PDAs are lifesavers for doctors, med students

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By Jennifer Couzin

(IDG) -- It's the middle of afternoon rounds in the intensive care unit at Stanford Medical Center when the attending physician asks third-year medical student Nate Evans to order a dose of the antibiotic Cipro for an elderly patient. Evans plucks his Palm from his coat pocket, taps it a few times, then scrawls dosage instructions on the chart hanging at the end of the bed.

A few minutes later, in a room down the hall, the intensive-care staff is arguing about a patient's course of treatment. Evans consults his Palm again and announces confidently, "The patient was extubated on the 13th."

Like medical students everywhere, Evans and his classmates at Stanford Medical School have stethoscopes slung around their necks and textbooks weighing down their bags. But they also carry personal digital assistants in their pockets. All first- and second-year Stanford students are given brand-new Palms loaded with study materials, class schedules, and drug and disease databases. With the handhelds, Evans and his fellow M.D.s-in-training can look up patient records and drug dosages in seconds - while they're bedside -- rather than poring over messy charts or thick manuals after rounds.

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At med schools across the country, PDAs are becoming an integral part of medical training. While handhelds are not widespread among practicing physicians, the technology will benefit doctors, nurses and patients. And they're not the only ones. Drug companies think that a doctor toting a handheld device could be a great marketing opportunity. So they're working with software firms to put their drug ads directly on those PDAs. But the experiments are kicking up controversy, worrying those who think that Big Pharma's marketing efforts already exert too much influence over medical practice.

The drug industry last year spent $9.3 billion marketing to doctors, nurses and physicians' assistants, according to Scott-Levin, a health consulting firm; by comparison, drug companies spent $2.5 billion reaching consumers. Those investments are apparently paying off. The five drugs most commonly pitched last year -- Celebrex and Vioxx for arthritis; Claritin and Allegra for allergies; and Lipitor for high cholesterol -- each brought in more than $1 billion in revenue, and together grossed more than $14.5 billion.

Some of that money paid for traditional forms of marketing -- advertising in journals, presentations at medical conferences and "detailing" (sending drug reps into doctors' offices to chat up the staff and drop off samples of the latest pills). But some of those dollars - drug companies won't say how much -- were spent testing marketing programs that target doctors' handhelds.

Those experiments take many forms. Aventis, which makes Allegra and other drugs, is looking into e-detailing: Instead of physically visiting doctors' offices, drug reps would make their pitches via real-time video streamed to handhelds. AstraZeneca, maker of the blockbuster drug Prilosec, signed a three-year agreement with tech firm ePhysician; the deal allows doctors to communicate directly with AstraZeneca -- and vice versa -- using ePhysician software. Other companies are testing ads that pop up when a physician writes a prescription on a PDA. Some firms are opting to keep it more subtle, offering downloadable research reports and insurance coverage information for their drugs.

EPocrates, which supplies the drug databases for Stanford's PDAs, is trying out several approaches. For starters, the San Carlos, Calif., company makes its databases available for free on its Web site; anyone with a Palm can download them. Drugmakers pay ePocrates to put marketing messages in front of users when they update the software. "It's a paid message, not an ad," says John Voris, CEO of ePocrates, emphasizing that doctors can opt not to read these "docalerts."

EPocrates is also testing a variation on the Stanford program: The company buys machines directly from Palm, which loads them with ePocrates software and stamps them with the ePocrates logo. EPocrates then lines up sponsors, which pay to put the Palms in the hands of select physicians. Eli Lilly, for example, recently underwrote a giveaway to 1,000 endocrinologists; Bristol-Myers Squibb is running a similar pilot program targeting a couple hundred cardiologists. Recipients get summaries of journal articles and information about the sponsor's drugs; sponsors get a highly focused audience for their marketing.

That targeting is what makes handhelds such a tempting marketing venue. Physicians are already bombarded with ads in medical journals and reference works. But PDAs give drug companies an unprecedented opportunity to get in front of the right doctors at the right time -- when they're on the job. "You can potentially control what the physician writes," says Richard Evans, an analyst at Sanford C. Bernstein.

One form of handheld medical software has remained ad-free. Interactive formularies -- from Allscripts, PocketScript and other vendors -- let physicians order prescriptions directly from their PDAs. Doctors choose a drug from a pull-down menu; the handheld then wirelessly beams the script to the pharmacy. Drug companies would like nothing better than to make sure their products get preferential placement in those formularies. So far that hasn't happened, perhaps because drug vendors know such manipulation could backfire. "We can't ever have the doc think the device is biased in one way or another," says Steve Burns, the founder of PocketScript. For its part, Allscripts has declined to sign marketing agreements with pharmaceutical companies, though CEO Glen Tullman won't rule them out. "Few of the large pharmaceutical organizations have not approached us."

Some in the medical community are skeptical about anything that helps drug companies insinuate their marketing efforts further into the doctoring process. "There's no way we're going to be hooked up with Palms that are hooked up to pharmaceutical companies," says Al Fisk, medical director of the Everett Clinic in Everett, Wash. It's not just the Palm giveaways he objects to. His clinic -- with nine locations and about 185 doctors -- took the unusual step of banning drug reps from its premises three years ago.

Indeed, many believe that pharmaceutical marketing is already out of hand, with or without PDAs. Says internist Robert Goodman: "The literature suggests that when physicians practice on the basis of promotion, they prescribe expensive and inappropriate medication." Goodman grew so tired of drug reps dropping by his office at New York's Columbia Presbyterian Medical Center that two years ago he founded No Free Lunch. The organization's goal: to get doctors to support a pledge promising to refuse money and gifts from drug companies. So far, he's signed up a couple hundred physicians.

The federal government keeps an eye on pharmaceutical marketing generally; already this year, the Food and Drug Administration has sent out 30 warning letters to drug companies for a variety of marketing violations, on the Web and elsewhere. But the handheld market is still too young to attract much federal scrutiny.

For now, it looks like drug companies may have found the perfect medium for reaching their market. Already, med students wonder how anyone managed without a PDA. Fresh from a morning class, second-year Stanford student Ritu Gupta shows off MedMath, a program that calculates things like water deficit and basal energy expenditure. The formulas are complex, at least as wide as the screen, but the software makes it as simple as addition on a calculator. No one really knows these things off the top of their head, says Gupta. "You have to go and look it up after you see the patient. This makes the process so much easier. Tap, tap, and there you have it."

Elizabeth Krieger contributed to this report.