The Internet offers widespread access to health information, affording

The rapid growth of epharma consumers has created new opportunities to tap into well-defined online patient communications channels for pharmaceutical marketers of prescription drugs and those promoting clinical trials directly to patients. Liz Moench Nick Halkitis Duncan Shaw The Widening Divide Between Study Sites and epatient Recruitment A U.S. Perspective The Internet offers widespread access to health information, affording patients the advantages of interactivity, information exchange, and anonymity. Furthermore, social networking sites and online patient communities have proven fertile ground for people seeking peer-to-peer social support, sharing experiences, and empowering one another. Where the Trends are Taking Us Ten years ago, more than 50 million people in the U.S. sought general health information online; these people were labeled ehealth consumers. A smaller subset of individuals looking for prescription drug information (called epharma consumers) was considered early adopters. According to Manhattan Research, a New York based company that studies the health and information technology trends of U.S. consumers, the epharma consumer subset has tripled from approximately 30 million in 2002 to more than 110 million in 2010 (see Figure 1). In comparison, the growth of ehealth consumers (the predominant group 10 years ago) has slowed. 1 The epharma consumer segment is still showing strong growth, and is expected to comprise the majority of U.S. adults by 2012. (Note: Although this article focuses on the United States, where 77% of the population is connected to the Internet, web access in many other countries is roughly on par with the U.S. 2 ) The rapid growth of epharma consumers has created new opportunities to tap into well-defined online patient communications channels for pharmaceutical marketers of prescription drugs and those promoting clinical trials directly to patients. Patient recruitment firms and advertising agencies are therefore competing for the attention of the same epharma consumers. These consumers in turn are able to assess more easily their choices online, both in terms of marketed drugs and clinical trials. A number of factors are driving the growth of the epharma consumer population. Older consumers are increasingly using the Internet as a search tool, with prescription drug information of particular interest in this population. In addition, many people now take multiple prescription medications; in the current economic climate, epharma consumers are carefully considering their therapeutic options. Many cost-conscious consumers are heading online in search of money-saving coupons and/or free trials for treatments that have been approved by the Food and Drug Administration (FDA) (as shown in Figure 2), while other consumers intentionally or by chance seek out clinical trials that offer free study-related medical care and treatment. An online search yields numerous examples of money-saving coupons. S o l u t i o n s - B a s e d T e c h n o l o g y x 39

Figure 1 More Than 110 Million epharma Consumers in 2010 Millions 160 110 60 10 epharma Consumers More Than 110 million epharma Consumers Today 2002 2005 2007 2009 2010 Source: Manhattan Research, Cybercitizen Health v10.0 (2010) Figure 2 Examples of Coupons Available Online (In the public domain online, Pfizer s Relpax offers a $15 off voucher on a consumer s next prescription for migraines, while Cephalon offers a seven-day trial for Nuvigil.) Additionally, at a time when drug safety issues frequently dominate the news headlines, consumers are understandably nervous, resulting in more people going online to learn about drug side effects (see Figure 3). 3 When epharma consumers hear from their peers (via social media or medical websites) about a drug s side effects, they can become less likely to fill their prescription and more likely to return to their physician to ask for a different therapy or to continue researching online. At present, this dynamic is different for clinical trials, as information regarding drug risk is generally shared offline between the study patient and a study s principal investigator. However, such interchanges may well change over time, as patients increasingly share information online. As patient recruitment shifts from traditional forms of advertising to online, specialty companies with inhouse emarketing and social media expertise are getting smarter at optimizing online recruitment strategies, using management and tracking technologies to capitalize on the advantages epatient recruitment offers. Companies are now able to target even more specifically with online advertising than was ever possible with offline advertising such as newspaper, radio, and television. Patient recruitment emarketers target their advertising to a range of psychosocial patient characteristics (age, gender, interests, behaviors, income level, and medical condition), and geotarget to match the location of any given research site (not just within the U.S., but elsewhere in the world). Although offline media are still being used to recruit patients, it comes with a price. Audience fragmentation is decreasing the value of each television, newspaper, and radio advertisement. At the same time, the rise of digital advertising media (the Internet, cell phones, mp3 players, etc.) gives companies cheaper, more convenient alternatives. The Internet offers advertisers a high level of flexibility in presenting their messages to consumers at a 40 x Monitor June 2011

Figure 3 Online Information is the First Point of Call for Consumers Seeking Out Health Information and Health Answers Online A doctor A family member A friend with a similar condition/issue Other Nowhere/no one 2% 2% 6% 4% 3% 6% lower cost than traditional 30-second TV spots. In 2006, Google and Yahoo! increased their Internet advertising revenues by 107% and 95%, respectively, and they continue to grow along with companies such as Bing and You- Tube. 4,5 The rise in Internet advertising was accompanied by a decline in offline advertising, with advertisers looking for more innovative, lower cost alternatives. Many companies are using traditional offline advertising selectively supporting only highperforming study sites with a proven track record in patient recruitment. 15% 20% 25% 30% Female Male 0 10 20 30 40 50 % of respondents in each group Note: n=2,618 ages 18+ Source: ivillage, Women s Health Survey conducted by Harris Interactive, March 18, 2010 38% 49% erally found online media costs to be significant lower, with per-patient recruitment costs reaching just one-eighth those for offline advertising costs (see Table 1, comparing costs across therapeutic areas). 6 As a result, many companies are using traditional offline advertising selectively supporting only high-performing study sites with a proven track record in patient recruitment, as well as study sites with the capacity to screen a greater volume of patients as part of an integrated recruitment strategy to expedite recruitment to meet a faster completion date at the lowest cost possible. For site-based recruitment efforts, however, the shift to emarketing has come too swiftly for many, and the knowledge and skill set required to master the dynamics of a continuously changing online marketing environment have created a digital divide for research sites. 7 It is also human nature to default to what we know, and the world of digital advertising is foreign to the majority of study staff. The Internet is also starting to undermine the effectiveness of mining internal site databases to source potential clinical trial patients, with people in the U.S. increasingly accessing information online rather than going to their physicians. Healthcare utilization data have shown that insured Americans are now using fewer medical services. Although freestanding research centers continue to market externally to bolster their patient databases, this downturn in healthcare utilization is likely to affect community-based practices that occasionally conduct studies and must seek patients from outside their database to meet their enrollment goals. This trend is further driving sites and clinical teams toward emarketing. Following the Money and Marshaling Resources Most study grants include a stipend for local site advertising, with study coordinators given the responsibility for spending these monies effectively. In an online survey of study sites, the majority of local advertising monies provided by study sponsors is spent on placing ads in the traditional, offline media, such as print, radio, and television, a tactic that tends to require less time and marketing expertise. Local advertising in general does not leverage the power of the Internet, since the majority of site-placed ads or commercials only prompt consumers to call the site s phone number rather Clinical teams that have embraced emarketing as an integral part of their patient recruitment strategies have gen- Table 1 Average Cost Per Referral by Media Type and Therapeutic Area Sleeprelated CNS Study Study Diabetes Pediatric Study Average Radio $595 $379 $831 $601 Newspaper $664 $586 $770 $673 Online $175 $83 $321 $281 $215 x 41

ers, Manhattan Research found that almost half of the respondents watched health videos as part of their online health research, and that these videos strongly influenced their behavior. 1 Biopharmaceutical companies that are leading the industry in patient recruitment for clinical trials are applying video emarketing methods to their recruitment efforts, and are placing specific clinical trials videos on You- Tube. Patients are directed to the study website for more information and prescreening, and many people click through. Research shows that nearly 75% of consumers conduct additional information research after watching online health videos, 3 and recruitment results certainly bear this out. 6 Where Do We Go From Here? As online media continue to grow in breadth and influence, today s marketing revolution is in danger of quickly becoming tomorrow s digital divide. than providing a study-related website. Creating a study website not only gives consumers easier, round-theclock access to study-related information, it can allow potential participants to prescreen online (through a series of questions or a full prescreener), which in turn can save site staff time and further optimize the patient recruitment process. As patient recruitment increasingly shifts to online strategies, study coordinators cannot be expected to have the expertise required to maximize emarketing opportunities without assistance. Although some study sites have the advantage of dedicated marketing managers, most sites are simply not equipped to harness the full power of web-based media. Owing to the popularity and effectiveness of search engine advertisements, banner advertising, and social networking outreach, the digital divide of emarketing knowledge is likely to widen at a rapid rate, and most study sites are likely to find that they are getting left behind. Succeeding at online marketing is more than simple arithmetic. Instead, a team well-versed in web-based outreach must interpret various search engine analytics and be able to translate that information into a nuanced understanding of a range of search engine capabilities. Even details such as the direction in which advertisements are positioned on a web page can influence the effectiveness of outreach campaigns. An effective emarketing campaign therefore requires constant and daily attention from dedicated site marketing managers with a highly defined skill set for launching and maintaining campaigns. emarketing success also requires monitoring trends, since these trends drive online advertising strategies. As a case in point, in 2009, in its survey of more than 6,000 epharma consum- These emerging strategies call for a full commitment of resources and staff. Given the meticulous nature of tracking daily key-word costs, cost per click-through rate, and response rates to each online strategy (banner ads, social network ads, context ads, key-word ads), time-strapped study coordinators cannot be expected to deliver optimal marketing results without support. Many sites that attempt to try their hand at digital marketing with limited knowledge have discovered their folly with poor numbers and rapidly diminished budgets. emarketing for patient recruitment is about more than placing recruitment ads on craigslist (classified advertising on the web), no matter how simple and low-cost it is for study coordinators to do this and monitor the results. Other forms of online advertising, such as key-word advertising, are often not visible since these ads appear at different times and locations due to advertising rotations. As a result, the physical nature of offline advertising (that can be seen and touched) makes emarketing seem intangible and amorphous. Recruitment tracking systems that deliver live data streams of advertising response rates allow emarketers to constantly review and refine patient recruitment campaigns, but this is only possible with dedicated staff with time and expertise to interpret and respond to these data. emarketing is labor-intensive. In the digital world, it can take only a matter of minutes to refine a campaign to target a subset of a study s population by gender, age, and ethnicity, but it requires hours of daily analysis to interpret results and apply these to then deliver optimal results. Such flexibility and precision is not feasible with traditional media. With the ability to instantly adjust an emarketing campaign, digital media is truly dynamic. The quicker online performance data can be collected and applied to the online campaign, the higher the return on investment (ROI) and the faster the recruitment goals can be achieved. The digital divide separates those companies that are responsive to incoming data from those that lack the tools to accurately collect such information. Responsiveness is so critical to an effective recruitment campaign because each day requires a fresh approach. In fact, rapid-response practices such as keywords bidding have become commonplace, with the cost per keyword changing on a minuteby-minute basis. With such a rapidly changing cost base, regular monitoring and continual adjustment are vital to maximizing patient recruitment ROI. What distinguishes a skilled emarketing team from one with less experience is the interpretation of online advertising metrics, the intimate knowledge of the workings of the major search engines and social networking sites, the applied use of behavioral data of epharma and ehealth consumers, and the ability to understand the varied online advertising options. It is a time-intensive process, and digital marketers have a wealth of tools at their disposal. Using a variety of methods, such as predictive modeling, customized targeting, and daily tracking, 42 x Monitor June 2011

study sites can now take full advantage of the power of the web when they partner with dedicated digital marketers. Conclusion As online media continue to grow in breadth and influence, today s marketing revolution is in danger of quickly becoming tomorrow s digital divide. In the modern environment of shrinking study grants and increased workload, study coordinators will be set up to fail without the proper training or support for emarketing. Furthermore, if emarketing opportunities to recruit patients and accelerate clinical trial enrollment are not capitalized on, everyone loses, because study sites will fail to meet recruitment targets; biopharmaceutical companies will pay more for their clinical trials and reap a lower recruitment ROI; and patients who could have potentially benefited from clinical trials are never reached. Study sites need to start applying emarketing for patient recruitment so they do not lose out. There are several ways to achieve this; for example, sites can employ experienced emarketers or contract out to experts. Study sites and coordinators desiring to advance their search engine advertising skills should learn how to use analytical data to make online advertising decisions, and expand the reach into online networks; Internet courses can provide excellent training. Help is available to learn this new virtual and ever-changing world of digital marketing; it is never too late to start learning. References 1. Manhattan Research. 2010. Cybercitizen Health v10.0. 2. www.internetworldstats.com. 3. www.emarketer.com. Accessed 23 August 2010. 4. AdAge. 2006. Factpack. http://adage.com/images /random/factpack06.pdf. Accessed 23 August 2010. 5. http://worldofdtcmarketing.com/. Accessed 23 August 2010. 6. MediciGlobal emarketing case studies, as of 23 August 2010. 7. MediciGlobal survey of study sites and use of emarketing strategies. July-September 2010. Further Reading Grandinetti DA. 2000. Doctors and the web: help your patients surf the Net safely. Medical Economics April: 28 34. Bulkley K. 2007. The digital persuaders. The Guardian, 24 September 2007. Liz Moench is president and chief executive officer of MediciGlobal, and has spearheaded the enhancements of the company s online tracking systems and the applied use of instant performance metrics to maximize return on investment and optimize recruitment results. She led the first direct-to-consumer campaign in the pharmaceutical industry more than 25 years ago. She can be reached at lmoench@mediciglobal.com. Nick Halkitis leads the global emarketing team for MediciGlobal. The team seeks to reduce recruitment costs and accelerate timelines for study sites. He has been recognized by clinical teams for the effectiveness of his online recruitment campaigns, and was named as one of the 2010 PharmaVoice 100 for his global emarketing leadership. Duncan Shaw is account director in the European office of MediciGlobal, applying more than a decade of healthcare communications experience to the development of online programs to reach and inform patients about clinical trials, among other management and consultation duties across a range of patient recruitment and retention programs. x 43