Interview with Donato Tramuto, Physicians Interactive (transcript)

Earlier this month I did a podcast interview with Donato Tramuto, President of Physicians Interactive. Here's the written version, lightly edited.David Williams: I'm David Williams, co-founder of MedPharma Partners and author of the Health Business Blog. Welcome to the first episode of the Health Business Blog's podcast series.Pharmaceutical sales and marketing field is changing fast. Sales people are finding increasingly difficult to get time with physicians; even then their messages are being treated with increasing skepticism. Tight formularies, evidence based treatments -- they are all reducing physicians' discretion in what they prescribe. Plus an increasing number of docs won't see sales reps at all. But pharma companies still need to get their messages out to physicians. Increasingly they are embracing web based solutions.I spoke earlier today with Donato Tramuto, President of Physicians Interactive Group. This company develops internet portals and enables pharma companies to engage physicians online in new ways.Donato Tramuto: David, thank you very much for having me.Williams: What is Physicians Interactive ?Tramuto: Physicians Interactive is a relationship management platform, augmenting the efforts of sales reps in the pharmaceutical industry. With physicians using the Internet more today and being able to identify --at their leisure-- how they want to access information, this is an opportunity to augment and take advantage of the Internet world.Williams: If I were a physician how would work? What would I see?Tramuto: We work with pharma [to] create the portal and develop the content and information. A physician would be invited through the portal and would be able to access e-detailing [and] e-learning at their convenience. And as it gets more difficult to access physicians via the traditional pharmaceutical route it’s a great opportunity to bring information to them at their convenience.Williams: Now when you talk about e-detailing, can you tell me what detailing is? And then, what is e-detailing?Tramuto: Sure. But let me segment this in two ways because we don't see ourselves simply as an e-detailing organization. E-detailing obviously it's kind of explained in its own terms. It's really taking your traditional ways in which you get information to the physician with onsite pharmaceutical representatives [and making it electronic]. This is another route of getting product information to the physicians. Pharmaceutical companies have done a great job managing products. I think that the tide is changing now [to] managing relationships. We have developed a software platform that will allow you to drop in various programs like e-detailing, e-sampling and speaker programs.Williams: Are your customers physicians or are they pharmaceutical companies?Tramuto: If we stated in a direct fashion, certainly yes the pharmaceutical companies, the brand managers... One of the things that we pride ourselves on within Physicians Interactive and AllScripts is our relationship with physicians. We understand the value of those relationships. We understand clearly the behavior of those physicians and so it's a dual management process, managing effectively our direct customers, the pharmaceutical and then also managing the understanding of physicians' behavior.Williams: If I were a physician and wanting to sign on and get some educational materials and maybe access e-detailing and sampling, do I have access to kind of a wide array of products and services or is that determined by the pharmaceutical companies?Tramuto: Basically it's defined by the pharmaceutical organization. There are some pharma companies that will start with one product and then what we do is, with our physician reach and our e-mail addresses, which have been validated with physicians to participate in this, we will send that invite out to the physicians. There are other cases where the pharma organization would like to have two or three products involved in the platform and the unique part about what we have is that it's not limited; you don't need a separate platform for a new product. You can drop different products into the system and then it would take on the traditional invitation to the physicians.Williams: I think I understand e-detailing: an electronic version of a traditional detail. But what does it mean to have a sample online? Obviously a sample is a physical thing.Tramuto: This is not our area of expertise right now but [we] are aligning with other organizations that have done a very good job in fulfillment of samples. With the platform you can drop many of these different services [in]. If you have the physician's attention now through the e-Detailing program could you then have access to their ordering samples and following the regulatory requirements to fill those samples electronically?Williams: I know that the reps often use the samples as their currency, as a way to get in to see those physicians who might not otherwise see them except for the samples. Is there a possibility in that case that the physicians may say, "Well, I am actually just going to get the sample electronically and I won't see the rep." I'm just wondering how pharma companies might feel about that.Tramuto: Let me kind of reverse that. What we have found is that you have that category of "no see" physicians, that regardless of what you try to do it's going to be difficult to see them. We feel that in that case we have a tremendous opportunity to reach them in ways that traditionally would be more difficult. Our experience is that even then in that other category where you have physicians who have for some reason elected this time around to access an e-Detailing program, it has not been our sense that they no longer see the representatives. It's an augmentation to what has been traditionally presented to them. You need to kind of separate out the categories. With the "no sees" this is a great vehicle to do something different, but for those physicians who are in fact seeable, this is a great way to augment those times when you just can't get in there.Williams: I have always been a little surprised that the pharmaceutical companies expend such a great emphasis on the top decile physicians and work hard to see them even if they are difficult to see. Then a rep may walk by two or three or four mid tier physicians. Is this just one more way to reach those top decile physicians and the no-see physicians. What about the moderate prescribers who might not see reps much today, is this tool for them?Tramuto: Well it's an interesting question. I think it predicates down to a recent study by Manhattan research. We are recognizing today that 74 percent of all US physicians are using the internet and are likely to access pharma information and services online and in that same study they are indicating that this is likely to increase to about eighty-four percent by 2010. Thirty-eight percent of those physicians agree that they change their behavior as a result of that Internet access. So regardless of how you segment this: high prescribers, moderate prescribers or low prescribers there is a recognition that the Internet is playing a significant role in how physicians access information. Certainly you can target it in the same way that you have just identified. However, I think the greater opportunity is to align the market to the way physicians or patients are accessing information.Williams: Another question is less on the information side and more on the administrative side. I have wanted to schedule appointments with physicians using the Internet and they don't seem terribly open to it. I also have heard about the companies that are trying to use technology to allow physicians and reps to coordinate appointment times when the rep is coming in. Is that piece of functionality that you either have or are considering?Tramuto: Very interesting. We don't have that yet, but I thank you for the idea. In my mind there are two aspects that are really driving the change right now: the evidence based medicine trend and the consumerism trend. [These trends] are intersecting . Whatever we can do to make it more convenient for the physician, certainly there is a tipping point occurring right now. Physicians are recognizing the value of electronic scheduling, they are recognizing the value of electronic detailing and I think that that's only going to escalate, if you look at the traditional methods of how consumers now access information. There has been a tidal wave. My 90 year old aunt is on the chat room, talking to different people about diabetes. So I think consumers are moving physicians in that direction and I think this whole e-scheduling is intriguing and something that I think we will probably take on over the next year or two.Williams: You mentioned that Physicians Interactive is part of AllScripts, which I think of as an electronic health record and e-prescribing company. Can you talk about the linkage there, because it sounds like some of what you are describing Allscripts is fixing with the digitization of the physician office.Tramuto: I think that there is a great linkage there. What AllScripts has done so very well is that they have developed a very, very successful model around physicians' relationships and how you really help physicians to optimize their performance. If you look at Physicians Interactive, while our paying customers are in Pharma, what really becomes valuable is how we understand physician behavior, how we understand what kind of information they are interested in. We can align our understanding of what physicians want, so that we are not wasting their time. So that we are giving them valuable information that really delivers high quality, cost effective care. The more we understand, that relationship, the more we bring value to any constituent in health care. If we do agree on the two trends of health care: evidence based medicine and consumerism, I think one would argue that the next big opportunity for us is really understanding how consumers make decisions, what are the data points and relationship building points that they are gong to require.Williams: Would that actually extend all the way to having the portal functionality available to the consumers?Tramuto: That's an interesting question, David and one that I would say would not be out of the realm of our kind of strategic consideration.Williams: And what about evidence based medicine? Is there any conflict between your working for the pharmaceutical company on the one hand and talking about evidence based medicine on the other?Tramuto: I don't think so at all. There is a tremendous gap in the kind of information that should be provided to the physicians and in many respects pharma companies are recognizing that they need to really be focused on health and not health care. If you look at health care as a whole, historically it's been kind of an agglomeration of outsourcing of different pieces. You outsource the pharmaceutical piece or you outsource the hospital piece and none of this data has come together in a way that could really help physicians and providers make the right decisions. I think that pharmaceutical companies [can] play an incredible part.Let me give an example here. A number of years ago, when I was heading up Protocare, my own company, we had done a study to really look at what was driving the various costs in pharmaceutical care. And there had been this kind of historical belief that inflation was causing the high increase in pharmaceuticals. And what we found was actually no, that if you took for example the field of asthma, that actually asthmatic cost went up, prescription cost went up, because there was a promotion with physicians to use more corticosteroids, which would help to prevent an asthma attack. Now how do we know that we should do that? Well, better signs and better medicines through the information helped pharmaceutical companies realize that taking your corticosteroid every single day as an asthmatic patient would help to reduce the hospital cost and would help to reduce the emergency cost. So pharmaceutical companies play a huge role in understanding the value of what a pharmaceutical agent can do in that specific case of asthma.If we know that hospital cost and emergency room cost can go down by taking a product, I think it's incumbent upon pharmaceutical companies and all stakeholders to work together to get that information out in the marketplace. Pharmaceutical companies have to be willing to step up to the plate. And if in fact, the data shows that this drug agent doesn't have value, then you have to be willing to take a step back and say, "Okay, in this case it's not going to be valuable for my product." However, in those cases where you do have good information, I think we need to do more promotion of it. For me, David it's the only that when we look at the 44 to 47 million Americans uninsured, it's the only way as we look at evidence based medicine, we can define what works in the right population and the right setting. It's the only way that I think you are going to reduce the cost, and free up those funds to bring in those who are uninsured. And pharmaceutical companies pay a huge role; they obviously have great relationships with physicians. They are going to have to be willing to have the discipline in place to say, the evidence doesn't show or support my product and you have to be willing to say you move on to where the products have value.Williams: One of the things that I am sure you must be talking about with your pharmaceutical clients is the area of medication adherence, because in the sort of examples that you are describing it's sort of win-win in that the pharmaceutical company is obviously going to drive revenue from the patients using a drug effectively and using it over a long period of time and the system is going to save money and there is going to be a healthier outcome. But adherence has been a slippery topic, hard for people to really make progress on. Is it something that you are addressing and are there ways that your service is actually effective there?Tramuto: If I may go back to my asthmatic example about the corticosteroid, here is a great example that supports your question. By the way, I am an asthmatic patient and I am a very poorly compliant patient. You know, I am in the health care field and I know right off the bat that if I were to take my corticosteroid every single day, I most likely would reduce my attacks and would stay out of the hospital, and would most likely not be thrown into a serious event...Williams: Is this the health care system's version of the cobbler's kids going out without shoes?Tramuto: There you go, you have it. In that case when we did our study in 2000, what we found is that less than five percent of the population who were asthmatics were taking their corticosteroids, so in that case, what is the problem? Here we have good medicine and good science that supports it. Here we have physicians who recognize it, and understand it. But where the message is lost is with the consumer and I think yes, to your point, I think we have a huge opportunity now to really get information on why consumers don't go to the pharmacy or when they do go to the pharmacy and they get it filled and they only take it once what are those behavioral trends that we can understand?Does it help the pharmaceutical companies? It depends from which lens you are looking at that. I would say when you mentioned the word health care system, if I were to look at it from that lens I would say, "Wow!" If I have more people taking their medication, then that means a higher cost, which is hospitalization and the physician visits and the ER visits go down and we have basically quantified that there is about a $180 per asthmatic per month savings when they take the corticosteroids. Yes the drug cost goes up, but there is a $180 per month net savings per asthmatic patient if in fact they take it consistently and we keep them out of the hospital. We have to work together as stakeholders to understand the system's benefit and not necessarily look at it piecemeal.Williams: One of the stakeholders that I didn't hear you mention explicitly although I am sure you have them in mind is the health plans.Tramuto: In the health plan field, there is a clear recognition now of the need to look at integrated data and that's really what the evidence based medicine model will do. If you look at a health plan, historically it's been in an agglomeration of outsourcing. You outsource the pharmacy to the PBM, you outsource the physicians to a physician group, the hospital groups and so each entity is watching their dollar. There is now, of course, a very significant push to integrate all that information and understand where the value points are and what's working and what's not and how to define the plan based upon those evidence points.Williams: What can you tell me about where Physicians Interactive stands in terms of how much progress you have made in the market. How widespread is the portal, how many users, how many customers do you have?Tramuto: By way of history, the concept of the platform portal was introduced about a year to 16 months ago. Since that time we have had five partnerships. We are seeing a very, very, very strong interest to really augment the sales force by these kinds of portals. So we remain very, very pleased with the progress to date. Having five key relationships is a very good marker of success and we anticipate this year that we will add another four to five customers to this strategy.Williams: As a final question, What do you think might be significantly different five years from now? Is there going to be a continuation of current trends or will there be some sort of discontinuity that you will expect in the market?Tramuto: I think I will go back to my original position that evidence based medicine linked with physicians and consumers [will be key] and for the pharmaceutical arena, I think there is going to be much more of closed loop marketing and approach. What I mean is understanding clearly the behavior of the customers that they are serving. And there is going to be a trend away from, just knowing your product. You really need to understand relationships and the constituents you are serving. And that places us in a unique position because as we learn and experiment and gain the understanding with the physician portal we intend to transfer that over to the consumer segment. So that we are understanding both constituents and ensuring that they are getting the kind of information that can help them make good and intelligent decisions and at the same time being able to give them the advantage of accessing that information at their convenience. That's managing relationships. I don't see that trend changing at all.Perhaps one I would add: there is going to be a greater need for measurement. And how do we measure? I gave you the example of the asthmatic patient. Which plan would not be willing to step up to the plate when you, in fact, can demonstrate that there is about a $180 per month savings per asthmatic patient when you use a drug agent that will keep patients out of the hospital and keep them out of the ER? Those are the kinds of data points and value added information that I think is going to really disrupt the market, so that we are in much more of a physician/consumer centric mode with information that can measure the outcomes and measure the results.Williams: Donato Tramuto, President of Physicians Interactive group thank you very much for joining us. I know I learned a lot from this discussion and I am sure the listeners could say the same.Tramuto: Thank you very much David. It was a pleasure to be a part of this.