The American Medical Association has launched a Web-based continuing medical education program in which physicians can obtain guidelines on best practices for specific conditions.
In addition, physicians will get a look at data gleaned from electronically gathered prescription drug sales, administrative insurance claims and the AMA's own database of physician information so they can compare their prescribing choices with the prescribing patterns of their peers both nationally and statewide.
The program is centered on a new quarterly online newsletter, Therapeutic Insights, that incorporates market information for prescription drugs compiled by healthcare data-miner IMS Health, Norwalk, Conn., including data in which diagnoses and prescription information are combined.
"The goal of the project is to improve the quality of patient care by increasing physicians' knowledge of the latest scientific evidence on the use of drug therapies, as well as providing insights into physician prescribing patterns," according to Edward Langston, chairman-elect of the AMA board of trustees, in a news release.
The most recent AMA collaboration with IMS Health comes as the physicians' organization continues to seek a balance between some of its members' discomfort with data-miners and its own lucrative relationships with data-miners and their pharmaceutical industry clients.
The AMA has long sold access to its comprehensive database on more than 650,000 U.S. physicians, called the Physician Masterfile, to data-miners, or what it calls health information organizations, or HIOs.
Physician Masterfile data is used for credentialing but also for pharmaceutical marketing campaigns and it is that latter use that has been at the center of a long-standing controversy within the organization.
In 2002, for the eighth consecutive year, a resolution came before the AMA's ruling body, its House of Delegates, asking that the AMA do what it could to prevent the pharmaceutical industry from obtaining access to physician prescription information to compile profiles of physician prescribing activity. The resolutionas were all seven previous versionswas voted down at the advice of AMA leaders who said the loss of revenue would hurt the association. Attached to the resolution that year was a note saying the AMA made more than $14.6 million annually from licensing data in the Physician Masterfile.
The AMA does not break out how much money from its database sales comes from pharmaceutical data-miners, but in its most recent annual report, the AMA noted that database sales, which include data and credentialing products and licensing royalties, had increased 10% to $44.5 million in 2005, up $4.1 million over 2004. In comparison, the AMA reported $280.1 million in revenue in 2005 and $38.5 million in profit.
In recent years, the AMA has taken steps to alleviate physician anxiety about detailers using a physician's own prescribing data against them. To get a handle on physician concerns, the AMA commissioned a Gallup Poll of 5,000 randomly selected physicians and learned that 77% of doctors were aware that pharmaceutical companies have access to their prescribing data, the AMA reported.
The poll showed, according to Langston, that "a vast majority of physicians (84%) indicated that either they weren't concerned over the release of their prescribing data, or their concerns would be alleviated if they could choose to 'opt-out' of having their prescribing data released to pharmaceutical sales representatives."
"Based on the results of the Gallup Poll, the nation's grass-roots physicians passed a directive instructing the AMA to create the Physician Data Restriction Program," Langston said. "Physicians representing the nation's 177 medical societies met in a grass-roots democratic forum in December 2005 and voted unanimously on a mandate that instructed the AMA to give individual physicians a voice in how their prescription data is to be used."
In 2005, the AMA launched the restriction program in voluntary cooperation with the pharmaceutical industry.
Under the program, pharmaceutical executives will still have access to physician prescribing data on specific physicians, but front-line pharmaceutical sales reps and their sales managers will not. About 7,700 physicians have signed up for the opt-out program thus far, with about 100 new physicians added each month, according to an AMA spokesman.
IMS Health is a purchaser of AMA data, a company executive confirmed. The publicly traded company reported sales of data products and services of $1.96 billion in 2006 and net income of nearly $316 million. The bulk of IMS Health sales are to the pharmaceutical industry to assist it in the marketing of drugs.
The first Therapeutic Insights newsletter addresses the diagnosis and treatment of migraine headaches in adult patients. It contains IMS Health data on the market share of each of seven drugs in the triptan family of medications commonly prescribed for migraine treatment.
The newsletter also contains a chart showing the distribution of the diagnosis of migraine with eight common co-morbidities, or concurrent diagnoses of other medical conditions. Another chart shows the percentages of patients diagnosed with migraine headaches who were treated with prescription drugs (36.8%) compared with the percentage who were similarly diagnosed but not given a prescription (63.2%), based on "a national medical claims database."
Two pie charts depict the most commonly filled prescription drugs for migraine and their market share nationally, and by the state of the physician receiving the online newsletter.
The AMA is funding the first phase of these reports as a member service with IMS Health supplying the prescribing data, according to an AMA spokesman. A second phase of the program, to be funded by IMS Health, is planned in which a physician can access his or her individual prescribing information for the conditions covered by the reports, according to the AMA.
PharMetrics, a unit of IMS Health that the company acquired 18 months ago, was the source of the data for the charts featuring both prescription and diagnostic information.
Physicians have long resisted pressure by the data-mining, pharmaceutical and pharmacy industries to have them write a patient's diagnosis on the patient's prescription, and the AMA has traditionally taken a similar official position.
While a majority of the AMA's House of Delegates members have consistently refused to cut off the money stream from sales of the Physician Masterfile to pharmaceutical industry data-miners, in 1993 that body first passed a resolution making it official AMA policy that the association should "work to eliminate requirements by pharmacies, prescription services and insurance plans to include such information as ICD-9-CM codes, DEA numbers and diagnoses on prescriptions."
The resolution also made it clear the AMA should take those steps "in order to protect patient confidentiality and to minimize administrative burdens on physicians." The resolution has been reaffirmed at three subsequent House of Delegates meetings, most recently in 2002, and remains official AMA policy.
But the data-mining, pharmaceutical and pharmacy industries joined forces last year to fight a constraint of their use of prescribing data. IMS Health was one of two plaintiffs in a lawsuit filed in mid-2006 in a New Hampshire federal court seeking to block implementation of a New Hampshire state law. The law sought to bar the use of prescription data for detailing physicians. Pharmaceutical and pharmacy trade groups filed friend-of-the-court briefs supporting the data-miners' position.
According to New Hampshire Attorney General Kelly Ayotte, whose office defended the law in federal court, the state had "a substantial interest in protecting the privacy of New Hampshire physicians, defending the sanctity of the doctor-patient relationship and reducing healthcare costs." A federal judge in Concord, however, ruled that the data-miners had a right to the use the data under free speech protections in the U.S. Constitution. Ayotte's office is appealing the decision.
In a telephone interview, Langston, who is a family practitioner from West Lafayette, Ind., said the decision to create the newsletter was borne out of AMA involvement with health information organizations.
"We'd had some questions arise on how the data was being used and (we tried) to devise an appropriate response to our members," Langston said. "The AMA knew that prescribing data was being used by the HIOs, so the effort was to find a way to make that information useful to physicians."
Langston said the program was piloted by state medical societies in California, Connecticut and Michigan, "and we got excellent feedback on that, so we decided to take it national."
Drug marketing data in the newsletter were customized by states or regions, "so you'll know what your contemporaries are doing," Langston said. Some data also are segregated by medical specialty.
"You can take a look at the prescriptions written, you can say what family physicians are doing and what urologists are doing. I don't know that that requires a diagnosis code as much as a (medical) specialty code," he said.
Robert Hunkler, the director of professional relations at IMS Health, said the company has been working on the concept embodied in the newsletter since 2004. The California Medical Association was "the primary incubator," but the data offering is part of a broader effort by IMS Health to make fuller use of the information it gathers and analyzes, he said.
"We do have a database license relationship with the AMA, but this is apart from that," Hunkler said. "We are just providing the content information as a service, largely because our information has not been as fully utilized as it might (be) by all healthcare stakeholders. We want to expand that. The combination of IMS (Health)'s evidence base of what is actually happening in the marketplace gives physicians a view that they simply have not had before."
The pharmaceutical industry "has traditionally been our core client base," Hunkler said. "We always have over the years made our information available to researchers. We are trying to expand the audience, and making that information available to physicians is part of that strategy, and there is no better way to do it than be a partner of an organization like the AMA."
According to Hunkler, although the electronic infrastructure is in place today to receive and transmit diagnostic codes from a physician's office to a retail pharmacy or a PBM, the codes are rarely included on retail prescriptions today.
"As e-prescribing comes to the fore, we're confident we'll have better access to diagnoses information," Hunkler said.
For now, the diagnoses are linked to a prescription by joining two separate data streams. One stream containing prescription information emanates from the pharmacy or pharmacy benefit management company where the prescription is filled. The other stream containing the diagnosis flows to data-miners from the patient's insurance company based on the claim for payment submitted, for example, by the physician for the office visit at which the prescription was written.
In the case of the data supplied to the AMA newsletter, PharMetrics linked the prescription to its diagnosis by joining the two data streams, using such data elements as the patients' name and date of the office visit to find a match.
"The data asset that they (PharMetrics) brought to the table was a medical and pharmacy claims database that covers about 60 million unique patients," Hunkler said, who added that the information in the database has been de-identified and the process is compliant with privacy rules under the Health Insurance Portability and Accountability Act of 1996.
Matching the two data streams is a process that is both cumbersome and incomplete. While most pharmacy data moves electronically "in real time," matching it with claims data is at least delayed by the time it takes a patient, provider and payer to file and process a claim, and can be stymied entirely if the patient pays for the visit out of pocket and a claim for the office visit is never filed.
But matching the diagnosis with the prescription is what information drug companies and researchers want, Hunkler said.
"It's always an interesting question for the pharmaceutical manufacturer, if a drug has multiple indications, which one is being used, to see how drugs are actually being used in the marketplace," Hunkler said. Another area of at least some interest to pharma is being able to quickly identify any off-label usage patterns for a prescription drug, according to Hunkler. Coupling a diagnosis code to a prescription "in real time" would be one way to spot quickly a new, off-label prescribing trend.
"Rogaine was originally an infusible product that was used intravenously for hypertension and they found these bald guys in intensive care" growing hair, Hunkler said. "Is that really the motivating factor for having more real-time information? I don't know that."
Physician Jerome Kassirer, distinguished professor at the Tufts University School of Medicine and the former editor-in-chief of the New England Journal of Medicine, wrote a provocative book, On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health.
Though admitting he is not an expert on migraines, Kassirer said after reviewing a copy of the first issue of Therapeutic Insights that he has some questions.
"Why offer a program that compares practices locally instead of acknowledged 'best practices?' " Kassirer asked. He also noted that four of the seven listed writers of the first newsletter "have received personal money (honoraria or consulting fees) from industry."
"Some or all of them might tilt toward drug therapy instead of other nondrug approaches," Kassirer said. "Some might have even tilted toward recommending drugs from one company. Why didn't the AMA ask only nonconflicted experts in migraine to formulate the program? They found three, so presumably they could find another" four.
Finally, Kassirer said, the financial ties between IMS Health and the AMA, "influences me to insist that the AMA disclose fully all of their relationships with IMS and all of IMS' relationships with industry. This program sounds like it could be somewhat intrusive. Doctors ought to know what this program is getting them into."What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.