THE DIGITAL i C C NOV 2015 DEBATE i

A REPORT ON HOW DOCTORS ENGAGE WITH DIGITAL TECHNOLOGY IN THE WORKPLACE THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT FOREWORD i C C

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PAUL MANNU Master Practitioner, Behavioural Insights [email protected]

Advances in digital technology have The research explores doctors’ perceptions Online interviews with become ubiquitous within healthcare, of how smart technology such as apps bringing about breakthroughs in diagnosis, and wearables can be used by patients to new treatment options and at the same better manage their health. time heralding the expansion of companies usually associated with technology into the The appendix section also includes our market place. findings on doctors’ preferences when 1,040 participating in research via a mobile app. certified doctors Enter Health, Apple Health, and HealthVault. These major players Throughout this report, consideration has are accompanied by IBM with ‘Watson’, been given as to what the survey findings a new cognitive system that processes mean for pharmaceutical marketing information more like a human than a strategies. If you would like to know computer. IBM claim Watson will be able more about the specific relevance of this to ‘see’ medical images once its advanced research to marketing, sales and business image analytics and cognitive capabilities intelligence please get in touch. are merged with a newly acquired medical imaging management platform. For more information about the full extent of the survey research, please do not 8 The potential for these new and symbiotic hesitate to contact us. Markets relationships is vast and doctors are at the heart of it. As such, they are well placed www.cellohealthinsight.com to report from the front line on how digital advances are impacting healthcare quality and efficiency, and how these developments can potentially help them to make better patient care decisions.

This report is a summary of findings from Cello Health Insight’s 2015 research survey of doctors across eight markets; including the UK, France, Germany, Italy, Spain, the US, China and Brazil. The research explores the ways in which doctors are interacting with digital communication channels and digital devices in the workplace – focusing on how they are using these to exchange information and communicate with peers, pharmaceutical sales representatives, and of course with their patients. THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT

Contents

1 Uptake of digital technology and online platforms • Access to digital devices • Communication via digital channels • Social media use in a professional capacity

2 Influence of digital channels on prescribing • Comparison of information sources • Influence of social media on treatment decisions • Rise in use of tablets for representative visits

3 Impact of digital on the patient-doctor consultation • Researching conditions online • Self-diagnosis online • Patients presenting with a named prescription

4 Potential for mobile apps and wearables to help the patient • Extent to which doctors are recommending health apps • What doctors might recommend apps for • Barriers to take-up of apps and wearables

5 Key segments emerging from extent of sharing via digital channels • Defining user levels • Chain of influence

6 Appendix • Methodology • About Cello Health Insight • How doctors feel about participating in surveys via mobile apps 1 UPTAKE OF DIGITAL TECHNOLOGY AND ONLINE PLATFORMS THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 01 ACCESS TO DIGITAL DEVICES

There is a growing trend for doctors to use There are some interesting differences in digital technology to assist them in their the number of doctors who agree with the work. Doctors use their smartphones and following statement: smart devices to access the web for a wide range of purposes – from communicating with their patients and peers, to finding “I find my smartphone / tablet of82 doctors own information that will help them to diagnose so much easier to use than my or have access to or prescribe. work desktop / laptop.” a smartphone The smartphone has been widely adopted at work by doctors globally, and it has become a close companion from which they can obtain information. As connected devices Almost one third (32%) of all doctors offer easy access to the internet from any in the survey agree with this statement. location via Wi-Fi and mobile networks, Doctors in emerging markets were much they are ideal for doctors on the move, more likely to agree with this statement especially for specialists. compared with those in Europe (67% vs. 22%). Globally, our survey finds that82% of doctors own or have access to a In Brazil and China, the data suggests smartphone at work, and 77% of them that doctors have embraced tablets and report that they regularly use it at work smartphones, which presents interesting opportunities for pharmaceutical of doctors58 regularly for professional purposes. Of these, doctors in Brazil are the most likely to companies to access them in their search for work-related regularly use their smartphone (90%), professional life. information on followed by doctors in China at 85%. UK doctors follow at 82%, which is a higher The lower result for Europe, where their handheld number than in the other European smartphone use in the professional setting countries surveyed – Italy 73%, France seems less advanced, is potentially due 73%, Spain 79% and Germany 68% – to the need for systems in Europe to link and higher than the US (73%). in with other local and national Health Electronic Reporting (HER) systems – Globally, 58% of doctors regularly search something that is more difficult via for work-related information using their a smartphone. tablet or smartphone. With 81% doing so in Brazil and 76% in China, this again puts them ahead of the curve. 02 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT COMMUNICATION VIA DIGITAL CHANNELS

The research explored Text messaging the ways in which doctors Widely used across all markets to are adopting digital channels communicate with colleagues. Globally, into their preferred methods 68% of doctors use mobile texting to communicate with their peers. Almost of communicating with one third (30%) use it to communicate peers, pharmaceutical sales with their patients, and 18% with representatives, and pharmaceutical sales representatives. Use was particularly strong in Brazil their patients. and China (82%).

WhatsApp / WeChat Phone calls of88 doctors have Embraced in China, Brazil and Italy for emailed their peers in Continue to be the primary channel of communicating with peers, patients and communication between doctors and pharmaceutical sales representatives. the last month patients across all markets. 89% of doctors reported talking on the phone France and the US are far behind other to colleagues in the last month, with countries in terms of using WhatsApp, 84% talking to patients, and 45% to or its equivalent – WeChat in China. pharmaceutical sales representatives. Doctors in Southern European markets, China and Brazil are using these platforms Email to communicate with peers, patients and 48report having pharmaceutical sales representatives. A major channel of professional emailed a patient in the communication between doctors, Only 2% of UK doctors and 4% of US same period with 88% surveyed having emailed their doctors report using WhatsApp to peers in the past month. 48% report communicate with patients in the previous having emailed patients in the last month, month, compared to 87% in Brazil, 61% in and 43% of doctors having used email to Italy and 50% in China. communicate with pharmaceutical sales representatives.

43report having emailed a pharma representative in the same period THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 03

Web platforms Skype

Offer an opportunity for a customised Has not taken off with doctors. While it is solution. Doctors are open to the idea often seen as having great potential for the of using dedicated web platforms to profession, less than 17% of doctors claim 33 communicate directly with patients, to have used the channel in the last month of doctors would like with one third (33%) of doctors globally to communicate with their peers, and only to communicate with agreeing with the statement: 4% with patients or pharmaceutical patients via a sales representatives. doctor-patient website “If I could communicate with Social media patients via a specialist doctor- patient website, it would be Has an increasingly important role to play in doctors’ peer-to-peer communications, more time-efficient.” but it is yet to take off for patient communication. 30% of doctors globally now claim to use consumer social media Doctors in Brazil and China were even to communicate with their peers. However, more likely to want to communicate in only 8% claim to use it to communicate this way, with 47% and 67% respectively with patients and pharmaceutical sales agreeing with the statement. representatives.

Digital channels most commonly used by doctors to communicate:

Communicating: with collegues with patients with pharma sales reps

Phone calls 89% 84% 45% Email 88% 48% 43% Text 68% 30% 18%

WhatsApp 31% 15% 12% Consumer social media 30% 8% 8% IM 25% 7% 5% Skype 17% 4% 4% WeChat 3% 1% 1% 04 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT SOCIAL MEDIA USE IN A PROFESSIONAL CAPACITY

There is wide regional variation in Wikipedia social media use, which pharmaceutical companies will need to understand for By comparison, the online encyclopedia / their strategy development. resource Wikipedia is used globally by about one half of doctors at work. The three social media channels used 63% of doctors in Brazil and China, 53% of global1 doctors2 use most widely at work ‘in the last month’ of doctors in Europe, and 42% of doctors Wikipedia at work for professional purposes are YouTube in the US report using it in the last month. (28%), LinkedIn (24%) and Google+ (21%). In Brazil and China there is significant use of YouTube in comparison to the other countries in the survey. In Brazil, 50% of doctors report having used it for professional purposes ‘in the last month’, and 37% claim this in China.

Use of consumer social media by doctors in a professional capacity (% of respondents): THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 05

IMPLICATIONS FOR PHARMA MARKETING:

Digital technology and online platforms are channels used by a significant proportion of doctors and each is a potential entry point for the promotion of a pharmaceutical asset.

Understanding doctors’ digital behaviours is vital for effective multi-channel marketing strategies. In particular, identifying the right message for the right person, through the right channel. 2

INFLUENCE OF DIGITAL CHANNELS ON PRESCRIBING THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 07 COMPARISON OF INFORMATION SOURCES

While face-to-face information from However, the data suggests that digital peers, key opinion leaders (KOLs) offerings can be useful alongside the sales and visits from pharmaceutical sales representative. More research is needed representatives are still all in the top four to help pharmaceutical brands understand channels for trust and influencing doctors’ what information is better communicated prescribing decisions, the use of some face-to-face and what works better sent digital channels is increasing. digitally.

The pharmaceutical sales representative In terms of using digital channels to access still remains the preferred source of pharmaceutical company information, only information – with 54% of doctors saying 27% of doctors surveyed had accessed a the representative is their preferred source. company website in the last 6 months, and 17% a branded product-related site.

Top 4 information sources:

1st 2nd 3rd 4th of doctors54 prefer a Exposure to in 67% 65% 64% 58% representative as their past 6 months primary source of Sales rep visit Direct mail ads Medical advertising Direct email information

Preferred source 54% 48% 42% 32% of pharma info

Sales rep visit Sponsored event F2F info from peers F2F with KOLs

Most trusted 48% 43% 34% 33% source of pharma info Conference / used a digital27 channel F2F info from peers F2F with KOLs Sales rep visit sponsored meetings to access company Most likely to 38% 35% 27% 22% information influence prescribing Conference / F2F info from peers F2F with KOLs sponsored meetings Sales rep visit 08 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT

Influence of social media on Rise in use of tablets for treatment decisions representative visits

35% of doctors globally agree with the Our research suggests that a shift is statement that: happening towards using tablets in visits from pharmaceutical sales representatives and that their use has caught up with the “Information from peers use of paper-based sales aids. on Twitter will increasingly According to the research, 80% of recent influence treatment decisions sales discussions have involved paper- based materials, and 74% have involved over the next one to two years.” a tablet. When it comes to preferred format, tablets win, but only just, at 46% compared to 43% for printed. However, In contrast, only 16% agreed that in Brazil and China there is a strong information from pharmaceutical brands preference for tablets (50% vs. 37% for on Twitter would increase in influence paper-based materials). over the same period.

Almost one quarter (24%) agreed that brand pages on will increase their influence on treatment decisions in the next one to two years, making this and other social media sites important access points for pharmaceutical 80of recent sales companies to consider. discussions have involved paper-based materials

of74 recent sales discussions have involved a tablet THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 09

IMPLICATIONS FOR PHARMA MARKETING:

The changing environment in terms of influences suggests that if pharma brands wish to maximise their presence they must indentify the optimal of face-to-face and digital channels. They also need to understand how both mediums work together in order to build relationships that will ultimately influence prescribing decisions. 3 IMPACT OF DIGITAL ON THE PATIENT- DOCTOR CONSULTATION THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 11 RESEARCHING CONDITIONS ONLINE

The patient-doctor consultation Patients presenting with increasingly indicates that digital is acting as a significant catalyst for the a named prescription democratisation of medicine, with patients having more influence over their treatment. 40% of doctors globally agree that In fact, one of the most interesting and patients will often specifically request of doctors69 globally say striking pieces of data we collected was named prescriptions based on their related to the influence of the patient. own online diagnosis. This behaviour that patients often look is more common in some markets, up their condition online With the wealth of information available particularly in Italy (65%), and close to prior to a consultation online, it’s no surprise that patients half of doctors in Brazil (47%), Spain are more informed than ever before (46%) and the US (45%) also report the when they arrive at a consultation trend. France and the UK both lag behind, with a doctor. Patients have a thirst for with only 28% of UK doctors and 33% of medical knowledge and currently 69% of French doctors claiming their patients ask doctors globally say that patients often for a named product. look up their condition online prior to a consultation. Digital has been instrumental This data highlights the ongoing increase in patient empowerment, and doctors are in online searching from both the patients’ accommodating this new behaviour rather and doctors’ perspectives. Crucially, than dismissing it. it reiterates the need for a strong online presence for pharmaceutical brands across of doctors62 globally agree a range of resources. that patients often arrive Self-diagnosis online Digitally connected patients are clearly having self-diagnosed Even more startling is the finding that empowered by the information they find 62% of doctors globally agree that patients online and are the carriers of essential often arrive having self-diagnosed from information into the consultation room. online research. Italian and Brazilian Pharmaceutical brands cannot ignore these doctors agree with this trend more than websites and platforms, but must consider other markets. exactly how to engage with them.

The majority (90%) of Brazilian doctors and 81% of Italian doctors agree that their patients look up conditions online, and 87% of Brazilian doctors and 71% of Italian doctors agree that their patients self- of40 patients will diagnose online. specifically request named prescriptions 12 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT

IMPLICATIONS FOR PHARMA MARKETING:

The new development and the increasingly democratic relationship between doctor and patient is hugely important for pharma brands. If one patient mentions a brand to a doctor they might ignore it, but if 20 patients mention the same brand then their voices will start to have an impact. THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 13 4 POTENTIAL FOR MOBILE APPS AND WEARABLES TO HELP THE PATIENT THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 15 EXTENT TO WHICH DOCTORS ARE RECOMMENDING HEALTH APPS

With smartphone penetration increasing What doctors might around the world, apps have become a key part of many people’s lives. According to recommend apps for published data1, there are some 165,000 consumer health apps available at present, According to our survey, globally, the but just 36 of them account for half of all top reasons that health apps would be of doctors41 globally downloads. This suggests that many are recommended are for diet and weight loss, general health and fitness, and agree with the following not being utilised at present, but that is likely to change. smoking cessation. statement: “Mobile apps could be a game-changer Perhaps it’s no surprise that health apps It is interesting that the situations in which are predicted to play a greater role in doctors would recommend a mobile app to improving health healthcare in the future, with 41% of are the more straightforward treatment outcomes in many of the doctors globally agreeing that: areas and nothing specialist emerged. This may point to doctors lacking patients I see.” awareness of more specialist apps – as suggested by a recent BMJ survey2, where “Mobile apps could be a game- the greatest reason for non-use was that changer to improving health doctors just ‘didn’t think about it’. outcomes in many of the Reasons doctors might patients I see.” recommend an app: However only just over one third (36%) Diet & weight loss of doctors globally say they are likely 70% to recommend a health app to their patients in the future. There are several 1. IMS Institute for Healthcare Informatics. General health & fitness reasons why doctors might shy away from Patient Apps for Improved Healthcare: activity 65% recommending apps. It could be that there From Novelty to Mainstream. Oct. 2013 are too many apps to choose from, so it Health monitoring e.g. glucose could be a case of information overload, 2. BMJ. The Ownership and Clinical Use levels, sleep, heart-rate 53% or there may be concerns about evidence of Smartphones by Doctors and Nurses and efficacy. Serious apps will need the in the UK: A Multicentre Survey Study. Smoking cessation 49% endorsement of doctors to gain traction. Oct. 2015

Compliance 45%

Patient support networks & information 37% 16 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT BARRIERS TO TAKE-UP OF APPS AND WEARABLES

The wearable tech market is estimated The next highest concern at 14% is to be growing rapidly and will be at the consistency and accuracy of the $20.6 billion by 2018. Based on this, data, with a further 11% of doctors we might expect a high rate of use, concerned about the inability for the recommendations and enthusiasm. data collected to integrate with other However, at present, ownership of healthcare operating systems, limiting of 33doctors would wearable health technology such as their usefulness. 10% of doctors also think recommend a wearable fitness tracking bands among doctors that doctors themselves currently lack the themselves globally is less than one in ten necessary time or skills to interpret the tech device in the future (9%), with the US market highest at 15%. results accurately. to their patients Globally, only 6% of doctors regularly use their fitness tracking bands at work. In the US it’s slightly higher at 11%. The regular use of fitness tracking bands by doctors is non-existent in Germany (0%) and Brazil (0%), and negligible in Italy (1%) and Spain (1%).

of36 doctors would Doctors globally say they are almost as recommend a mobile likely to recommend a wearable tech device to patients (33% would recommend health app in the future in the future) as a health app to their patients (36% would recommend in the future). Our survey highlights key concerns among doctors about the accessibility of health apps and wearable technology, and ultimately how effective they are in managing disease burden.

Almost one third (28%) of doctors surveyed said that the biggest barrier to them recommending health apps is that they don’t believe all patients own a smartphone. THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 17

IMPLICATIONS FOR PHARMA MARKETING:

Digital departments in pharma need to understand how to overcome logistical barriers before engaging or collaborating with digital initiatives.

Universality and integration are vital components to consider. Until health apps and wearable technology can be used for the majority of their patients and can integrate with existing hospital based electronic systems, they are unlikely to be widely used. 5 KEY SEGMENTS EMERGING FROM EXTENT OF SHARING VIA DIGITAL CHANNELS THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 19 DEFINING USER LEVELS

The increasing use of digital communication tools has led to the emergence of ‘influencers’ – doctors who are proactive, high sharers of information online either via specialist websites for healthcare professionals, of doctors42 globally are or via general consumer social media such classified as ‘influencers’ as Facebook and Twitter. From our survey data we classify 42% of doctors globally (online KOLs) as ‘influencers’, and these can be regarded as online KOLs.

They represent an opportunity for pharmaceutical companies in helping to generate noise and interest via digital channels, sharing information from a variety of sources including medical journals, product information / reviews, conferences / events and patient support web sites. of doctors23 globally are 23% of doctors can be considered classified as ‘engaged’ ‘engaged’, and are low to medium sharers of information, while 35% are passive (being low to medium ‘observers’ who only read information. sharers of information) However, in all cases, social media represents the perfect channel for sharing content – whether posting it proactively or receiving it passively.

of doctors35 globally are passive ‘observers’ (they just read information) 20 | THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT CHAIN OF INFLUENCE

They may be small in number, but the Types of information being ‘influencers’, or ‘digital shared and read by doctors: KOLs’, are an important audience for any pharma company operating in Being shared: today’s landscape. They represent a key On specialist websites: On consumer media: target for a virtual Medical journals 39% Patient support websites 16% ‘wisdom of the crowd’ Product information / reviews 32% Conference / event 16% Specific therapy area31% Product information / reviews 14% approach. Conference / event 28% Medical journals 14% Patient support websites 24% Career development / training Identifying them, understanding what they are sharing and Career development / training or new posts 12% developing strategies to provide or new posts 24% Specific therapy area10% them with the right information Samples 24% Samples 9% to share will maximise their potential as ‘virtual sales people’.

Listening to their conversations and understanding how they are steering the stream of debate can also provide an early warning Being read: system for potential problems. On specialist websites: On consumer media: Medical journals 56% Patient support websites 20% Product information / reviews 50% Conference / event 20% Specific therapy area 50% Product information / reviews 17% Conference / event 41% Medical journals 16% Patient support websites 32% Career development / training Career development / training or new Posts 15% or new Posts 31% Specific therapy area11% Samples 31% Samples 10% THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 21

IMPLICATIONS FOR PHARMA MARKETING:

Pharma needs to ask whether they place as much emphasis on digital opinion leaders as they do on face-to-face experts at conferences. They also need to indentify whether the nature of the message communicated should be the same. News travels much faster in the digital space. 6 APPENDIX

Methodology About Cello Health Insight

1,040 interviews were conducted across Established in 1983, Cello Health Insight is a range of primary and secondary the global marketing research arm of Cello physicians in eight markets between 10th Health, with offices in London, New York and 31st July 2015. The markets covered and Chicago. were the US, the UK, France, Germany, Spain, Italy, China and Brazil. www.cellohealthinsight.com

Each interview was 15 minutes in length and was conducted online with panel provider M3 Global Research. All respondents were verified as being healthcare professionals. The final sample was un-weighted.

Sample:

US n=330

Europe (UK, France, Germany, Italy, Spain) n=650 Emerging Markets (China & Brazil) n=60

Total n=1,040

Fieldwork conducted by online panel provider M3 Global Research THE DIGITAL HEALTH DEBATE 2015 | ©CELLO HEALTH INSIGHT | 23 HOW DOCTORS FEEL ABOUT PARTICIPATING IN SURVEYS VIA MOBILE APPS

Supplementary research

The vast majority (88%) of doctors who • 86% are prepared to use took part in our global survey said that ‘slider’ answers they would be happy to take part in • 78% will watch video content mobile app surveys. Additionally, 80% of • 71% will listen to other media doctors said that they would be willing to • 69% will complete open text questions participate in a market research study via • of doctors88 in global an online community. While doctors may be happy to engage survery would be happy with video content, the survey reveals In order to understand doctors’ preferences that very few have an appetite for content to take part in mobile when they are participating in research creation. Less than one half (48%) would app surveys surveys via a mobile app, we conducted a complete an online diary, only 40% would short additional survey with a sub-sample upload images and less than one quarter of the respondents in the UK and US. (24%) would be prepared to upload a video of themselves talking to camera. Although doctors the world over are The message for clients and market notoriously short of time, the majority of research companies is clear: keep it respondents (60%) who answered our short and simple if you want to hold specific questions about mobile research doctors’ attention. indicate that they would be prepared to dedicate up to 15 minutes to complete a Using mobile technology for surveys of doctors80 would be survey via their mobile phone. One quarter allows for ‘in the moment’ examination would only spend up to five minutes on a of the motivations and experiences of willing to participate in survey. The ability to complete a survey in doctors, asking pertinent questions a market research study stages is considered a benefit. of their experiencing self rather than their remembering self. This is a great via an online community Although many doctors are already happy opportunity to gain in the moment to complete surveys on mobile apps, more insights. However surveys must be kept could be done to optimise the experience short, a 45 minute mobile survey would for respondents. 22% cite the need for counteract the attraction of the medium. a clear and simple design, and the same proportion note that surveys need to be optimised for mobiles and tablets.

Doctors have high expectations of survey design and execution. They expect of doctors60 would be researchers to make it easy for them to participate, and the research suggests prepared to dedicate up that automated questions encourage to 15 minutes to a survey completion of mobile surveys. via their smartphone www.cellohealthinsight.com