An electronic health record (EHR) is a secure software system that replaces the paper‐based records of patient health information. The EHR is used by the provider and their staff to manage a broad range of patient care, such as administrative, lab test ordering/reporting, prescribing and patient communication. A complete system includes both patient heath records and an e-prescribing interface. According to CMI Media Vitals research, 88% of physicians report using EHR technologies. 2016 Media Vitals data also show Epic to be the most widely used EHR system with 32% of HCPs using it, followed by Cerner and Allscripts, both with 13% of adoption. Manhattan Research indicates that average use is 3.3 hours per day – higher than the 1.6 average for all other digital resources (2015). The uptake of EHR use has been primarily driven by federal and state legislations that require eprescribing and offer financial incentives or levy penalties correlated to. These include The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As time elapses, stricter requirements for EHR adherence are introduced: moving from data capture & sharing towards advanced clinical processes and improved outcomes.
Opportunities for Pharma
EHRs offer Pharma an additional channel to reach relevant HCPs within a patient care setting. They also offer an opportunity to provide additional tools and resources to HCPs at a time when they are prescribing. According to 2016 Media Vitals, physicians use an EHR system during 45% of patient visits while in the exam room with the patient present. The most used functions in an EHR system are ICD9/ICD10 coding look up (67%), electronic prescribing (79%), entering clinical notes (79%), and viewing (77%) and ordering lab results (68%). 92% of physicians or staff at the physician’s office print.
An opportunity exists for Pharma to integrate during two key moments to influence the prescribing decision within the health records or reinforce the prescribing decision within the e-prescribing interface. While not all EHRs allow for Pharma integration, those that do still account for a large percentage of the physician and patient population. Opportunities to influence the prescribing decision consist mainly of banners within either the administrative or consultation workflow. These may act as awareness or reminder messages or assist in identifying appropriate patients. They can typically be targeted by physician specialty, target list, geography, past prescribing behavior, patient demographic, current therapy, or patient diagnosis (ICD10). Opportunities to reinforce the prescribing decision consist of banners within the eprescribing interface triggered by selected therapy and potentially layering geographic, access, or diagnosis targeting, as well as the integration of e-coupons or printed patient education materials in to the EHR system. This creates a unique occasion to have a branded presence during the point of encounter between physicians and patients. Offering support materials also fulfills a primary request physicians are making of Pharma as it relates to EHR integration.
As the focus of EHR requirements shifts towards more rigorous health information exchange (HIE), increased requirements for eprescribing, and electronic transmission of patient care summaries across multiple settings, partners are beginning to enable advanced workflow functionality. This includes offerings such as auto-enrollment in patient adherence programs or population of prior authorization forms. Currently pockets of availability exist but scale is limited. Emphasis on improving outcomes through decision support tools and patient access to self-management tools is also increasing. Capabilities exist to enable clinical decision support messaging/alerts based on available clinical guidelines and triggered by the patient population of a particular provider. Application for marketing is limited as current messaging is restricted to approved third party medical guidelines (associations, payers, government).
Overcoming Challenges to Marketing within EHRs
Challenges for Pharma marketers include the fractioned EHR market – the largest EHRs do not allow advertising and within those that do accept Pharma content, targeting and reporting capabilities remain limited. This means that Pharma must find efficient solutions for distributing content across a wide variety of platforms and has led to the rise of “EHR networks”: software service companies that specialize in healthcare information management are embedding their technologies into EHRs and physician workflows to help meet the demands of their end users including clinical messaging, e-prescribing, e-prior authorization, etc. Because a number of EHRs utilize their services, they are able to integrate with Pharma in a “network” capacity, offering a scale that is unattainable through most direct partnerships. Additionally, communications companies aggregate both EHRs and the software service companies in order to provide an even greater scale and standardize offerings. Another challenge is the delay in drugs being entered into EHR systems as well as inaccuracies in formulary information, both of which may be solved through the rise of partners specializing in compendium management. The uptake of patient portals has been slower than expected. In a 2015 survey conducted by Sharecare of 11,000 patients, only 18% had accessed a patient portal. Over half of responders had either never heard of a patient portal or did not know if one was available to them (MM&M, October 2015). Because of this, the media opportunities within portals that we expected are not yet widely available. However, similar to the auto-enrollment or clinical decision support functions, those offerings that are available should be viewed as pilot programs to build learnings for future applications.
Finally, CMI/Compas expects increased advertising regulations within EHRs in the coming years. Florida is one of a handful of states to pass a statue (456.43) on Electronic prescribing for medicinal drugs stating: Electronic prescribing software shall not use any means or permit any other person to use any means, including, but not limited to, advertising, instant messaging, and pop-up ads, to influence or attempt to influence, through economic incentives or otherwise, the prescribing decision of a prescribing practitioner at the point of care. Such means shall not be triggered or in specific response to the input, selection, or act of a prescribing practitioner or his or her agent in prescribing a certain pharmaceutical or directing a patient to a certain pharmacy CMI/Compas has modified contract language with suppliers to ensure the programs they are selling comply with all state and federal regulations. We have determined there is minimal risk to the agency (CMI) or the advertiser (our clients) with running programs in any of these states. However, because of these anticipated changes, the formerly mentioned post-script pull-through tactics will likely offer the most opportunity for pharmaceutical marketers in the future. Please see EHR Addendum for additional information on current statutes. “We recommend approaching EHRs as a completely unique channel.”
CMI/Compas recommends approaching the EHR space as a completely unique digital channel. Specifically, EHRs require a strategy distinct from display media. Context is an advantage with EHRs over most digital channels. When a HCP is reached in a clinical prescribing environment, the opportunity to impact behavior is greater. We recommend prioritizing the moment within either the health records or e-prescribing interface as most meaningful based on brand objective. Prioritize partners based on their capability in addressing that moment of meaning. Further refine by utilizing CMI/Compas’ proprietary ByDoctor database or Media Vitals survey data to match target physicians or segments to their respective EHRs. Maintain awareness of state laws and utilize caution in advertising prior to the prescribing decision, whether within a dedicated prescribing software or an EHR that may be linked to prescribing software. Content of Pharma messaging within this channel should be valuable and clinically relevant. In the PDR’s Prescriber EHR Message Survey, over 80% of prescribers indicated that in-EHR message was useful when done properly. A broad range of messages were perceived as having utility; national managed care coverage, less frequent administration and new clinical data were among the most useful ones to physicians. Clear and concise messages work better in an EHR system.
CMI/Compas recognizes that as we see a growing need for physician-patient engagement, Pharma needs to strategize ways to optimize this relationship. The EHR platform is less about bombarding HCPs with traditional media and brand messaging, and instead about providing physicians beneficial tools for their practice and patients. The physician needs to see a value in what the Pharma message is offering in order to engage. We also recommend developing a measurement strategy specific to this channel. The challenge in measuring success of EHRs is that they cannot be directly compared to other electronic media. For example, we do not feel that click-through rate is generally a relevant metric because a physician does not have time to leave the EHR interface during a patient consult. We recommends conducting test and control studies to see the impact of EHR advertising on physician script-writing. CMI/Compas is actively working with our supplier partners to make sure their data sharing solutions are compatible with both changing EHR landscape and the needs of our pharmaceutical clients.