Introduction
Doctors are familiar with pharmaceutical advertising in professional journals and newspapers, as well as with direct marketing by pharmaceutical representatives. Such advertising serves not only to inform prescribers about new products and new or changed indications for existing products, but also to promote the sales of the products. There is a wide range of opinion on the effects of pharmaceutical advertising, with long-standing opposition in some quarters pitted against ready acceptance in others. This situation is mirrored by some of the conflicts inherent in Australian pharmaceutical industry policies. The Commonwealth Department of Health and Aged Care (DHAC) seeks to control the cost of the Pharmaceutical Benefits Scheme by co-payments, premium brand pricing and authority prescriptions, whereas the Department of Industry, Science and Resources works to promote the profitability of the pharmaceutical industry. Other conflicts have arisen by accident - the government was a founding shareholder in Heath Communications Network (HCN) which has recently acquired one of the prescribing software companies which uses advertising.
The market
General practitioners are increasingly using computer software for accounting, prescribing and medical records. The development of computer technology has encouraged efforts to develop clinical systems to do more than prescribing. However, because of the limited number of users of clinical software, there have been problems with the viability of medical software companies. Until recently there have been no incentives for the use of clinical software, other than the potential for improved patient care. Doctors even had to purchase special prescribing paper for their computers whereas the printed prescription pads were provided free of charge by the Health Insurance Commission (HIC). Medical software companies faced with increased costs could put up the prices of their products, abandon research and development for product improvement, or find supplementary sources of income. Advertising was one such source. Two of the three largest prescribing software suppliers have allowed pharmaceutical companies to advertise on screen. This has enabled the software companies to develop and supply their products at an affordable price.
Current trends
The use of prescribing software by general practitioners is increasing with the provision of specific payments for users under the Practice Incentives Program (PIP) of the DHAC. The increased number of users will perhaps allow software suppliers to be less dependent on advertising. According to personal communication with one source within the DHAC, it has been proposed that the PIP payments might eventually be made subject to the use of approved software not containing advertising. However, there may be a continued role for advertising which meets new, yet to be decided, standards.
Advertisements were shown to be effective some 17 years ago in promoting better quality antibiotic prescribing.1 Perhaps this strategy could be used in computer prescribing. As consumers will (and should, according to an expert general practice computing group) view the screen during the consultation, any regulations should take the educational potential of computers into account.
Advertising in prescribing packages
Currently two of the three main prescribing packages contain advertising. One package has full-screen advertisements which are displayed after the choice of drugs has been made and the print button is pressed. The other package has smaller adverts approximately 10 x 4 cm (about 12% of the screen). These are present in the drug selection area of the program at the top right-hand corner of the screen and are changed several times per minute. Neither of these programs has any linkage of the advert to the drug class or the patient's condition.
Potential disadvantages of advertising
Using a computer in the prescribing process can improve the quality of care through improvements in prescription legibility, interaction checking and patient medication management.2 Advertising may negate many of these benefits because of the new ways in which it can appear in a prescribing package. The obvious important issue is the degree to which advertising in prescribing programs influences the prescribing decisions of the doctor. For quite some time, normal print-based advertising has been known to influence prescribing. What is new about computer-based advertising is that it is much closer to the act of prescribing. The adverts may be much more effective from the advertiser's point of view, by being activated when the decision to choose one drug over another is taken. This is analogous to point-of-sale advertising. Linking advertisements to the patient's condition or to the class of drug being chosen is technically feasible. Previous versions of some prescribing software have included these links. Accurately aimed advertising probably increases its effectiveness.
The advertisements appear on screen during the consultation so the patient will also view the advertising. This might result in embarrassment for the patient and doctor if, for example, sexual themes, as used in some print-based adverts, are used to promote treatments for sexually transmitted diseases. Patients are not equipped to critically view advertisements claiming breakthroughs in treatment, or those that are visually appealing and may unduly influence the interaction between doctor and patient. The presence of inappropriate material may damage the credibility of the doctor if they seem to be receptive to advertisements.
Industry self-regulation
The Australian Pharmaceutical Manufacturers Association (APMA) has developed a code of conduct for drug advertising. This code has recently been redrafted to include product advertising within computer software.3 Both the government and the software industry have contributed to this redrafting. The pharmaceutical industry has been allowed to retain control of advertising because of its willingness to self-regulate. The redrafted code could have set stricter controls on the advertisements which can be screened by member pharmaceutical companies.
A stricter code might have:
- limited the content of adverts to include only the brand and generic names and no other information
- excluded advertising from parts of the program where the patient record was opened, thus removing the direct intrusion of advertising into the clinical decision-making process
- banned the linking of advertisements to any special characteristic of the doctor, patient demographics or characteristics, or drug or drug class considered by the doctor.
In contrast to the pharmaceutical industry, few of the professional medical colleges have developed codes of conduct governing the use of electronic prescribing programs that contain advertising.
Conclusion
Pharmaceutical advertising has supported the availability of high quality software at lower prices. The need for this support has however hindered the ability of smaller players to compete on a level playing field, as they have been less able to attract advertising and hence have had less capital to devote to product development. While it is difficult to predict what effect any restriction on advertising might have, it may cut off smaller developers from this source of badly needed income. The DHAC is currently investing millions of dollars through the PIP to promote the use of computers. It should take care not to inadvertently reduce the industry to a monopoly through poorly conceived interventions. This might occur if the larger developers are allowed to overtake the others because of the money they receive from the pharmaceutical industry. There is currently an opportunity to ensure that any advertising at the point of prescribing is controlled and does not overwhelm unbiased drug information and clinical guidelines.
