Thursday, June 19, 2008

Electronic Health Records too Expensive

A survey sponsored by the Federal Government and the Robert Wood Johnson Foundation and published online by New England Journal of Medicine suggests that costs of adaptation of EHR (also called EMRs and PHRs and MDRs) by the medical community are a road block to wide adaptation of EHR. This is ironic since EHRs are supposed to cut costs from the health care system.

The detailed study briefly mentions that the number of years in practice was taken into account when analyzing the results, but does not provide detailed data broken down by this variable. It is highly probable that physicians in practice 1-20 years are much more likely to use EMR than those in practice 21-40 years and beyond. Older physicians are less computer savvy, were not “raised” on computers, and have a more difficult time adapting to EMR, e-Prescribing and even computerized practice management systems. Additionally, when younger physicians join a mature practice they are likely to push the senior physicians in the practice into a computerization process. As a result, the “4%” mentioned in this article may be innacurate if the doctors surveyed tended to be on the “older” side. is currently performing an online physician survey on the subject of EMR. The physicians who participate in our surveys tend to be more computer friendly, and our preliminary results indicate a much higher EMR implementation than the 4% mentioned in this article.

Some additional interesting data from our survey reveals that only 53% of doctors who purchased an EMR system find that it is of benefit to their practice efficiency and that it was worth the cost of purchase and maintenance. Only 50% of doctors felt that their EMR system helped them provide better care for their patients. (No wonder that EMR hasn’t taken off). 69% of physicians polled were in favor of having a secure and privacy-protected universal, online EMR system.

Interestingly, 11% of physicians have found that patients are asking for copies of their medical records for the purpose of posting them on line on systems such as Microsoft HealthVault and GoogleHealth. This could become a major new trend and indicates that Google’s and Microsoft’s strategies are working. (If this trend mushrooms, many doctors’ offices may be overwhelmed by fulfilling the numerous requests for copies of their medical records).

We will be posting the results of this June 2008 survey soon. To view our October 2007 survey on EMR and Healthvault visit this link.

Robert Cykiert, M.D.

Eye on Genentech: Similar drug, 40 times more expensive

Genentech is restricting the use of its cancer drug Avastin, which is also widely used for patients with wet macular degeneration. There is suspicion that Genentech is doing this because Avastin competes directly with its other wet macular degeneration drug called Lucentis. Avastin costs about $50 per dose and Lucentis costs about $2,000 per dose. You can read more about this saga that has drawn the attention of FDA and senate investigators at Jacob Goldstein's WSJ blog.

As an ophthalmologist, I have seen incredible results in patients who are being treated for wet macular degeneration with Lucentis and Avastin.

Most ophthalmologists and retinal specialists seem to think that the two drugs are equivalent, but there are some anecdotal reports that Lucentis may be the preferred initial treatment, and Avastin may work better for follow up treatments, since most of these patients need monthly injections of these drugs into their eyes. performed an online physician survey of ophthalmologists to find out what their preferences are. The December 2007 poll revealed that doctors preferred Avastin over Lucentis by a 2 to 1 margin. 84% believed that Avastin and Lucentis were equivalent medications, and 94% of ophthalmologists said that Genentech should not place any restrictions on the sale or distribution of Avastin to ophthalmologists or pharmacies that prepare Avastin for use by ophthalmologists.

Click here to see survey results.

We’re all awaiting the results of the NIH study to find out what’s best for our patients.

Robert Cykiert, M.D.

Friday, June 6, 2008

Pfizer's Failure to Communicate

The Wall Street Journal Blog by Avery Johnson reported that Pfizer invited the media, including the WSJ Health Blog, to a roundtable about Chantix at the company’s 42nd Street HQ. The purpose of the meeting was to send the following message regarding recent negative Chantix media reports:

#1 Smoking is a serious health problem that kills people.

#2 Most of the adverse events that have been reported recently are already in the Chantix label.

#3 Smokers who are trying to quit can be depressed and irritable.

#4 Paying close attention to adverse-event reports helps the FDA and Pfizer enhance drug safety.

As I noted previously, all of the Chantix-related side effects are also known to be associated with cigarette smoking and cigarette smoking cessation withdrawal.

I’m glad to see that Pfizer called a round table to clear up this issue with the media.

However, Pfizer needs to also communicate MUCH better with its physician customers since they are the ones who write prescriptions for Chantix, and have to face the anxious and nervous patients who read the worrisome media reports. The same patients that lead to the media reports!

Last time I looked, no one at the Wall Street Journal blog was writing scripts for Chantix.

Pfizer management needs to understand the physician communication concept much better or all the other Wall Street analysts will be following Goldman Sachs’ lead.

Robert Cykiert, M.D.

Thursday, June 5, 2008

I’d like to see Pfizer rate Goldman for a change

The Wall Street Journal Blog by Scott Hensley reports that
Goldman Sachs lowered rating of Pfizer stock from buy to neutral.

Let’s not forget that Goldman Sachs is down over 30% since November 2007 because of the mismanagement in the entire banking sector. If the Fed+Chase’s bailout of Bear Sterns had not occurred, then Goldmans Sachs' stock may have sunk far lower than Pfizer's.

It fascinates me to see how financial institutions and investment bankers rate stocks and trigger market fluctuations in that sector, that many capitalize on.

I’d like to see Pfizer rate Goldman for a change.

By the way, much of Pfizer’s Chantix problems, and other pharmaceutical company misfortunes can be attributed to spending more time with Wall Street analysts than they do with their most important customers--physicians.

Doctors wrote prescriptions for about $270 billion in 2007. They control pharmaceutical sales to a great degree, yet pharma tends to ignore them and not communicate well when bad news comes out about a particular drug or class of drugs. The failure to communicate leaves doctors to make decisions based on sometimes exaggerated or sensationalized media reports rather than science from the drug manufacturers. The classic example is the recent Vytorin debacle which we’ve written about here.

The pharmaceutical sector will come back most likely sooner rather than later since health is the most important thing to humans, and advances made by pharma are responsible for much of our good health and extended longevity in recent decades. Clearly there is much more work that needs to be done.

However, I don’t think we’ll need to see the government bailing out Pfizer.

Robert Cykiert, M.D.

Putting the cart before the horse

Wall Street Journal reports that congress is working to force doctors to switch from hand-writing prescriptions to using new digital technology referred to as E-Prescribing.

E-Prescribing like all e-Things sounds great until you try to implement it. The problem with e-Prescribing at this time is that there is no one standard that doctors can adhere to, and no assurance that current platforms and protocols will persist.

One of the main reasons that physicians are not buying into electronic medical records is that they do not want to make a huge initial investment, pay for maintaining the system, and invest huge time in training staff only to find out that the government or some insurance industry group changes the standard in a year or two making their expensive systems obsolete.

A minority of physicians already have e-Prescribing in place, but it has limited value for the patient because the doctor’s system is tied to their office, and current pharmacy that the patient uses. If a patient goes to another doctor or switches from Rite Aid to CVS, then all the e-Pharmacy-Records become worthless.

Ideally, as with electronic medical records, there should be an online, universal e-drug-record that is accessible to all treating physicians, pharmacies and hospitals.

Bottom line: before the government mandates e-Prescribing and penalizes paper-prescribers, it should set a standard.

Robert Cykiert, M.D.

Monday, June 2, 2008

Another failure to communicate with Doctors

In a Wall Street Journal Blog, Jacob Goldstein talks about Anemia drugs sold by Amgen and J&J (Aranesp, Procrit and Epogen) that may stimulate the growth of tumors in some cancer patients. Research suggests a genetic link that could potentially be used as a biomarker to figure which patients should and should not receive those drugs.

At the end of the WSJ article, Goldstein quotes Tony Blau, the lead researcher who said that “The definitive answer to this question lies locked in the files of pathologists’ offices.”

What a shame.

If drug companies had better communications with doctors, research on what works and what does not could be significantly enhanced. performed a February 2008 online physician survey of oncologists and hematologists on the subject of Aranesp, Procrit and Epogen prescribing practices. See detailed survey and results.

65.6% of doctors agreed that certain dosages of these drugs resulted in more rapid growth of certain cancers and a decreased cancer survival rate. Consequently, about 66% of doctors have either reduced the dosages they prescribe, or reduced the number of patients they prescribe the drugs to, or reduced drug usage in certain cancer patients.

Amgen and Johnson & Johnson should do more prompt research on this issue and get answers as quickly as possible since many doctors are clearly nervous about using these drugs. Ironically, the answers are probably "locked in the files of pathologists’ offices."

The longer doctors are kept uninformed, the more likely they will be influenced by media reports as opposed to science, as occurred in the Vytorin debacle. See Analysis of Vytorin Surveys.

Failure to communicate promptly and effectively with physicians will certainly cause further erosion of sales of these drugs, as is occurring with Vytorin.

Robert Cykiert, M.D.

Yogurt for everyone except doctors

As a sign of our times, the Wall Street Journal blog
noted that Eli Lilly had a white sign at their Oncology meeting in Chicago with the following message:

Food, beverages and/or meals will not be provided by Eli Lilly and Company for the following parties:

* Physicians and individuals with prescribing authority in Minnesota in order to comply with Minnesota statutes

* Government employees in New York (both city and state) in order to comply with New York statutes

Particularly tempting was the frozen yogurt that everyone could have except Minnesota doctors and NY government employees.

Lilly’s sign prohibiting free frozen yogurt to MN doctors is a clever way to make a point, tongue in cheek. Free pizza, and other trinkets have no effect whatsoever on physician prescribing patterns since doctors receive the “gifts” from all the companies. Therefore, no one company has an advantage. If you ban all trinkets by all companies in all states then the pharmaceutical companies will simply divert those marketing funds to things like DTC, eDetailing, and online sponsorship of CME courses. A much better way to deal with pharma gifts to doctors is to require all medical companies to post all gifts on their public web sites. The transparency will keep everyone honest. performed a December 2007 online physician survey of 290 doctors in various specialties to determine their views on medical company marketing to doctors. Click to view survey.

While 40.5% of doctors agreed that medical companies shouldn’t give any gifts, 71.6% said that doctors are not influenced by these small gift items. It seems like detailed public posting of all gifts with specification of doctor recipients would keep everyone honest. I checked Lilly’s web site--don’t see the frozen yogurt listed there yet.

Our publicly posted surveys are performed on randomly selected physicians, the doctors fill them out voluntarily and are not identifiable, and are completely anonymous. Therefore, the doctors have no incentive or advantage to give false or misleading answers in the survey. Doctors then read our publicly posted surveys to see what their colleagues are thinking on major issues in healthcare. It’s one of the few effective ways that doctors can take the pulse of their colleagues on controversial issues that affect their livelihoods and affect patient care.