Telehealth Special Feature: The Doctor Will See You … Online

Telehealth boomed during the pandemic, and experts believe that even with the world opening back up, pharma companies will have to continue to shift and strengthen tactics to reach physicians and patients virtually. 

By Christiane Truelove • [email protected]

The COVID­-­19 pandemic has changed many things during the past year and a half, and it’s had an indelible effect on healthcare. During the shutdown of 2020, when doctors’ offices were not open, telehealth boomed. Even though doctors and clinics are taking in-person appointments again, things are not expected to get back to normal, especially when it comes to sales reps interactions with physicians. Experts say while telehealth appointments will decrease overall, in certain therapeutic categories they could stay the same or even increase. And as many offices still remain closed to sales reps, pharma will need to engage with physicians and patients in these online spaces. 

The impact of COVID-19 and the telehealth boom

Figures from McKinsey & Company show how physician expectations of how to interact with pharma have been reset by telehealth. McKinsey reports that in the first quarter of 2020 compared with the same period in 2019, there was a 50 percent increase in telemedicine and enduring utility in some categories. And 42 percent of physicians adjusted their prescribing habits, with one example being preferring to write scrips for medicines that could be administered by the patients themselves. In April 2020, overall telehealth utilization for office visits and outpatient care was 78 times higher than in February 2020, but has since stabilized at levels 38 times higher than before the pandemic, at levels ranging from 13 to 17 percent across all specialties.

“This utilization reflects more than two-thirds of what we anticipated as visits that could be virtualized,” wrote McKinsey’s Oleg Bestsennyy, Greg Gilbert, Alex Harris, and Jennifer Rost in July.

These experts say they are seeing differences in the uptake of telehealth across all specialties, with the highest penetration in psychiatry at 50 percent, and substance abuse at 30 percent. Rounding out the top five are endocrinology and rheumatology at 17 percent each, and gastroenterology at 16 percent. Only 2 percent of visits in orthopedic surgery and opthalmology were telehealth ones.

As of April 2021, 84 percent of physicians were offering virtual visits and 57 percent would prefer to continue offering virtual care. 

In the meantime, HCP preferences for how they choose to engage with pharma have also evolved, McKinsey reports, with 75 percent of physicians indicating they will have restricted access in 12 months. Sixty-eight percent of the physicians McKinsey surveyed said they prefer to be engaged by remote only or by a hybrid engagement of remote and low-frequence in person interactions. And 50 percent of the HCPs who said they wanted to be interacted with in a hybrid manner said they only wanted to be engaged one to three times a year.

Additionally, 75 percent of the physicians surveyed by McKinsey reported a mismatch between preferred and actual channel mix in engagements with pharma. These physicians said they were unsatisfied with the quality of the offering from many pharmaceutical companies, stating that there are many unmet needs existing related to scientific collaboration and peer-to-peer exchange.

Genevieve P. Kanter, Ph.D., writing in the September 8, 2020 issue of JAMA, observed that, “The upheavals brought about by COVID-19 have led to growth of telehealth and other services that have been advances in how health care is delivered.”

She adds that these changes “also present an opportunity to reset the boundaries and norms for physician-industry interactions.”

“As clinics and hospitals, as well as drug and device firms, regroup, policy makers, physicians and patients should be intentional in re-establishing rules for doctors’ engagement with industry,” she says.

According to Dr. Kanter, the switch to video meetings and online presentations has made drug promotion far less costly for companies, with “no travel expenses for sales reps and doctors, no fine dining events, and low fixed costs of producing video content that can reach a large audience. History and economics tell us that the lower the costs of doing something, the more firms will engage in it.”

Riding the wave

For ePocrates, athenahealth’s mobile medical reference app, the increase in telehealth and online interactions has produced an increase in interest in what the company can do from pharmaceutical clients.

Jason Bernstein

According to Jason Bernstein, director and head, medical communications strategy, at ePocrates, parent athenahealth observed in April 2020 that about 17 percent of visits were telehealth ones versus 1 percent before the pandemic. At present athenahealth is seeing nearly 15 percent of healthcare organizations are holding about a third or more visits via telehealth. 

Bernstein says there are wide variations from organization to organization, depending on how integrated telehealth is to their EHR, and what kind of billing or front-end systems they have.

From the pharma side, Bernstein told Med Ad News that many companies are trying to use telemedicine as an intersection point to essentially engage with patients, whether in virtual waiting rooms as the patient is waiting for their doctor sign in, or through a pharma website. “For instance, if a patient is interested in birth control, or something that they’re a little bit uncomfortable to speak to their doctor with, there can be a link to a telemedicine tool,” he says.

What athenahealth and ePocrates also observed during the pandemic in 2020 was session lengths actually increasing as doctors engaged with content. 

“So doctors, even though they were seeing less patients, seemed to be spending more time on channel to engage with content, particularly from pharma,” Bernstein says. “And from all the market research that we saw, and it could be well above 90 percent, doctors were interested to hear from pharma … Doctors took the time, essentially to catch up on the latest medical news.”

In 2020, ePocrates saw a 40 percent increase in spend from pharma on tactics at the point of care, according to Bernstein. The intersection point occurred when physicians were searching for information about drugs. There was also a 45 percent increase in what he called “proactive medical education updates.”

“Because the reps couldn’t see the doctor, what they did was they use mobile, for instance, as a platform to send highly targeted educational messages against the need of that particular doctor,” Bernstein says.

ePocrates is seeing similar growth in pharma spending in 2021, Bernstein says.

“We’re in quarter two, and as you know, the pharma planning cycle is very cyclical – in the fall of the previous year is when they start their planning for the following year,” he says, “So quarter one, quarter two, tends to be a little bit quieter from a spending side. However, let’s put it this way, from a request for proposal, or for a client showing interest, we’ve seen about a 30 to 35 percent increase.”

ePocrates’ clients are definitely looking to spend more in digital. “And in fact, in quarter two, we probably had our best year on record,” comparing second-quarter 2020 with second-quarter 2021. 

“Clients are still looking to reach out to physicians with that tactic at the point of care, there’s been a very strong uptake, so we don’t think it is letting up,” Bernstein says.

Another important trend ePocrates is keeping in mind is next-best action or next-best engagement – basically, content journeys that are driven by artificial intelligence. 

“What’s happening is that because pharma can’t see the doctors directly, they’re trying to react in real time to a physician’s interest, or an action,” Bernstein says.

For example, if a physician engages with a platform on the web, the company will then, based on the AI, send a message fairly quickly, after a few days. 

“In a way, they’re trying to follow physicians across that entire non personal promotion landscape,” Bernstein says. “And what we’re seeing is clients asking us more and more, how a property can support that type of real action type of content journey, so that they can seize upon the interest of a doctor in real time.”

Bernstein likens this to what Amazon does, “where you look up something on Amazon, and then it just happens to follow you at different points across the web or on mobile.”

Because of COVID, he believes pharma is trying to accelerate its understanding of how to personalize non personal promotion “I would say probably within the last year, the number of clients doing these artificial intelligence driven, next best engagement type programs almost has doubled, from the portfolio of clients that we work with,” he says.

ePocrates’ pharma clients work with third-party providers to map out the activity of doctors across different platforms. “And what would happen is, is that any given week, let’s say for Sanofi, we would get a list of physicians, and be told, ‘All right, we want this list to get a message on efficacy. Here’s another list, these doctors should be getting a story about patient identification,” Bernstein says. 

Once ePocrates determines which physicians should get which message and moves the content into place, as soon as these physicians engage with that content, that data goes back to the artificial intelligence. Then these physicians may get a follow-up message on the web, to give them a deeper form or a variation of what was previously told, Bernstein says.

As far as the rest of 2021 and into 2022, even as physicians offices continue to open up to patients, Bernstein believes sales rep access is either going to stabilize or continue to decline. Additionally, recent research has predicted an 18 percent increase in pharma digital spend in 2021, which is projected to continue into 2022.

“And the reason is, is that while doctors appreciate that face to face contact, because they’re so busy, and the cost of that visit is so expensive, and non personal promotion provides so much data, it’s actually much more cost efficient for pharma to use digital tactics, they’re proven,” Bernstein told Med Ad News. “So I think while sales reps will still be there, and you may get a slight uptick, again, as some of the redundancies or layoffs that you saw during COVID are reversed, I think the digital trend is definitely here to stay, and you will see an acceleration of the sophistication of that technology of really personalized thing, ensuring that the content is sent to the doctor at the right time when they need it most.”

What does this mean for ePocrates? An expansion to beyond the mobile app, perhaps. 

Bernstein notes, citing recent research from Decision Resources Group, that 90 percent of physicians use mobile phones for professional purposes, 98 percent are using laptops, and 60 percent “triple screen,” with phones, tablets and laptops. 

“For 12 years, we’ve been No. 1 in the mobile space, that’s our value proposition,” Bernstein says. “But we are looking to expand our network into online for instance, because we know that physicians are spending so much time within the EHRs.”

By expanding its network, ePocrates wants to make information even more convenient for physicians. “We have a tactic that can message a physician when they’re looking up a particular drug online, so that when physicians are going outside of their EHR – we know a majority do because the EHRs don’t have the latest prescribing information within them – ePocrates will be able to fill them in,” Bernstein says. 

The goal is to create a “surround sound” approach. “For instance, if I have a message in ePocrates, and for whatever reason the doctor doesn’t come across it, but they’re engaging with other points within the platform, what we’re being asked by pharma is if we can map out an ecosystem within the platform, that if a physician doesn’t hit touch point A, I know then that I can get them in touch point B, or C,” Bernstein says. “If they’re not with a patient, and they’re catching up on educational news, we could potentially hit them. If they’re in front of a patient, and they’re looking up drugs that are within a particular therapeutic area, we can hit them.”

How successful can this approach be? “When we have run ROI studies, and we put forth to a doctor a full surround sound approach on channel, we’re seeing an ROI of 17 to 1 or more,” Bernstein says.

Bringing the value

For the healthcare advertising agencies trying to guide their pharma clients in the post-pandemic, more virtual healthcare world, they have to help their clients figure out how to create more value with physicians.

Nadine Leonard

“Clients need to get a handle on which of their physician clients are technology-forward versus not,” says Nadine Leonard, president of Heartbeat. 

For the physicians who are technology-forward, Leonard believes there are lots of things pharma can do to help create value in that relationship. 

“For the ones that have not. It’s probably a more a matter of assessing,” Leonard says. “Are they open to having help in that area? Because there are some of these baby-step-like things that you can do that make it so that the physician doesn’t have to themselves be really technology-forward.”

One of the repercussions of COVID is that a lot of people have gotten a taste for what telehealth can offer in terms of convenience, Leonard says. 

And for pharma and agencies, “How do you help take that kernel of a good experience, a beautiful benefit, and really make it into an even more valuable interaction? If you’ve got physicians that are that are interested in that, really being able to help make that interaction more valuable is a big deal,” Leonard says. “Giving them the guidance, giving them the tools, giving them the content, any of that kind of stuff to really take it and run with it.”

Leonard some brands more than others have fit better into a telehealth experience, and will continue to do so.

“If you think about the things that are typically categorized as lifestyle drugs, or maybe even birth control, those are places where telehealth has played a big role, but could probably play a much bigger role, and where we’re really encouraging clients to explore, and how to make the most of a newly empowered patient population,” she says. “I think some of the reasons that those lifestyle indications have fit so well into telehealth is because they’re things that people aren’t super comfortable talking about, so sometimes it’s just easier to do it from the privacy of your own home.”

Other groups who might be more comfortable with using telehealth appointments are “younger patient populations who are really comfortable with technology, and don’t have an established relationship with a specific physician,” Leonard told Med Ad News.

Heartbeat is drawn particularly to “the opportunities where there are brands that can really go much harder in a sort of DTC model that incorporates telemedicine, like right at the brand site,” Leonard says. “I think that can be really exciting for certain brands.”

Early on in the pandemic, Heartbeat was helping neurology brands assist neurologists in having more effective virtual visits. But Leonard is not sure if these clients will continue this tactic, or other clients will explore something similar, as more patients actually get seen in the office.

 “I think the [clients] that started out being technology-forward are going to see this as an opportunity to really enhance that part of their value proposition, and I think others are going to be excited to go back to the way things were,” Leonard says.

Focus on the rep

Nicky Battle

The pandemic “basically up ended every way that we knew to sell,” says Nicky Battle, senior VP, engagement strategy, CDM Princeton. “And I was encouraged to see how quickly the industry adapted.”

CDM Princeton saw the agency’s media partners offering more opportunities for pharma companies to get in front of physicians and patients in a telehealth environment, Battle says. “So on the HCP, side, we were able to run some messaging for telehealth, but on the patient side, one of the most interesting things that we were able to do was offer up a waiting room experience.”

Depending on the platform being used by the physician, Battle says the agency had two partners offering up the possibility of providing the patient a waiting room before their physician joined the call. The waiting room offered some discussion guide questions to ask.

“What I loved about that is that we weren’t boiling the ocean,” Battle told Med Ad News. “We knew specifically those messages that were going to be in front of folks with a particular condition.”

 This happened within the first three months of the pandemic and the move to telehealth. “So that was probably one of the smartest things that we quickly pivoted to,” Battle says.

“We focus a lot on being customer centric, and when we talk about customer, we talk about our core stakeholders, being the physicians and the patients,” Battle says. “But last year, made us focus on the rep, specifically, and making sure that they were in this, in terms of our omnichannel plans.”

The agency had to determine what materials reps needed to be successful, and what new things could be tried to get them to personalize and get creative about getting in front of physicians. “Even though telehealth helped us kind of keep things moving, it definitely didn’t fill that gap, it didn’t replace the amount of the in-person visits,” Battle says. “And then on the telesales side, we still see that overall sort of decline of the reps being in front of folks.”

Battle doesn’t know if in-person sales rep visits will ever come back to pre-pandemic levels. “So it’s about adjusting to this new normal, and making sure that we’re arming everyone, from patients and physicians and reps, with the materials that they need to make these virtual visits much more impactful.”

“We won’t know, until maybe next year, this time, for sure what’s going to happen with the volumes,” Battle says. “But every time I read a new survey, or we asked a particular group of physicians what do they see happening at the beginning of 2022, or this time next year, they just still don’t think that they’re going to get back to the same volume of visits.”

Battle puts an asterisk next to that statement, because there are some physicians – psychiatrists and psychologists in particular – who were enthusiastic early adopters of telehealth. 

“And we’ve seen across the board, they’ve had the most sustained telehealth volumes throughout,” she says. “So they’re going to be fine in the long run, but there are, you know, quite a few other specialists that are saw declines in volume and are also trying to figure out how to close that gap.”

From the agency perspective, “it’s more of making sure that, from a physician perspective, that they’re doing what they can do, in order to encourage more visits, whether in person or virtual.”

That might mean helping physicians create a “more savvy” digital presence, so that reps know the best way to have a visit, which visits are best for in person, and what’s going to be convenient for both parties to meet virtually. 

Agencies talk a lot with their clients about being proactive with their tactics, but the pandemic pushed everyone into a different mode.

“Last year forced us to be reactive,” Battle says. “While I can’t speak for everyone. I think what we all learned is that reactive planning is still very, very important.”

Pharma must engage in crisis scenario planning and thinking through what might happen, if something goes wrong with access to physicians and patients. “Being proactive in terms of selling is always going to be something that we’re focused on, but having fuller playbooks on ways to pivot is something that we’re all definitely keen on finalizing this year,” Battle told Med Ad News. 

Although other tactics have experienced a slowdown in the pandemic, digital work has increased.

‘I’m sure if you’ve talked to anyone else in digital, the work has tripled,” Battle says. “And I will say it’s probably outsized.”

While the amount of work has tripled, Battle believes that the focus on digital work “has been exactly where we were supposed to be all along. But finally, the directives came from up high to make sure that we had really smart, intuitive omnichannel approaches for all of our stakeholders.”

Battle has noticed pharma agencies have been trying to build the smartest ecosystems on behalf of their clients. “They finally have been able to close the gaps on any disconnects between data integration or not having a presence on channels that we knew would be impactful,” she says. “So, I think that that’s been the biggest difference that I’ve noticed.” 

“We need to have this first-party data … everyone is focused on making sure that we are collecting as much as possible, and democratizing it across the folks that need to have it,” Battle says. “What do the reps need to know? What do we need to know, as marketers? What do the commercial teams on the brand side need to know? And I think what has happened in terms of digital is that kind of stewardship has increased, and will continue to increase.”

The days of biannual meetings with vendors to discuss how campaigns are performing are past. “We’re looking at the data much more often, and we’re being asked to read out and discuss the data much more often,” Battle says. “And it sounds like our clients are going to be adapting and getting used to the fact that their internal infrastructure has to provide for a more quick review process, quick approvals, and quick pivots.”

What is CDM Princeton preparing in terms of digital deliverables? “That is really going to vary, because it depends on the sales team, it depends on the actual rep, what their comfort level is – at the end of the day, I think it is about whatever tool the rep is most comfortable with,” Battle says. “And if that’s some sort of virtual sales tool, it’s about making sure that they have a very easy, intuitive content repository with a super simple interface, in order to access everything that they need for their calls, whether it’s in person or virtual.”

Battle adds, “We’re finding that we’re having more touches with the rep teams to share our learnings and insights together, which has been really good for our work, it informs the messaging on our side, but also, they’re getting the tools that they need and the formats that they need, so that they can feel more successful.”

The learnings, and the tools developed from them, are going to continue to evolve. “These challenges definitely lit a fire underneath quite a lot us,” Battle says. “And the solutions that we’re getting to, and the experiences that we’re building, are some of the coolest I’ve ever seen in this space. So I’m excited about it.”

Telehealth and account-based marketing

Chandani Rao

According to Chandani Rao, VP account group supervisor, digital, at Ogilvy Health, telehealth visits may have dropped, but there are still a consistent level of new scrips and refills being written.  

“We have seen the drop,” Rao says. “I was talking to one of our partners, and they said they felt their platform had like a 30 to 40 percent drop since the height of the pandemic, but it’s still a much better volume than it was before.”

And when it comes to constructing campaigns around telehealth systems, not all are built the same, Rao points out. Some are integrated into the EHR platform. Some of them are partners to Ogilvy Health, other ones are standalone. Some allow advertising, and some do not.

 “We’re trying to do everything we can to, in the end, help the patient or make things simpler for them, whether it’s through the doctor or not,” Rao says.

When pharma sales forces were grounded by the pandemic, Ogilvy Health saw a “huge jump” in tactics around EHR programs and account based marketing. The advantage of account-based marketing, Rao says, is “we can also hit some of those no-see doctors, that we couldn’t have targeted with reps before anyway.” Account-based marketing and tactics through the EHR allowed pharma to get messaging across to some of these closed institutions.

Even with the drop in visits, Rao says the use of telehealth is not going anywhere. “It’s a factor to be considered in any program, and I think some people consider it a program unto itself,” she told Med Ad News. “Honestly, I look at this more holistically as part of our full program because there are some of those telehealth platforms that you cannot have ties to or put your messaging on. And therefore, we need to make sure that physicians are getting the messaging.” 

It may be more difficult to get messaging to patients because patient portals may not be available to advertisers. Additionally, before the pandemic, patient portal adoption was very low. But that has increased, as patients have been forced to find and make their own appointments. And some have grown to like that interface. “I don’t know if you’ve ever used yours, but I love scheduling my appointment with my doctor that way, for my annual visits, it’s somewhat simpler,” Rao says.

With some of its more flexible partners, Ogilvy Health has been able to create programs that can trigger messaging in the EHR for the HCP to then send right to the patient portal. “That helps ensure compliance,” Rao says. 

And the messaging can also be forwarded to the patient via their preferred method of communication, established when they enrolled in the portal program. This can be by phone call, text, email, or only in the portal. “They get to choose,” Rao says.

Ogilvy Health also uses AI, but more with account-based marketing, “to try and leverage all of the intent data that’s out there,” Rao says.  

Depending on the typical therapeutics conditions that the client is targeting, there are a lot of different inputs that go into how to best target and craft the messaging to reach the right people. 

There are some takeaways that should be considered in any tactics involving telehealth programs, according to Rao. “Focus on the customer, the patient experience and the HCP experience,” she says. Even if the client just wants to reach the physician, the experience the HCP has will also trickle down to the patient.