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BCG

European Physicians and the Internet

BCG REPORT

1463.CVR 3/28/03 7:58 AM

The Boston Consulting Group is a general management consulting firmthat is a global leader in business strategy. BCG has helped companiesin every major industry and market achieve a competitive advantage bydeveloping and implementing winning strategies. Founded in 1963, thefirm now operates 58 offices in 36 countries. For further information,please visit our Web site at www.bcg.com.

Vital Signs: E-Health in the United States

A report by The Boston Consulting Group, January 2003

A Revolution in R&D: How Genomics and Genetics Are Transforming

the Biopharmaceutical Industry

A report by The Boston Consulting Group, November 2001

Vital Signs Update: Doctors Say E-Health Delivers

A BCG Focus, September 2001

Vital Signs: The Impact of E-Health on Patients and Physicians

A report by The Boston Consulting Group, February 2001

Patients, Physicians, and the Internet: Myth, Reality, and Implications


Ensuring Cost-Effective Access to Innovative Pharmaceuticals:

Do Market Interventions Work?

A report by The Boston Consulting Group and Warner-Lambert, April 1999

The Pharmaceutical Industry into Its Second Century:

From Serendipity to Strategy


In addition, BCG’s Health Care practice publishes Opportunities for Action

in Health Care, articles on topical issues for senior executives.

For a complete list of BCG publications and information about how to

obtain copies, please visit our Web site at www.bcg.com.

The Boston Consulting Group publishes other reports that may be of interest to senior health-care executives.

Recent examples include:

1463.CVR 3/28/03 7:58 AM

www.bcg.com

ALASTAIR FLANAGAN

PHILIPPE GUY

STEFAN LARSSON

CAMILLE SAUSSOIS

M A R C H 2 0 0 3


1463.TEXT 3/28/03 8:06 AM Page 1

© The Boston Consulting Group, Inc. 2003. All rights reserved.

For information or permission to reprint, please contact BCG at:E-mail: [email protected]: 617-973-1339, attention IMC/PermissionsMail: IMC/Permissions

The Boston Consulting Group, Inc.Exchange PlaceBoston, MA 02109USA

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Table of Contents

NOTES TO THE READER 4

EXECUTIVE SUMMARY 5

INTRODUCTION 7

Busy Physicians Seek Medical Information, Efficiency, and Improved Patient Care Online 7

Patients Fuel the Rise in E-Health 8

E-HEALTH IS GAINING ACCEPTANCE AND INFLUENCING CLINICAL PRACTICE 9

Professional Use of the Internet Is Increasing 9

Physicians Seek Credible Web Sites for Clinical Information 10

Doctors Look to E-Health to Improve Efficiency and Quality of Care 11

Health Care Players Have a Powerful New Way to Reach Doctors 11

DOCTORS WILL CONTINUE TO USE ONLINE INFORMATION IN MORE SOPHISTICATED WAYS 13

E-Detailing: Learning About Drugs Through the Internet 13

Meeting the Increasing Demand for Online Medical Training 15

Building Patients’ Knowledge in More Efficient Ways 16

E-HEALTH TOOLS PROMISE TO IMPROVE PATIENT CARE 18

Using Electronic Data to Improve Patient Care 18

Experimenting with Remote Disease Monitoring 20

Communicating with Patients Online 21

STRATEGIES FOR HARNESSING THE POWER OF THE INTERNET 22

A Powerful New Sales and Marketing Tool for Pharmaceutical Companies 22

Quality Care at an Affordable Price for Payers 25

A Chance for Providers to Restore Their Image Along with the Bottom Line 27

An Opportunity for E-Health Vendors to Add Value for Physicians 28

CONCLUSION 29

METHODOLOGY 30

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Notes to the Reader

4

About the Authors

Alastair Flanagan is a vice president and director in the London office of The Boston Consulting Group.Philippe Guy is a senior vice president and director in the firm’s Paris office and head of the global HealthCare practice. Stefan Larsson is a manager in BCG’s Stockholm office. Camille Saussois is a manager inBCG’s Paris office.

Acknowledgments

The authors would like to thank Andreas Poensgen, head of BCG’s efforts in Germany, Austria, and Greece,and Carina von Knoop, head of the firm’s E-Health topic area. They would also like to acknowledge the con-tributions of the project team: Jacob Calmvik, Mary DeVience, Marc Durance, Yasmina Langevin, BentLüngen, Eddy Schmitt, Patrik Schulz-Vanheyden, Balazs Szathmary, and Lars Textorius. Finally, the authorswould like to thank the editorial team of Barry Adler, Katherine Andrews, Patricia Berrian, and NancyGraham.

For Further Contact

BCG welcomes your questions and feedback. For information about this report or BCG’s Health Carepractice, please contact:

Alastair FlanaganBCG LondonTelephone: 44 207 753 5353Fax: 44 207 753 5750E-mail: [email protected]

Philippe GuyBCG ParisTelephone: 33 1 40 17 10 10Fax: 33 1 40 17 10 15E-mail: [email protected]

Stefan Larsson BCG StockholmTelephone: 46 8 402 44 00Fax: 46 8 402 46 00E-mail: [email protected]

Andreas PoensgenBCG HamburgTelephone: 49 40 30 99 60Fax: 49 40 33 79 45E-mail: [email protected]

Camille SaussoisBCG ParisTelephone: 33 1 40 17 10 10Fax: 33 1 40 17 10 15E-mail: [email protected]

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Executive Summary

The potential for using online tools to gather med-ical information and deliver patient care was justbeing recognized when we surveyed the Europeanlandscape for our 2001 report, Patients, Physicians,and the Internet: Myth, Reality, and Implications. Ourlatest study, conducted in 2002, shows that as theconstraints on physicians’ costs, time, and practiceshave tightened, many doctors in France, Germany,and Sweden have embraced e-health for its prom-ised gains in efficiency and improved patient care.This study also reveals that the medical informationand the tools that doctors are finding in the virtualworld are having an impact on their real-world med-ical decisions in significant ways.

E-health is gaining acceptance among more andmore physicians, and it is having a greater impacton their practice of medicine. Most physicians inEurope are now online. Sweden leads the nationswe surveyed with 74 percent of its doctors online; inGermany and France, 64 percent and 55 percent ofphysicians, respectively, use the Internet. Nearly allof the physicians who are now online (96 percent)reported using Internet technologies for profes-sional reasons, with many spending a significantpercentage of their time online for that purpose. Inaddition, a vast majority of European physiciansonline claimed that the information they find therehas an impact on their professional knowledge,diagnoses, and prescription writing. Overall, theInternet represents a large and growing opportu-nity for health care players seeking to reach andinfluence busy physicians.

Doctors are using the Internet in more sophisti-cated ways to acquire knowledge. To save time andbecome more productive, the vast majority of physi-cians (84 percent) have already shifted a portion oftheir clinical queries online, and many are hungry

for more sophisticated offerings, such as Web-basedmedical courses and seminars. Furthermore, aboutone-third to one-half of the European physicians wesurveyed reported that they welcome the Internetas a complementary channel to visits from drugreps. The doctors apparently believe that acquiringdrug information online will maximize their knowl-edge about new treatments while minimizing theirtime away from patient consultations.

In the hope of using consultation time with maxi-mum efficiency, doctors are enthusiastic aboutreferring patients to high-quality Web sites thatallow them to learn more about conditions andtreatments after they leave the doctor’s office.Physicians view the sites as a way to strengthen theirbonds with patients and exert more control overthe health information patients view on the Web.

Physicians are embracing e-health tools to improvethe care they deliver to patients. Roughly two-thirdsof European doctors are now using electronic med-ical records, whereas about one-third have adoptedelectronic prescribing systems. These doctors haveturned to the technologies largely for the gains inefficiency they provide. But they are just beginningto tap the potential of the tools when it comes toimproving patient care. For example, doctors canuse e-health tools to screen prescribed treatmentsfor compliance with the latest formulary restric-tions as well as for possible drug interactions. Inaddition, the tools can help physicians instantly ex-change the most comprehensive and up-to-date pa-tient data between colleagues and facilities.

Because of the enhanced interaction that thesetools afford, the Internet will facilitate disease man-agement networks—groups of medical professionalsfocused on developing standards of care in a thera-peutic area by improving coordination among the

Photos TK

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various health-care and social-service constituentsresponsible for delivering that care. Already, about20 percent of European doctors are communicatingdirectly with patients online in order to ensurefollow-up and provide more comprehensive treat-ment. Such initiatives to coordinate and managecare are bound to gain in popularity in the comingyears—with emerging remote-disease-monitoringtools fueling the initiatives’ growth. Early adoptersreport that the tools perform, and they preventcostly invasive or emergency care. Left to beresolved, of course, are many questions about thefinancing of these initiatives and the standardiza-tion and development of these technologies. Never-theless, initial analyses demonstrate that such toolsyield financial benefits for payers while significantlyimproving the quality of patient care.

E-health offers health care players a critical op-portunity to inform and influence physicians—anda powerful way to redefine the economics of theirbusiness. By electronically enabling the coreprocesses in their industry—communicating withphysicians, capturing and sharing patient data, andmanaging diseases and care—health care playersare finding ways to reach more doctors, ensure bet-ter care, and reduce costs. It is not surprising, then,that during the e frenzy, many players—technology

and health care companies alike—pursued the e-health space that serves physicians. Finding theright business model in the online environment,however, has proved to be a difficult task. Clearly,the type of online services or features that a healthcare player offers should vary according to the in-dustry subsector in which it plays, the customersand activities it targets, and its place in the healthcare value chain. Over the last two years, distinctstrategic opportunities have begun to emerge.

For pharmaceutical companies, which are increas-ingly pressed to differentiate themselves in salesand marketing, e-health provides enhanced, lower-cost access to physicians as well as many new oppor-tunities to influence payers and patients. For pay-ers, e-health is emerging as an important tool forcontaining health care costs. E-prescribing canboost doctors’ compliance with formularies andhelp reduce spending on drugs. Similarly, Web-enabled disease management can improve care and cut costs for chronic patients. For Europe’sresource-constrained providers, e-health supportsimproved operational efficiency and provides an opportunity for increasing revenues by allow-ing hospitals and other providers to exploit themedical expertise and wealth of clinical data they possess.

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Introduction

In 1999, The Boston Consulting Group began regu-larly checking the pulse of e-health in Europe andthe United States, measuring the penetration andimpact of online medical information and toolsamong physicians and patients. The current reportreveals that European doctors are using e-healthmore frequently, in more sophisticated ways, and with more of an impact on their practice ofmedicine.

This report paints a far different picture from theone we drew in January 2001, when we publishedour last report on the state of e-health in Europe,Patients, Physicians, and the Internet: Myth, Reality,and Implications. Back then, the e-bubble had ex-panded to capacity and was about to burst. Sincethe shakeout, many organizations throughout theEuropean health-care industry have abandonedtheir investments in the online channel. Some weredisillusioned by the Internet and happy to return tobusiness as usual. Others, suspecting that e-healthstill held some promise (although uncertain aboutits precise value and how it could be optimized),stayed in the game but scaled back projects target-ing online dissemination of medical research, druginformation, and patient data.

Although both reactions seemed to make sense, thecurrent report reveals that they haven’t for the mostpart reflected the realities of the market. In fact,physicians have moved online at high rates. Theyare using e-health not only as a source of infor-mation but also as a medium for communicationand a platform for new tools that support clinicalpractice.

Our findings are based on interviews with morethan 600 physicians in three European countries.Conducted during 2002, the study highlights theonline behavior of physicians in France, Germany,

and Sweden, and explores the impact of suchbehavior on the practice of medicine. We focusedon France and Germany because they constitute thetwo largest markets for health care in Europe. Weselected Sweden because it leads Europe in terms ofonline penetration among physicians. (For a morecomplete discussion of our survey’s focus, see Meth-odology, page 30.)

Busy Physicians Seek Medical Information, Efficiency,and Improved Patient Care Online

Under strong pressure to limit growing health-carecosts, physicians today are increasingly burdened bygovernment restrictions on budgets and reimburse-ment as well as by payer-mandated practice require-ments. In such an environment, doctors must findways to fit more patient consultations and paper-work into their busy workdays.

In France, for example, where the governmentclosely regulates the fees doctors are allowed tocharge, data from the French Committee forHealth Education revealed that in 2000 generalpractitioners had to consult with an average of 22patients a day in order to cover the expenses asso-ciated with operating a medical practice. In the faceof tightening restrictions, that number has probablyalready risen to 24.

Confronted by these constraints, physicians findthemselves not just with less consultation time perpatient but also with less time to read journals,complete continuing-medical-education (CME)courses, undertake research, attend conferencesand symposia, and meet with drug representativeson detailing visits—all critical steps if they are tokeep their medical knowledge up-to-date. The pres-sure is becoming particularly intense given thegrowth in the number of new products, treatment

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options, and practice guidelines that are releasedeach year.

To help alleviate these mounting pressures,European doctors are embracing the Internet as asafety valve of sorts—seeking the improved access toinformation, efficiency gains, and patient-careenhancements that its connectivity affords. In fact,despite the retreat by health care organizations, theenthusiasm of doctors and patients alike has causede-health to progress faster and farther in Europethan was originally forecast.

The real value of e-health lies not merely in the factthat it makes traditional data available in new ways;it also changes the way doctors use that informationin their clinical practice. These results echo thefindings reported in our companion study, VitalSigns: E-Health in the United States.

For example, European physicians reported that e-health helps them enhance their professionaldevelopment through online tools for building andsharing knowledge. It also helps doctors improvetheir relationships with patients by providing toolsthat foster communication and deliver customized,interactive materials for explaining conditions andtreatments. Furthermore, Internet-based technolo-gies that support diagnosing, monitoring, and deliv-ering care also improve efficiency. These so-calledremote-disease-monitoring (RDM) technologies,when combined with the connectivity that theInternet builds among providers, will enable diseasemanagement networks—groups of medical expertswho devise and implement standards of care forparticular conditions—to achieve even better clini-cal outcomes.

Patients Fuel the Rise in E-Health

Laws in most European countries limit consumers’ability to use the Internet to get information aboutspecific drugs. Nevertheless, the demand for gen-eral medical information is growing: almost half ofEuropean physicians report that their patients haveasked about treatments they’ve learned about on-line. Indeed, it appears that European consumersare following in the footsteps of their U.S. counter-parts, who are becoming increasingly involved intheir own medical care as a result of improvedaccess to health-related information. In our study ofmore than 10,000 patients in the United States, wefound that about 80 percent seek medical informa-tion online and that about 75 percent of the pa-tients online report that e-health has changed theway they communicate with their doctor. Patients inthe United States—and increasingly in Europe—arebeginning to view physicians as decision-makingpartners and expert guides rather than as the solegatekeepers of medical information or the unques-tioned dispensers of health treatments and advice.

Our survey provides solid evidence that e-health—although hardly a panacea for all that ails thehealth care industry—is not a passing fad amongphysicians in Europe. The doctors who have addede-health to their medical kit told us that they like itand that it has an impact on their decisions aboutpatient care. Thus, the Internet provides pharma-ceutical companies, payers, health care providers,and other health-care organizations with a goldenopportunity for educating and influencing physi-cians: the most integral and influential players inthe prescription of drugs and the delivery of care.

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E-Health Is Gaining Acceptance and Influencing Clinical Practice

Photos TK

Once online, physicians reported that they use theInternet for professional reasons—with 75 percentspending a minimum of 30 minutes per week exploring medical issues on the Internet. Thesemore active users of the Internet spend an averageof about 60 percent of their online time, or aboutthree hours per week, addressing professionalissues—for example, e-mailing colleagues, search-ing and reading online journals, and completingCME coursework.

The vast majority of European physicians seek med-ical information online when they are not at work.Eighty-six percent log on after work and 71 percentdo so on weekends, compared with 46 percent go-

The barriers that initially impeded doctors’ use ofe-health are disappearing. Our 2001 report found,for example, that European physicians, althougheager to use the Internet, were not moving onlinebecause they were concerned about the time andresources required to adopt the new medium.

It seems that those concerns have dissipated: a largemajority of doctors, both specialists and generalists,are now online and dedicating significant time tothe medium for professional purposes. Most impor-tant, the knowledge they gain online influencestheir clinical behavior.

Professional Use of the Internet Is Increasing

Among the three countries surveyed, more thanhalf of physicians are now using the Internet: 74percent in Sweden, 64 percent in Germany, and 55 percent in France. (See Exhibit 1.) This pene-tration has increased sharply over the past fewyears; in Germany, for example, only 47 percent ofphysicians were using the Internet in 2000, accord-ing to a study conducted by the German marketresearch group NFO Infratest.

Although it is growing steadily, Internet penetra-tion among physicians in Europe still lags the U.S.rate, where 96 percent of physicians are online. Ifrecent European e-health trends continue, how-ever, the gap will narrow significantly: we expectphysicians in Sweden to catch up to their U.S. coun-terparts by the end of 2003, and we predict thatabout 90 percent of physicians in France and Ger-many will be online by 2005. Not surprisingly, therate of Internet adoption among younger physi-cians (defined in our study as those under 40 yearsold) is 20 percent higher than the rate among thephysician population overall.

EXHIBIT 1MOST PHYSICIANS ARE NOW ONLINE

80

100

60

40

20

Internet penetration among doctors, 2002

Doctors who spend more than 30 minutes per week online for professional reasons

Doctors who spend less than 30 minutes per week online for professional reasons

Germany France Sweden

Percentage of doctors surveyed

5564

74

SOURCE: BCG proprietary physician survey, 2002.

NOTE: The number of respondents was 254 in Germany, 251 in France, and

101 in Sweden.

1463.TEXT 3/28/03 8:06 AM Page 9

ing online between patient consultations and just16 percent doing so during consultations. (SeeExhibit 2.) Overall, European physicians tend tospend about half of their professional time onlineat home. This finding suggests that much of theonline time doctors dedicate to medical issues isalso time when they are undistracted by office busi-ness and are otherwise inaccessible to health careplayers. Note, however, that the amount of time thatdoctors use the Internet from home for profes-sional reasons varies considerably by country:German physicians spend 65 percent of theirprofessional time online at home, French physi-cians spend 45 percent, and Swedish physiciansspend just 25 percent.

Physicians Seek Credible Web Sites for Clinical Information

No matter where they are when they log on—in their homes or at the office—the vast majority of doctors online (84 percent) use the Internet to seek clinical information. Not surprisingly, they look for reliable sources. In comparison withtheir U.S. counterparts, European physicians seemto be particularly sensitive to the potential com-mercial bias associated with Web sites or contentsponsored by corporations or payers. This sensitiv-

ity, which we first identified in our 2001 report,appears to be particularly pronounced in Ger-many, where concerns have recently surfaced about physicians’ dependence on pharmaceuticalcompanies for drug information and treatmentdecisions.

As a result, the physicians we surveyed are usuallydrawn to objective, third-party sites—such as thosesponsored by universities, medical centers, andmedical associations—as well as to health portals,which offer a point of entry to materials on a broadrange of diseases and treatments. Nearly 60 percentof physicians tend to start their research throughindependent search engines such as Medline—adatabase of academic journals—largely becausemany doctors are suspicious of online medical con-tent that is not academically reviewed in the waythat medical journal articles are.

A doctor’s online destination is also determined bythe type of medicine he or she practices. Generalpractitioners visit primarily nonspecialized healthportals, such as egora.fr and multimedica.de. Bycontrast, specialists prefer Web sites that focus onparticular diseases or therapeutic areas, such as theorthopedics site sofcot.com.fr.

Because 80 percent of doctors online prefer sites intheir own language, physicians typically visit sitesthat are either country specific or local versions ofglobal sites. When asked to name the sites they visit,Swedish doctors most frequently mentionedronden.se, which has provided a broad set of serv-ices to members of the Swedish Medical Associ-ation. Owing to excessive operating costs, however,the site was scheduled to shut down in March 2003.

In addition, chu-rouen.fr, a health portal sponsoredby one of the largest French university hospitals,was named by the greater number of French doc-tors, whereas medline.de was named by the greaternumber of German physicians. However, no site wasmentioned by more than 10 percent of the Euro-pean physicians—a major difference from trends inthe United States, where a single Web site, WebMD,commands a 23 percent share of physicians who usethe Internet.

In all three countries, physicians are drawn to pro-fessional Web sites in traditional ways: throughprint ads in medical journals and word of mouth

10

EXHIBIT 2PHYSICIANS TEND TO USE THE INTERNET AFTER WORKAND ON WEEKENDS

80

100

60

40

20

Do you look for medical information on the Internet . . . ?

On weekends

Percentage of doctors online

71

After work

86

Betweenpatient

consultations

46

Duringpatient

consultations

16



86 in Sweden.

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from peers. (See Exhibit 3.) Specialists, in particu-lar, value their peers’ opinion of a site.

As our 2001 study found with European patients,European doctors will give a Web site a limitednumber of chances. Physicians do not return to asite if it does not meet their needs on an initialvisit—for example, if the information they find istoo superficial or not up-to-date. Also, doctors tendto abandon their efforts to access a site immediatelyif the registration process for entering it is too cum-bersome—for example, if they have to fax docu-ments or make a phone call in order to acquire apassword or gain entry.

Doctors Look to E-Health to Improve Efficiency and Quality of Care

Because budget pressures limit the time that doc-tors can spend with patients, quality of care is indanger of eroding. In France, for example, fee lim-its and other factors have reduced the average con-sultation between general practitioners andpatients to around ten minutes, which many physi-cians consider inadequate to explore and resolve apatient’s problems effectively.

Compounding the problem of the shrinking con-sultation are three issues.

• The first is the growing expectations of patients.Generally more active in their care, moreinformed about their illnesses, and often armedwith information they find online, patientsincreasingly demand more answers and involve-ment from their physicians.

• The second issue is the rise in demand for healthcare. As the European population ages, patients’need for health care mounts. In addition, currenteconomic conditions and living standards hint atan increased prevalence of chronic diseases, suchas asthma, diabetes, and heart disease.

• The third issue is the declining ratio of phy-sicians to patients. For a number of reasons, ascarcity of doctors is forecast for both France and Sweden over the next five to ten years—particularly in specialties such as radiology andobstetrics in France and psychiatry and geriatricsin Sweden.

Because they help address efficiency and qualityissues, such tools as electronic medical records(EMRs), electronic prescribing systems, RDM tech-nologies, and online communication with patientsare beginning to surface in doctors’ officesthroughout Europe. All these tools promise to shiftthe nature of interactions between physicians andpatients toward better-coordinated patient careacross providers and diseases. They also enable doc-tors to draw on the latest and most comprehensivepatient information when addressing the needs ofindividuals.

Health Care Players Have a Powerful New Way to Reach Doctors

Organizations that build credible Web sites andsucceed in drawing physicians to them stand tohave considerable influence over health care deci-sions. (See Exhibit 4, page 12.) Seventy-four per-cent of European physicians online said that theinformation they find on the Internet has an im-pact on their knowledge, both of symptoms anddiagnoses. Nearly as many—68 percent—said that ithas an impact on their prescribing behavior. And afull 84 percent said that it has an impact on theirknowledge about new treatments, including drugs.Doctors clearly view the Internet as an importantmedium for gathering information and boostingtheir knowledge.

EXHIBIT 3DOCTORS ARE DRAWN TO WEB SITES BY PRINT ADS AND WORD OF MOUTH

30

25

35

20

15

10

5

How did you learn about your most frequently used Web site?

Percentage of doctors who regularly visit sites for health-related information

Fromyour

colleagues

15

Fromprintads

27

Froma searchengine

12

Fromdrugreps

9

Fromhealthportals

5

Yourpracticeuses it

5



86 in Sweden.

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12

EXHIBIT 4THE INTERNET HAS AN IMPACT ON PHYSICIANS’ KNOWLEDGE AND BEHAVIOR

Has the information you have found online had an impact on . . .

No impact at all Minor impact Major impact

. . . your knowledge about new treatments, including drugs?

. . . your knowledge about symptoms and possible diagnoses?

. . . the way you interact with your patients?

. . . your prescription of treatments, including drugs?

. . . the types of diagnoses you have made?


84

74

56

68

59

33

20

12

10

11

51

54

44

58

48

16

26

44

32

40


NOTES: The number of respondents was 117 in Germany, 102 in France, and 86 in Sweden. Figures do not always add up to 100 percent because respondents could

also choose “not sure” or “decline to answer.”

Since e-health in Europe is likely to evolve in waysthat mirror its widespread acceptance and use inthe United States, we expect that the number ofdoctors online and the amount of time they spendthere addressing professional issues—whether it’sto gain knowledge or treat patients—will rise dra-

matically over the next three years. Furthermore,the Internet promises even greater value to doctorswho integrate it more fully into the workflow oftheir office and their delivery of care. As that hap-pens, well-positioned health-care players will reapsubstantial benefits, too.

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Doctors Will Continue to Use OnlineInformation in More Sophisticated Ways

E-Detailing: Learning About Drugs Through the Internet

Physicians have traditionally spent a significantamount of time meeting with drug reps. In France,for example, the average physician has about six vis-its with reps per week. Since drug reps promoteabout three products on average per visit, the aver-age doctor in France experiences about 18 weeklydrug details.

Doctors—even the busiest ones—told us that theyenjoy the face-to-face interactions with reps, valuingequally the reps’ knowledge about drugs and treat-ments and the opportunity to socialize. But giventhe heightened time pressures on doctors and therising number of marketed drugs, detailing visitsare growing shorter and less informative, forcingphysicians to seek out additional drug information

As investments in biomedical and clinical researchhave grown exponentially in recent years, the num-ber and complexity of new products, treatmentoptions, and practice guidelines have escalated aswell. This onslaught of increasingly technical clini-cal information makes it difficult for physicians tostay up-to-date. In this environment, e-health siteswith depth, accuracy, and credibility save doctors agreat deal of time and effort in finding answers toclinical queries.

The vast majority of European physicians who use the Internet seek clinical information (84 per-cent) and read journal articles (72 percent) online.(See Exhibit 5.) A large number are also goingonline to communicate with colleagues, look forspecific drug information, and research CMEcoursework. They are also using e-health to helpshare their medical knowledge with patients.

EXHIBIT 5PHYSICIANS SEEK CLINICAL INFORMATION ONLINE—AND ARE ADDING NEW ACTIVITIES

80

100

60

40

20

Do you use the Internet to . . . ?


84

Research clinicalinformation

Read articles from medical journals

Communicatewith colleagues

Research specificdrug information

Research CME Find sites torecommend to patients

72

51 5046

36


NOTE: The number of respondents was 117 in Germany, 102 in France, and 86 in Sweden.

1463.TEXT 3/28/03 8:06 AM Page 13

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on their own. In Europe, 50 percent of physiciansonline now spend part of that time seeking druginformation. This trend is most noticeable inSweden, where 70 percent of doctors online use thechannel to learn more about pharmaceuticals.

It is important to note that physicians do not viewthe Internet as a substitute for drug reps; rather,they perceive e-health as a complementary channelthat can provide additional information on medi-cines and other treatments. (See Exhibit 6.) So-called e-detailing encompasses a wide range ofofferings, such as virtual or interactive live sessionsand scripted, on-demand video or downloads. Invirtual e-detailing, which is provided by companiessuch as iPhysicianNet, doctors who commit to takepart in live videoconference sessions hosted by drugreps receive a free PC, software, and Webcam fromthe vendor. In scripted e-detailing, which is pro-vided by companies such as Physicians Interactive,doctors view a series of interactive screens, commu-nicating with drug reps by e-mail or phone.

E-detailing is still in its infancy in Europe, whichhelps explain why 36 percent of doctors there areskeptical about its value. Only about 3 percent ofphysicians have actually had any experience with e-

detailing to date—primarily through pilots run byselected pharmaceutical companies. For example,Pfizer, GlaxoSmithKline, and Novartis have exper-imented with scripted models of e-detailing. In Germany, Aventis has tested several different e-detailing options, such as a videoconferencemodel and a noninteractive online e-detail.

Although they constitute a small group, these earlyadopters reported that e-detailing provides a valu-able additional channel to in-person detailing. Mostsaid that they like the idea of scheduling details atthe times most convenient to them—generally afterwork hours. Doctors also reported that they appre-ciate the incentives provided by these activities.Aventis, for example, operates a loyalty programcalled MediMiles that awards physicians points forparticipating in e-details and allows them toexchange the points for free medical publicationsor medical office products.

With face-to-face contact valued so highly amongEuropean physicians, e-detailing is unlikely toreplace reps. Yet, given stiffening competition foraccess to doctors and restrictions on physicians’time, the Internet offers physicians a uniquelyattractive combination of flexibility and efficiency.Thus, e-detailing may carve a niche for itself, sup-plementing drug rep visits and probably evenchanging the way reps interact with physicians dur-ing live visits.

Pharmaceutical companies embracing this newsales technique in Europe will need to tailor their e-detailing approaches to each country. The follow-ing specifications will be key.

• Technical requirements: e-detailing by videocon-ferencing, for example, would probably not bewell received in countries where most physiciansuse a 56K dial-up modem.

• Legal constraints: in a notable departure fromthe United States, most countries in Europe pro-hibit pharmaceutical companies from buying PCsfor physicians.

• Cultural norms: in Sweden, for instance, a signif-icant share of today’s offline detailing takes placeat lunch meetings—a format that may be chal-lenging to match with e-detailing.

If they succeed, e-detailing programs promise notonly increased access to doctors but also cost-

EXHIBIT 6PHYSICIANS VIEW THE INTERNET AS A COMPLEMENTARY CHANNEL TO DRUG REPS

50

60

40

30

10

20

How do you think e-detailing could change your interaction with drug reps?

Replaceinteractionwith drug

reps to some extent


12

Replaceinteractionwith drug

reps completely

3

Be an extra tool

43

Add no extra value compared

with directinteraction

36



101 in Sweden.

1463.TEXT 3/28/03 8:06 AM Page 14

15

search of medical training. But most are disap-pointed with the offerings they find, and, as aresult, only a small percentage actually completemedical training online. (See Exhibit 7.) Physiciansfind current CME programs lacking—primarilybecause the sector, like e-detailing, is still in itsinfancy in several European countries. Content onmany sites is not yet interactive, so physicians cando no more than read basic case studies on com-puter screens. Even chu-tours.fr, which the nationalcommittee for continuing medical education (theComité National de Formation Médicale Continue)ranked as the best CME site in France in 2001,offers merely an online version of an offline coursealready administered to students. The onlinecourse lacks interactive options, animated illustra-tions, and films.

We believe, however, that physicians’ interest inonline CME courses will continue to grow as newregulations on such training emerge throughoutEurope. Although no laws currently require physi-cians to update their skills, a new law could beimplemented by the end of this year in Germanythat would require doctors to complete certifiedmedical training in order to maintain their licenses. Already, in anticipation of these regula-tions, a few online medical-education pilots, such asmedizinonline.de, multimedica.de, and dgn.de, arestarting to emerge in Germany.

effective access. Novartis, in a 2001 study, foundthat using iPhysicianNet’s videoconference systemin the United States yielded significant savingswhen compared with in-person reps. “Virtual” repscould attain more sales calls per day (13 comparedwith 8 in-person visits); longer details (9 minutescompared with 3 minutes); and lower costs per min-ute of detail ($14 compared with $58). Of course,the low-cost, easy access afforded by e-detailingmust be balanced against its impact on doctors.

Meeting the Increasing Demandfor Online Medical Training

Just as the Internet can make it easier for doctors toaccommodate drug rep “visits,” e-health also helpsdoctors fit continuing medical education into theirhectic schedules. Although physicians place highvalue on learning, they don’t always have the timeand money to spend traveling to medical seminars.In interviews with BCG, for example, physiciansmade the following comments: “Attending continu-ing education courses in the evening and on week-ends takes too much time away from my family” and“If I have to obtain further education as a doctorseveral times a year, I would definitely make use ofonline offerings.”

Already, a large number of surveyed physicians—ashigh as 61 percent in Germany—surf the Web in

EXHIBIT 7EUROPEAN PHYSICIANS SEEK, BUT CAN ’T FIND, ONLINE CONTINUING MEDICAL EDUCATION

Germany

Do you use the Internet to . . . ?

80

60

40

20

Research CME

61

Complete CME

20

–67%

France

80

60

40

20

Research CME

33

Complete CME

29–12%

Sweden

80

60

40

20

Research CME

35

Complete CME

15–57%

Percentage of doctors online Percentage of doctors online Percentage of doctors online


NOTES: The number of respondents was 117 in Germany, 102 in France, and 86 in Sweden. Differences across countries result in part from varying regulations and the

value of current offerings.

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Medizinonline.de, sponsored by Springer, offersthe broadest German CME offering, covering 14specialties ranging from anesthesia to urology.Doctors read about the topic of their choice (typi-cally in an article from a Springer journal), com-plete the questionnaire to test their understandingof the article, and e-mail their answers to an onlineevaluation service. For each correctly completedtest, physicians earn one CME credit.

In the United States, where similar regulations haveexisted for some time, around 60 percent of physi-cians now complete medical training online at Websites with certified educational offerings. The pri-mary providers of such coursework are medicalschools, specialty associations, and nonprofit organ-izations. Grants from pharmaceutical companiespay for half of the cost. Those drug companies thataward grants are not allowed to influence the sites’content or to offer product- or disease-related con-tinuing education on their own sites.

In Sweden, where CME requirements are currentlybeing considered, a consortium called IPULS hasbeen formed jointly by professional associationsand payers to evaluate and coordinate all continu-ing medical education at a national level.1 All CMEsuppliers, private as well as public and offline aswell as online, are encouraged to submit their cur-ricula to a review committee at IPULS, whichassesses the quality of courses from both a scientificand an educational viewpoint. Accredited courseswill be presented and applications will be handledon a Web site starting in the spring of 2003.

Because demands on doctors’ time are likely tocontinue to escalate, online CME will almost cer-tainly grow in Europe over the coming years.Universities, medical centers, and associations,along with the medical press, are best positioned tooffer this educational service since they have credi-bility and can draw on their existing academiccourses. By contrast, the ability of pharmaceuticalcompanies to offer online classes that are certifiedby medical institutions or associations remainsuncertain in Europe. Some companies are nonethe-less starting to offer valuable courses, as Aventisdoes at ZoomCancer.com. Ultimately, however,European concerns that corporate-sponsored offer-

ings may focus too heavily on product marketingmay mean that the role of pharmaceutical compa-nies in Europe will be limited to indirect sponsor-ship, as is the case in the United States.

If pharmaceutical companies are allowed to com-pete in this arena, the content of their courses mustbe unique and must differentiate them from aca-demic or media sponsors. Because doctors focus ondelivering more cost-effective care, for example,they will be seeking proven practice guidelines thatcan help them rationalize their approaches to treat-ment and care. This need presents an opportunityfor pharmaceutical companies to supply, for in-stance, evidence-based medical databases and re-sulting practice guidelines in local languages.

Although payers have already published selectedguidelines for most critical treatments, they remainunavailable for an entire range of less common orcritical diseases—primarily because the economicbenefit of developing such guidelines is low and thecosts are prohibitively high. Creating theseevidence-based databases and deriving practiceguidelines from them would allow drug companiesto improve their relationships with physicians byincreasing doctors’ efficiency and efficacy; improvetheir relationships with payers by helping themensure the best outcomes and thus better managethe costs and quality of care; and ensure a higherlevel of compliance with drug regimens that pre-scribe the companies’ products.

Building Patients’ Knowledge in More Efficient Ways

Doctors aren’t the only ones interested in buildingtheir medical knowledge online. In Germany, forexample, 70 percent of physicians said that patientshave asked for treatments they learned about onthe Web, whereas 55 percent reported that patientshave requested specific drugs they found online.Such requests place additional time pressures onphysicians, who must help patients correctly inter-pret study data or medical information, and thenmust justify the selection of treatments and drugsthat they feel are most appropriate.

Given patients’ appetite for information and theburden that misinformation creates for doctors,

1. IPULS, the Institute for the Professional Development of Doctors in Sweden, was founded by a consortium consisting of the Swedish MedicalAssociation, the Swedish Society of Medicine, and the Swedish Federation of County Councils.

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about one-quarter of European doctors surveyed—and 55 percent of German doctors—are eager tofind and recommend high-quality Web sites thatexplain health conditions and their treatment to patients. Physicians view the sites as a way tostrengthen their bonds with patients, exert morecontrol over the information that patients view onthe Web, and free them to focus consultations on their patients’ most pressing issues.

Physicians we interviewed for our survey said thatWeb sites worthy of their recommendation shouldprovide patients with the background informationthat physicians would share in detail during officevisits if they had the time. Such sites, doctors said,should also

• exploit the interactive benefits of online media,tailoring information to different levels of under-standing and providing illustrative online moviesand presentations

• offer easy-to-print, customizable information thatphysicians can give to patients who aren’t likely tofollow up online

• avoid actions that appear to direct physicians’treatment decisions in overt or biased ways

According to the physicians we interviewed, noexisting Web destinations serve as model sites forpatients. In the three countries, about 25 to 40 per-cent of the physicians who sought to refer patientscould not find a site that met their criteria.

When doctors did refer patients to Web sites foradditional information, more than 90 percent ofdoctors in France and Germany and almost 80 per-cent of doctors in Sweden directed individuals todifferent destinations than those the doctors pre-ferred for their own use. The likely reason is thatdoctors don’t believe that any of the current offer-

ings serve both groups well. However, our compan-ion U.S. study revealed that more than one-third ofU.S. doctors who recommended Web sites directedpatients to professional association sites, many ofwhich feature patient-reference sections. If thisapparent convergence of patient and physician sitesplays out in Europe, it may create attractive oppor-tunities for integrated marketing that reaches bothaudiences.

Of the online health-related destinations to whichdoctors do refer their patients, sites sponsored bypatient associations, such as the Swedish DiabetesAssociation (diabetes.se), are viewed as the mostreliable resources. Interestingly, in Germany anumber of surveyed physicians refer patients totheir own personal Web sites, where they have bet-ter control over the type and quality of contenttheir patients access. Universities, medical centers,and patient associations (known as Selbsthilfegroups) all possess the credibility that patient sitesrequire. Some of these organizations have al-ready developed comprehensive offerings, such asthe psoriasis-bund.de site in Germany. Althoughthe Web site was created by the psoriasis Selbsthilfegroup, information provided on the site is spon-sored by Biogen, among others.

Like Biogen, pharmaceutical companies could takethe opportunity to sponsor Web sites that educatepatients with unbiased and comprehensive in-formation about diseases or therapeutic areas.Some of these pharmaceutical-sponsored sitescould even bear the brand of the drug company.ZoomCancer.com is one such site, offering patientsand physicians information on disease and treat-ment, self-training, and practical tips while bearingthe Aventis brand. Information like this could alsobe packaged and made available to physicians whowant to post it on their own Web sites.

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E-Health Tools Promise to Improve Patient Care

18

care. (See the insert “The Future of Internet-Enabled Disease Management.”)

Using Electronic Data to Improve Patient Care

Rising patient demand for more personalized carewill increase physicians’ need for more comprehen-sive and up-to-date patient data. EMRs and e-prescribing systems already enjoy widespread pene-tration in Europe because physicians appreciate theefficiency of computerized access to their patients’medical histories and the ease of printing out pre-scriptions rather than writing them by hand.According to our survey, more than 60 percent ofphysicians in France, Germany, and Sweden useEMRs today, while about 30 percent have adopted e-prescribing. (See Exhibit 8.) These physicians

Because they help address efficiency and qualityissues, tools such as EMRs, electronic prescribingsystems, RDM technologies, and online communi-cation with patients are beginning to surface indoctors’ offices throughout Europe.

Once incorporated into physicians’ arsenals, thetools—in their ability to capture and share patientdata online—promise to advance the long-soughtgoal of coordinating care for individual patientsacross all the conditions, treatments, and providerswho affect the patient’s health.

Today in France alone, more than 120 disease man-agement networks exist. The networks involve alarge number of players, including hospital- andoffice-based physicians, nurses, and pharmacists.These groups coordinate the care delivered to a sin-gle patient so that

• the best and most integrated care possibleimproves the patient’s quality of life

• savings are achieved by eliminating redundantexams, dangerous interactions among medica-tions, and the need for urgent, invasive care

• the various constituents working with a patient—including social service providers—have an openchannel for communication

• the patient receives critical information—onnutrition, for example—and works with care-givers to participate in treatment decisions

• doctors can track outcomes to formulate anddeploy practice guidelines in a therapeutic area

Although the Internet hasn’t created these net-works, e-health will certainly promote their devel-opment with new, cost-effective ways to improve

EXHIBIT 8THE WIDESPREAD USE OF E-HEALTH TOOLS PROMISES IMPROVED CARE

80

100

60

40

20


Electronic medical records

Penetration of patient-care tools

Germany France Sweden

Electronic prescribing

6661

73

38

28 27



101 in Sweden.

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19

currently view the tools primarily as offline admin-istrative resources. Very few have yet embraced theinteractive possibilities that Internet-enabledpatient-care systems will afford.2

There are notable exceptions to this rule—particu-larly in Sweden, where Internet penetration is high.There, it is estimated that more than 70 percent ofall doctors—and more than 90 percent of generalpractitioners—use EMRs. And in southern Sweden,the country’s state-owned pharmacy monopoly,Apoteket AB, is running a pilot that integrates doc-tors’ e-prescribing tools with pharmacies via theWeb. The integration enables pharmacies to receiveand aggregate information about patients’ pre-scriptions automatically, and to customize fulfill-ment services to the individual. This informationcan facilitate home delivery and compliance pack-aging, which dispenses prescriptions in single,prepackaged doses to be taken on specific days or atcertain times of the day. If successful, the model islikely to be rolled out fairly rapidly in other parts ofthe country. In Sweden’s northernmost Norrbottenregion, more than 90 percent of physicians arealready using e-prescriptions, lowering the barriersto future integration with pharmacies.

Given the tools’ early promise and already highrates of adoption, EMRs and e-prescribing could

improve the quality of patient care. For example,doctors could use online patient records as amedium for instantly exchanging data, test results,and even medical imaging with colleagues and med-ical facilities. Such connectivity would ensure thatpatients receive the most continuity possible intheir care, even if they switch doctors, see special-ists, receive emergency care in their home countryor abroad, or are admitted to or discharged from ahospital.

Similarly, prescribing errors and their conse-quences could be significantly reduced by linking amedical office’s prescription-generating systemwith other tools—such as the latest online informa-tion on drug interactions available from a univer-sity; the standard dosage recommendations from amedical association or consortium of pharmaceuti-cal companies; and the computer systems of thepharmacies where the prescriptions are filled.Automatic transmission of prescriptions wouldreduce both errors and the huge volume of callsthat pharmacists must make to physicians whenthey cannot read their handwriting.

Furthermore, automatically cross-checking pre-scriptions against payer formularies online couldensure that the most cost-effective treatments areprescribed. In certain Swedish counties, such as

Although obstacles remain, the growth of diseasemanagement networks is likely to accelerate inFrance: new laws regarding social security andpatients’ rights are beginning to address financingand other issues associated with the networks. InGermany, the government has recently undertakenan effort that targets the development of diseasemanagement schemes for a limited set of chronicdiseases. A modification of the risk structure com-pensation scheme has created powerful incentivesfor the German payers, the Krankenkassen, to en-roll patients in such programs. However, physicianassociations in Germany have voiced some con-cerns about sharing patient and practice data with payers.

Payers have much at stake. In the United States, forexample, disease management programs have his-torically delivered cost reductions of up to 30 per-cent for major disease groups. Recently, a study bythe French research group Réseau d’Evaluation enEconomie de la Santé indicated that Résalis, anassociation of health care professionals focused onasthma care, improved patient health and generatedcost savings. The Résalis programs included com-puterizing all the consulting clinics where networkpatients were seen and facilitating the exchange ofmedical records. In just one year, these and other ef-forts increased the number of patients whoseasthma was controlled by 15 percent while reducingquarterly costs per patient by about 30 percent.

T H E F U T U R E O F I N T E R N E T - E N A B L E D D I S E A S E M A N A G E M E N T

2. BCG’s questions about EMRs and e-prescribing asked doctors whether they used computer- or Web-based technologies. In the European health-careindustry as a whole, use of Web-based tools is currently limited.

1463.TEXT 3/28/03 8:06 AM Page 19

Jönköping, where doctors have already embracedthis approach, formulary compliance rates are dou-ble those in counties where doctors are not pre-scribing online (50 percent versus 25 percent).

In the near future, doctors should also be able touse integrated e-prescribing to ensure that patientsare filling and refilling their prescriptions at thepharmacy. Such monitoring could lead to increasedcompliance with prescribed drug regimens andthus improved health. Roadblocks remain, ofcourse—including the security of patient data, thefinancing of universal systems, and acceptanceamong physicians. Still, Web-enabled e-prescribingis more widespread in the United States, and there-fore increased use is feasible in Europe.

E-prescribing that is fully enabled electronicallycould also make it easier for payers to enforce drugformulary recommendations or required substitu-tion of generic medications. In the extreme, doc-tors’ increased compliance with formularies woulddilute the influence that drug reps enjoy today, giv-ing payers greater bargaining power when theynegotiate drug prices with pharmaceutical compa-nies and distributors.

E-prescribing offers pharmaceutical companiessome advantages as well—despite the risks of pric-ing concessions and diminished marketing influ-ence. Because e-prescribing systems can be used tosubmit prescriptions for fulfillment automaticallyand monitor the frequency of refills, they can helppharmaceutical companies boost drug compliance.They can also eliminate the problem of patientsfailing to fill prescriptions—which is estimated tooccur among one-third of all new prescriptions in France.

Still, pharmaceutical companies might be best offworking behind the scenes—for example, by offer-ing grant money to promote the growth of toolssuch as e-prescribing and EMRs. By contrast, part-nering with a software company, for example, tocobrand a practice management tool might berisky, given physicians’ comments in interviews thatthey might view such offerings as biased and lessthan credible. Physicians also explained that anytechnical problem they experienced with a spon-sored device or piece of software could reflect neg-atively on the image of the sponsoring pharmaceu-tical company.

Experimenting with Remote Disease Monitoring

By capturing, analyzing, and reporting patients’vital signs and health data, RDM tools could oneday prove invaluable for certain portions of thepatient population. One example is PolymerTechnology Systems’ BioScanner 2000. This blood-testing device—designed for diabetes patients touse at home—measures blood sugar, total choles-terol, HDL cholesterol, triglycerides, and lethalketone levels. The data collected by the electronictesting device can be uploaded to a personal Website, where they can be tracked and reviewed byboth patient and physician. As a result, doctors canidentify potentially dangerous trends and adjustmedications as necessary. Another example isLifeScan’s OneTouch, which monitors glucose lev-els with only a small blood sample. Its companionsoftware automatically creates in-depth reports andevaluates progress vis-à-vis goals.

Today RDM tools are still in their infancy in bothEurope and the United States. Only about 6 per-cent of online physicians in Europe and 7 percentin the United States use the technologies. But earlyadopters have reported high levels of satisfaction.In our survey, more than 80 percent of doctors whohave participated in pilots experimenting withRDM tools said the technologies allow them to de-liver better care and improve patient satisfaction.Given such success, doctors are likely to embraceadditional technologies as the field expands intonew specialty areas and diseases. The type and num-ber of devices used to monitor diseases elec-tronically are already growing to include watchesthat function as glucometers, such as Cygnus’sGlucoWatch Biographer, and hand-held urinalysisdevices that test kidney function.

One limitation to the development of such tools isambiguity regarding who should finance them: pay-ers, doctors, health care networks, or other players.In the United States, few insurance companiesreimburse medical offices for the cost of thedevices. But that may change. Studies show thatRDM reduces the cost of care while improving qual-ity—two outcomes that might inspire payers tofinance the devices.

A 2001 study published by U.S. managed-careplayer PacifiCare, for example, determined thathospitals using RDM devices for patients with

20

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21

Communicating with Patients Online

Although it enjoys neither the widespread use ofEMRs and e-prescribing nor the high rates of satis-faction associated with RDM, online communica-tion with patients represents an important use ofthe Internet for doctors. Today about 20 percent ofonline physicians in Europe communicate by e-mailwith their patients—primarily because patientsthemselves request the contact. But doctors tend tolimit their online interactions to only about 2 to 6percent of their patient base.

The tools—mostly e-mail—permit interactionsbetween physician and patient, and the delivery ofmedical advice as soon as symptoms surface. Thus,they promise to help patients avoid more serioushealth problems, office visits, and even hospitaliza-tions. Yet doctors are skeptical about online com-munication, fearing that answering queries by e-mail will sap even more of their already scarcetime without generating efficiencies or payment forthe time they spend on the Web. Some physiciansalso fear that e-mail may entail legal risks associatedwith the confidentiality of patient information andliability for incomplete diagnoses and resultingtreatment errors.

For payers, however, online communication be-tween doctors and patients can offer a major ad-vantage if the tool helps reduce the number ofunnecessary office visits. In the United States, anumber of payers have partnered with medical soft-ware providers to test pilots that reimburse doctorswith reduced fees—that is, lower than the re-imbursement physicians receive for office visits—inexchange for “seeing” patients virtually throughunique, structured interfaces. Initial results indi-cate that the cost savings and patient satisfactionassociated with the tool could be significant. Still,those who make such offerings available will needto prove to doctors that communication with pa-tients can be profitable and manageable. Other-wise, physicians will not be willing to grant patientsInternet access to them.

chronic heart failure realized a 174 percent returnon their investment. The devices helped patientsreturn home sooner and avoid further cardiacevents that would have required emergency careand readmission.

In a similar study published in 2002 by the Uni-versity of Colorado, researchers concluded thatteenagers with type I diabetes who share theirblood-sugar readings with physicians every twoweeks through a modem could manage their dis-ease as effectively as they could with quarterly officevisits. The modem transmissions cost about one-sixth of the $300 total cost of office visits.

For medical software vendors and medical devicemanufacturers, the market potential for RDM ishuge and largely untapped. To exploit these oppor-tunities, technology players must overcome twoimportant challenges. First, RDM devices must becompatible with other information tools—no easytask in a highly fragmented market lacking univer-sal technology standards. Second, players mustensure that the tools actually deliver on the prom-ise of improving care and reducing costs.

No matter how much information a new piece ofsoftware or new device provides, it will become justanother expense on a health care player’s balancesheet unless manufacturers employ change man-agement strategies to help integrate the tool intophysicians’ workflow. Technology companies thatdo so stand to build a very strong competitiveadvantage. As our 2001 report illustrated, doctorsare reluctant to take the time to learn multiple soft-ware programs and technologies. As a result, physi-cians will likely stick with one device once they haveinvested time in mastering it.

Payers stand to gain as well. By facilitating commu-nication, data capture, and data sharing amonghealth care constituents, the combination of RDMtechnologies and fully Internet-enabled EMRs willenhance the efficiency of disease management net-works—garnering greater interest and participationamong physicians, and cutting medical costs.

1463.TEXT 3/28/03 8:06 AM Page 21

If e-health is just a sideshow or a passing fad inEurope, as many naysayers in the health care indus-try have contended, it appears that no one has yetbroken the news to doctors. To the contrary, Euro-pean doctors have found that the Internet canfundamentally transform their interactions withtheir health-care constituents and add value to theirpractice and patients. In a similar way, health careplayers that integrate e-health into their operationscan alter the processes and economics that havelong defined their businesses.

Indeed, the future of e-health and of health caredelivery in Europe will be closely intertwined. As offerings become more cost effective, user friendly,and powerful in enhancing the quality and effi-ciency of care, more payers, physicians, and pa-tients will have a compelling reason to use them.This growth will fuel the need and demand forwidespread standards, such as Health Level 7 (stan-dards for communication) and DICOM (standardsfor digital imaging in medicine), which facilitatethe sharing of patient and other data online. Suchstandards are likely to increase dramatically in im-portance, driven largely by initiatives from localgovernment payers and the European Commission.

Ultimately, we believe, the organizations thatexploit e-health successfully will be those that bal-ance the tradeoff between lower-cost and higher-quality care.

A Powerful New Sales and Marketing Tool for Pharmaceutical Companies

Pharmaceutical companies’ sales and marketingstrategies and capabilities are perhaps their mostimportant levers for success in today’s environment.Pipelines for new products are less robust than

financial analysts demand; competition amongexisting and impending products is fierce; and thepayers and consumers of health care seek increas-ing control over the selection, price, and delivery ofhealth care treatments. Yet in formulating their all-important marketing strategies, many pharmaceuti-cal companies are operating below their potential;that is, they treat online and offline channels as aneither-or proposition, comparing the costs and ben-efits of each and then choosing one over the other.In reality, the channels are complementary and farmore powerful when used together.

We believe that the most effective way to handlemarketing is to integrate offline and online market-ing into a cohesive strategy that targets patients andphysicians—and payers—simultaneously. Payers willlikely gain greater influence over prescribingoptions in the future and have already voiced nega-tive sentiments about the pricing strategies of phar-maceutical companies. By demonstrating its com-mitment to helping payers hold down costs andimprove care, a pharmaceutical company may beable to alleviate tensions with payers and therebydifferentiate itself from the competition.

The Internet is an attractive tool in this mixbecause it changes the nature and economics ofcommunicating to patients and physicians. First,pharmaceutical companies need no longer rely ondoctors as the sole gatekeepers of medical informa-tion. Although they cannot reach patients directlythrough their own Web sites, pharmaceutical com-panies can sponsor content on unbiased third-partysites that doctors will recommend to their patients.Second, as the Novartis study illustrated, pharma-ceutical companies can use online technologies toreach a far greater number of doctors more cheaplythan in-person rep visits ever could.

Strategies for Harnessing the Power of the Internet

22

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23

Coordinating the entire mix of online and offlinemarketing ensures that the messages received by allthe constituents in health care are aligned. It alsoallows pharmaceutical companies to make tradeoffson the basis of the return on investment that indi-vidual marketing channels and approaches con-tribute to overall marketing goals. For example,pharmaceutical companies may find the low-costaccess of e-detailing to be sufficient when market-ing a me-too drug to general practitioners whodon’t prescribe many drugs. But they probablywould continue to rely on more costly rep visits thathave greater impact when reaching out to heartspecialists with messages about the first product tobe unveiled in a new class of drugs.

Although companies that integrate their marketingwill benefit from exploiting similarities and contentacross national markets, they will also need to tailorsome activities to individual countries and take intoaccount legal, cultural, and technical differencesamong those countries. With the vast majority ofphysicians preferring Web sites in their own lan-guage, offering well-translated clinical informationwill be important. Of equal or even greater impor-tance, however, is understanding the legal environ-ment for e-health in various European countries.What’s permitted—and what’s not—as well as thepotential risks associated with e-health vary quite abit among countries. An e-detailing approach thatworks well among highly wired Swedish doctors, forexample, might be illegal in France, where lawscould prohibit companies from providing Web-conference equipment to physicians.

From our own extensive work in the area, we havedeveloped a framework—the demand leakage model—to help our clients analyze the optimal marketingmix to spur drug sales. (See the insert “IncreasingDrug Sales: Eight Chances to Capture the Con-sumer,” page 24.) Our framework lays out the chainof steps required if a particular drug is to be pre-scribed and sold. It then assesses just how many ofthe patients who could be helped by a drug actuallymove through all the steps to become consumers of the drug. The degree of demand that “leaks out”at each step represents an opportunity for pharma-ceutical companies to deploy online and offlinemarketing to capture a greater share of the market.

Once pharmaceutical companies identify where thebiggest leaks in demand occur for the drugs they

are selling, they must identify which barriers arecreating those leaks and which potential levers theycould pull to increase demand. Leaks at either endof the cycle—that is, in patients’ awareness of acondition and their willingness to consult a doctorat the front end or in filling and then complyingwith prescriptions at the back end—must beaddressed by reaching the patient. By contrast,leaks that occur during the middle stages—whenthe doctor diagnoses a disease and selects a drug toprescribe—must be addressed largely with physi-cians. At each of these steps, the most effective mar-keting approaches should be identified. They willinclude both traditional offline activities and e-health initiatives.

Awareness and Consultation. E-health and offlineofferings should educate patients about symptoms,explain the consequences of not seeking treatment,lay out therapeutic options, and identify wherepatients can turn for help. Because most Europeancountries forbid advertising targeted directly topatients, one option for pharmaceutical companieswould be to find a partner outside the pharmaceu-tical industry. Given the importance of their per-ceived neutrality and expertise, academic medicalcenters and medical associations would be the mostvaluable branding partners.

Diagnosis and Prescribing. The key here is to in-crease physicians’ general understanding of a disease and the value of drug therapy. Marketing at this stage has long been dominated by rep visitsand advertising to physicians. Although theseapproaches should continue, online medical sup-port—such as databases highlighting clinical out-comes and updated practice guidelines—could beused to help increase the number of doctors whocorrectly diagnose a condition and prescribe a com-pany’s drug of choice. In addition, CME could be aprimary tool at this stage. Again, partnerships withmedical centers and internationally respecteddoctors are likely to be important from a brandingperspective.

Market Share. Historically, companies seeking toboost market share have targeted physicians withmessages about the advantages that their drugsoffer in efficacy, safety, and patient compliance. Butgiven the increasingly active role of payers andpatients in treatment selections, these groups toohave become important targets.

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24

To understand how a company can use BCG’s de-mand leakage model, consider the hypothetical case of apharmaceutical company marketing antidepressantmedication in France. The first step in the marketingprocess would be to estimate the total size of theaffected market—that is, all the patients who mightbe served by the drug (1). In this case, up to 6 mil-lion French people are estimated to suffer fromdepression, under the widest definition of the dis-ease. But not every sufferer will be aware that his orher symptoms are abnormal (2), and even amongthose patients who are concerned about their condi-tion, only some will visit the doctor to discuss theirproblem (3).

Doctors will not diagnose all cases of depression cor-rectly (4), and those who do will not always viewdrug therapy as the best approach (5). When doctorsopt to prescribe antidepressants, however, they willchoose from a multitude of drugs, so that only a por-tion of their prescriptions will be written for any onecompany’s product (6). Out of these written pre-scriptions, many will go unfilled (7), and many filledprescriptions will not be taken in compliance withthe prescribed regimen (8). Ultimately, at the end of

this long chain, pharmaceutical companies oftenfind that they serve a mere fraction of the total mar-ket their product can potentially benefit. (See theexhibit “Demand for Drugs ‘Leaks Out’ at VariousStages of Patient Care.”)

How does this translate into a marketing strategy?Each step along the chain represents a decision thateither drives a customer toward a sale or limitsdemand for the drug. The steps at which the great-est demand for a drug “leaks out” will vary by indi-vidual disease, specific drug, its position in theproduct life cycle, and market-specific conditions.

When considering depression, for example, the leak-age between the number of sufferers at step 1 andthe number of sufferers aware of their disease atstep 2 will be much higher than for other diseasessuch as psoriasis, in which the rate of prescribing atsteps 5 and 6 may pose the greatest potential lossof drug sales. Once a drug company figures outwhere it is losing the greatest number of potentialcustomers, it can decide which mix of sales tech-niques will be most effective to stop leakage andincrease demand.

I N C R E A S I N G D R U G S A L E S : E I G H T C H A N C E S T O C A P T U R E T H E C O N S U M E R

DEMAND FOR DRUGS “LEAKS OUT” AT VARIOUS STAGES OF PATIENT CARE

Suffering Awareness Consultation Diagnosis Prescribing Market share Fulfillment Compliance

1 2 3 4 5 6 7 8

SOURCE: BCG analysis.

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Gaining access to the first target group, physicians,has become increasingly difficult as the number ofcompeting drugs in many therapeutic areas hasrisen. But, as our study shows, online messages cansupplement offline rep visits and reach doctorswhen they are logged on at home. Similarly, e-detailing can reinforce messages about a drug’svalue and help reps tailor drug information to aphysician’s queries or prescribing behaviors. E-detailing might also present an opportunity forsmaller pharmaceutical companies without largesales forces to reach physicians.

The second target group, payers, already try toinfluence doctors’ drug selections. Therefore, in-fluencing payers’ drug selections is the next logicalstep in building market share. Although uniquedrugs that don’t have much competition may havelittle problem gaining a recommendation on pay-ers’ formularies, me-too drugs excluded from auto-matic and electronic formulary listings may riskbeing cut off from large groups of potentialcustomers.

In Sweden, formulary recommendations have amajor and rapid impact on a drug’s sales. There, a drug’s inclusion on a formulary is determined notonly by efficacy and safety but also by price andpharmacoeconomic data, the latter progressivelyreceiving more attention. Several other majorEuropean markets may be moving in the samedirection in the near future.

To differentiate their products so that price is notthe only criterion for drug selection, major phar-maceutical companies can use patient and out-comes data captured through e-health sources tomake an economic case for the value of their prod-ucts to formulary committees. Given current skepti-cism surrounding such pharmacoeconomic data,collaboration with trusted academic medical cen-ters will be critical. For me-too drugs, Web-enableddisease-management networks may help a productdifferentiate itself and ensure better clinical out-comes. With both approaches, pharmaceuticalcompanies may be able to secure risk-sharing agree-ments with payers that specify that a drug’s inclu-sion on a formulary is based not solely on price butalso on delivered savings or quality improvements.

The importance of influencing the third targetgroup, patients, should not be understated.

Although direct-to-consumer advertising is bannedin most of Europe, health portals, university sites,and other e-health destinations sponsored by thirdparties can serve as an important source of infor-mation that legally influences patients, who theninfluence payers.

Fulfillment and Compliance. The goal of improvingthe rate at which patients fill prescriptions andcomply with drug regimens is shared by pharma-ceutical companies and payers. The opportunityexists, therefore, for the two types of organizationsto jointly make the significant up-front investmentneeded to track these actions and communicatewith patients, pharmacies, and physicians. FullyInternet-enabled EMRs, e-prescribing systems,RDM tools, and disease management networks all would improve the rate of fulfillment and com-pliance.

Quality Care at an Affordable Price for Payers

For the most part, all European payers face thesame critical issue: How can they maintain orimprove the health of a population without spend-ing more than they can afford? One option is gov-ernment reforms. And indeed, since the 1980s pay-ers in Europe have been struggling to institutechanges that will rein in health care spending. (Seethe insert “Reforms in Europe Could Give E-Healtha Shot in the Arm,” page 26.)

Two areas of e-health offer important opportunitiesto address payers’ goals: e-prescribing and Web-enabled disease-management networks.

E-Prescribing. Payers could help significantly boostdoctors’ compliance with drug formularies—andtherefore help contain drug costs—if they helpedroll out e-prescribing tools integrated with EMRsand formulary information. First, the use of e-prescribing technology would make it easier fordoctors to write prescriptions for drugs that are onformulary by making formularies automaticallyavailable at the exact moment when physiciansreview patient data and write prescriptions. Second,combining online technologies with financialincentives will encourage even greater formularycompliance among physicians. Holding doctorsfinancially accountable for the costs of the drugsthey prescribe can be a particularly powerful lever.

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Today doctors in Sweden comply with formular-ies on about one-quarter to one-half of the pre-scriptions they write. If budget incentives and e-prescribing tools linked to payer formulariescould boost this number, securing a spot on theformulary would become essential to pharmaceuti-cal companies seeking to command a leading shareof their market. Ultimately, this shift would deliverbargaining power to payers, who could demand sig-nificant price concessions from the manufacturersof me-too drugs.

Furthermore, once e-prescribing is fully integratedwith pharmacies’ own databases, physicians will beable to follow up on patient compliance with pre-scribed drug regimens. By helping increase thenumber of patients taking their medicines as pre-scribed, payers could realize substantial improve-ments in clinical outcomes and reductions in emer-

gency or in-patient treatment costs. Finally, fullyintegrated e-prescribing tools could also enablepharmacies to increase efficiency significantly, par-ticularly in terms of reducing costly inefficienciessuch as stockpiling.

Web-Enabled Disease Management. Using theInternet to enhance disease management has evengreater potential for improving outcomes and lim-iting costs in health care. The concept of diseasemanagement is hardly new; it was first introducedby BCG about a decade ago. But the improved com-munication and enhanced monitoring that e-healthtechnologies provide have given disease manage-ment a significant boost in the United States bymaking it more feasible and cost effective. Al-though Internet penetration in Europe lags behindU.S. rates, disease management in Europe hastaken off in response to growing cost concerns.

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In health care systems that are financed largelythrough public funds, as they are in most of Europe,government authorities have introduced reforms inan attempt to curb health care costs, which threatento grow faster than the European economy as awhole. Those reforms make it difficult for health careplayers to succeed using their traditional businessstrategies—and thus create an environment in whiche-health offers distinct advantages.

Reform in France. Attempts at cost containmenthave been aggressive in France. Drug reimbursementhas been limited for older or less efficacious prod-ucts, and drug prices are being renegotiated everythree years with price-volume agreements. But suc-cess has been elusive. Despite a law mandating sub-stitution, for example, only about 4 percent of pre-scriptions in France substitute brand-name drugswith available generics. In this environment, govern-ment debates have explored even more stringentregulations. Possibilities include limiting reimburse-ment for off-patent drugs to fixed fees and man-dating that doctors deliver care consistent with prac-tice guidelines drawn from outcomes experience.

Reform in Germany. In a full-scale attack againstescalating costs, Germany has attempted to slash

health care spending by designating diagnosis-related groups (DRGs) of services as the basis forprovider reimbursement; establishing a major, soon-to-be-introduced program for disease managementof a small group of serious chronic conditions; andenacting a law requiring generic substitution of pre-scription drugs. In addition, during the next year ortwo, major reforms are expected to deregulate threecritical components of the state’s health-care sys-tem: provider monopolies will be broken up; so-called sick funds will be granted greater freedom tooffer differentiated services; and drug distributionwill be opened to online and mail-order retailers.

Reform in Sweden. DRGs have been in effect inSweden for ten years. And in October 2002, thecountry turned to mandated generic substitution forprescription drugs. At the same time, a new govern-mental body, the Pharmaceutical Benefit Board, isgearing up to evaluate which new and existing drugsshould be reimbursed by the state. Finally, over thelast 12 months, responsibility for the drug budgethas shifted from the state to the same public bodiesresponsible for the cost of health care services:county councils. The councils are in the best posi-tion to evaluate the total cost and quality of care.

R E F O R M S I N E U R O P E C O U L D G I V E E - H E A L T H A S H O T I N T H E A R M

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Future growth of disease management in Europedepends on four developments in e-health. First,EMRs must make patient data accessible across allproviders serving a patient. That means all the con-stituents in health care must be online and theirsoftware and technologies must be compatible.Second, EMRs, e-mail, and all platforms for sharingpatient data must be secure, protecting patients’privacy. As new disease-management programs rollout in Germany, for example, sharing patient andpractice data has emerged as a major early concernamong doctors. Third, e-health tools must be highlycustomized and interactive to permit communica-tion between physicians and patients, and allowpatients to learn more about their specific condi-tions and treatment options. Fourth, RDM toolsmust be easy to use and affordable for patients; theyalso must do more than just dump patient data onphysicians. Careful monitoring will occur only if themonitoring tools use automatic features and alertsto submit data regularly and help physicians inter-pret them.

Promoting the use of these tools and integratingthem into a disease management network will gen-erate significant costs and new responsibilities forpayers. Thus, payers should experiment with pilotprograms that identify the optimal mix of bothtechnology and physician and patient involvementto ensure effective disease management for mini-mum added cost and maximum long-term gain.

A Chance for Providers to Restore Their Image Along with the Bottom Line

Health care providers in Europe—including hospi-tals, clinics, and academic medical centers—face acritical lack of public funding and increasing criti-cism from patients for failing to eliminate what canbe lengthy waiting times to see a physician or to getneeded treatments or surgeries. In some countries,providers’ close collaboration with pharmaceuti-cal companies—particularly on clinical trials—isalso coming under scrutiny. To help combat thesefinancial, operational, and image problems, major health-care providers can take advantage of e-health tools to address three areas central totheir survival: improving operational efficiency,building on their broadly respected expertise inmedicine, and deriving greater value from theirproprietary clinical data.

Improving Operational Efficiency. There is nodoubt that doctors’ widespread use of EMRs inEurope has moved providers closer to improvedefficiency throughout their networks. But the pri-mary advantage offered by many providers’ EMRsystems today is the time saved by no longer havingto search for paper-based files; that is, few providerstap into the power that fully integrated medicalinformation affords, such as computerized analysisof patients’ illnesses, treatments, and outcomes.

Efficiency will be improved dramatically andpatient care coordinated across departments onlywhen e-health systems and platforms offer theseadvanced capabilities and facilitate integration ofpatient information with other key applications inthe network. For example, analyses of patient flowand waiting times in addition to improved planningof both clinical activities and human resourcesneeds could unlock significant value. Such moveswill prove critical: in Germany, for instance, pro-viders will increasingly be reimbursed per case, andpayers will be benchmarking clinical performanceacross provider systems.

Promoting Medical Expertise. Academic medicalcenters and major hospitals enjoy unique credibilityas sponsors of e-health sites that physicians respectand visit. These players can draw on their expertisein therapeutic areas and on the information theydevelop through teaching and research to offerhigh-quality content. Another possibility for med-ical centers is to develop online CME programs. Aninternationally renowned academic medical centeror university hospital enjoys a global brand thatcould command a large market and potentially gen-erate attractive revenues in the training realm.

Providers may find pharmaceutical companies will-ing to cobrand and finance developments in certaintherapeutic areas to gain access to both the clinicalexpertise and the key customer groups that theypossess. One example of a site embracing thisapproach is sfdermato.org, the association portalfor dermatologists in France, which is sponsored byRoche, Novartis, LEO Pharma, and Pierre Fabre,among others. In a sector where providers willincreasingly need to compete for patients andresources, strong e-health offerings could helpthem attract the most desirable patients whileboosting their influence among the most active andprominent doctors.

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All health-care players introducing e-health offeringswill want to engage the same forces that move doc-tors and patients to trial: demonstrated efficacy, thebacking of key opinion leaders, and targeted market-ing. These elements offer the greatest opportunity forsuccess in launching e-health products.

Detail aggressively. Take the new products directlyto doctors and train them in how to use the tools.Engage reps not only in sales but also in training andcustomer service and support.

Provide evidence of efficacy. Furnish doctors withcompelling data on the tools’ effectiveness.

Cultivate a network of key opinion leaders. Re-spected peers can provide professional recommen-dations and personal testimony.

Engage in strategic partnerships to copromotetools. This includes relying on incentives from pay-ers, providers, and pharmaceutical players.

Help educate and mobilize patients. When possible,support and sponsor efforts to make superior infor-mation about general health issues more readilyavailable—and valuable—to patients.

A P R O V E N M O D E L F O R M A R K E T I N G E - H E A L T H

Mining Clinical Data. By fully integrating all theirdata-generating systems, health care providerscould perform sophisticated analyses of the carethey deliver, using automated reviews and othertools to identify inaccurate diagnoses, suboptimaltreatments, and poor medical outcomes. In fact,pooling and analyzing their patient data couldallow providers to document the clinical outcomesassociated with particular drugs and treatments—evidence pharmaceutical companies will increas-ingly be willing to pay for as their negotiations heatup with drug formulary committees.

An Opportunity for E-Health Vendors to Add Value for Physicians

There has been a shakeout among the vendors thatdeliver e-health content and technologies. Many ofthe providers that emerged on the scene in 1999have now folded or been absorbed. Although thenumber of players has declined in the wake of con-solidation, the variety of vendors and offeringsremains. Some vendors focus on only one type oftool; for example, MyDocOnline offers a uniqueWeb interface for online communication withpatients. Others offer a broad range of products toa defined audience; for example, Amicore—a col-laboration of Pfizer, Microsoft, and IBM—offerscomplete clinical automation for small practices.

No matter the scope of their offering, e-health ven-dors must assess how they generate value and whowill be willing to pay for it. The tools that many ven-dors deliver provide technologically advanced func-

tionality that providers may find desirable but thatadd only marginally to operational efficiency.Instead, e-health tools must add value for physi-cians by increasing reimbursement, saving time, orcutting costs. If new technologies don’t deliver onthose imperatives, doctors won’t be able to justifythe costs of adding them. For example, to fosterwider acceptance among physicians of online com-munication with patients, the vendors that providethese interfaces will need to prove three things: thatpatients will not use the Internet to inundate physi-cians with demands, that information shared onlineis secure, and that payers will reimburse physiciansfor time spent with patients online.

Players will be well positioned if they succeed inestablishing standards or, more likely, open plat-forms onto which the plethora of today’s applica-tions can be integrated. Examples include HealthLevel 7’s Version 3 standards and the OracleHealthcare Transaction Base, a repository andinfrastructure for storing and sharing data. And ifsuch platforms facilitate proper and sophisticatedanalyses of patient flow, performance metrics, andcosts, the potential for value creation—and themarket value—of such products will be staggering.

In rolling out new technologies and services thathelp achieve such balance, e-health technology ven-dors—indeed all health-care players—will want toemulate an approach that has proved successfulwith doctors: the drug launch process. Thatapproach consists of five steps highlighted in theinsert “A Proven Model for Marketing E-Health.”

28

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Conclusion

Photos TK

Two years ago, e-health in Europe was a great, butunfulfilled, promise. Today it is a reality that is hav-ing a significant impact on health care players andlocal health-care systems. Although it emerged qui-etly, it has become a powerful force among doctorsin Europe.

By transforming all the components of health caredelivery—from the way a prescription is written,submitted, and filled to the way outcomes fromtreatments are monitored and used to generatepractice guidelines—e-health promises to changethe nature of medical interactions and economicsin the health care industry. And that represents anenormous opportunity for pharmaceutical compa-

nies, payers, and health care providers, who can usee-health tools to reach and influence physicians andpatients in a way that will benefit everybody withlower costs and higher quality of care.

Clearly, e-health is imperative for achieving successin the information-intensive, resource-constrainedhealth-care industry. Progressive players will gaincompetitive advantage if they embrace and fullyintegrate the online tools that complement andenhance their business strategy. Those that don’tadopt the tools risk falling behind and losing theircompetitive edge, as technology continues to trans-form the health care landscape in fundamental,powerful, and permanent ways.

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Methodology

The objective of this survey was to develop an in-depth understanding of European physicians’Internet behavior in 2002 and to track the evolu-tion of e-health in Europe since our last report inJanuary 2001, Patients, Physicians, and the Internet:Myth, Reality, and Implications.

For this study, we surveyed 606 physicians in threecountries: Germany (254), France (251), andSweden (101). We chose France and Germanybecause they are the two largest health-care marketsin Europe. We selected Sweden because it is at theforefront of Europe in terms of online penetrationamong physicians. We chose respondents randomly

to represent the overall physician population. Forexample, 50 percent were general practitioners,and 50 percent were specialists in cardiology, der-matology, obstetrics and gynecology, orthopedics,and radiology.

Independent research companies Sinus Sociovisionand Navigare administered the survey betweenApril and July 2002. This report complementsBCG’s e-health research in the United States, thefindings of which were published in Vital Signs: E-Health in the United States, the third report in ourVital Signs series.

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The Boston Consulting Group is a general management consulting firmthat is a global leader in business strategy. BCG has helped companiesin every major industry and market achieve a competitive advantage bydeveloping and implementing winning strategies. Founded in 1963, thefirm now operates 58 offices in 36 countries. For further information,please visit our Web site at www.bcg.com.

Vital Signs: E-Health in the United States


A Revolution in R&D: How Genomics and Genetics Are Transforming

the Biopharmaceutical Industry

A report by The Boston Consulting Group, November 2001

Vital Signs Update: Doctors Say E-Health Delivers

A BCG Focus, September 2001

Vital Signs: The Impact of E-Health on Patients and Physicians

A report by The Boston Consulting Group, February 2001

Patients, Physicians, and the Internet: Myth, Reality, and Implications


Ensuring Cost-Effective Access to Innovative Pharmaceuticals:

Do Market Interventions Work?

A report by The Boston Consulting Group and Warner-Lambert, April 1999

The Pharmaceutical Industry into Its Second Century:

From Serendipity to Strategy


In addition, BCG’s Health Care practice publishes Opportunities for Action

in Health Care, articles on topical issues for senior executives.

For a complete list of BCG publications and information about how to

obtain copies, please visit our Web site at www.bcg.com.

The Boston Consulting Group publishes other reports that may be of interest to senior health-care executives.

Recent examples include:

1463.CVR 3/28/03 7:58 AM Page 2

AmsterdamAthensAtlantaAucklandBangkokBarcelonaBeijingBerlinBostonBrusselsBudapestBuenos AiresChicagoCologneCopenhagenDallasDüsseldorfFrankfurt HamburgHelsinki

Hong KongHoustonIstanbulJakartaKuala LumpurLisbonLondonLos AngelesMadridMelbourneMexico CityMiamiMilan MonterreyMoscowMumbaiMunichNew DelhiNew YorkOslo

ParisRomeSan FranciscoSantiagoSão PauloSeoulShanghaiSingaporeStockholmStuttgartSydneyTaipeiTokyoTorontoViennaWarsawWashingtonZürich

www.bcg.com

BCG


BCG REPORT

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