. And they must learn to respond to those needs.

More specifically, companies must study how medical schools are training students to utilize information, and ready themselves to deal with a new wave of info-savvy doctors. The industry must face its commercial failures, such as some e-detailing efforts, and recognize that they have not become mainstream information channels, usually because they do not present data how, where, and when the doctors need it. Finally, pharma must realize that the sources of information that do succeed—such as Epocrates and UpToDate—do so because they reflect a genuine understanding of these principles, and thus provide genuine information value to physicians by telling them not only what they need to know, but by giving them the information when, where, and how they need it.

Little more than background noise

The average practicing physician reports that point-of-care data and updates meet most of their daily information needs. There are, of course, numerous other messages directed at physicians, many of which are accessed far less frequently and then only for special purposes.

CME courses, for example, are delivered through medical journals, in-person and online. Most practicing physicians report that they use such courses to gain the credits needed to retain certification, not primarily as sources of information they rely upon for daily decisions.

Journals and other sources of information having to do with "practice management" are reportedly of little interest to most practitioners, since increasing numbers of doctors are associated with group practices large enough to employ business managers.

Journals, books, and other sources of information that focus on "pure science" are also of little interest to most practitioners, constituting what one of our respondents referred to as "coffee table reading," i.e., information to be consumed in the unlikely event that spare time is available.

Promotional information provided in the form of detailing, e-detailing, dinner meetings, etc., is reported by many of our respondents to be of questionable value due to obvious commercial biases. They are also less frequent now that the PhRMA guidelines preclude the sort of lavish entertainment, trips, gifts, and honoraria that the industry traditionally built into such events.

Richard B. Vanderveer is group chief executive officer for GfK US Healthcare Companies. He can be reached at rvanderveer@gfkushc.com