For over a decade, as evidence mounted that Big Pharma influence can lead to all sorts of stupid decisions and harmful outcomes, regulators and medical societies have been reigning in the amazing ways pharmaceutical companies market to doctors.



Nearly gone are the days when drug reps would parade around exam rooms with fancy new pill bottles, when doctors would be flown to Hawaii for medical conferences, and when pens and pads emblazoned with industry logos would be spread around hospitals and clinics.



But, according to a new article in the New England Journal of Medicine, the pharmaceutical industry has simply moved out of clinic and into digital world for much more covert and insidious forms of marketing.



While doctors report that visits from sales representatives have fallen from 77 percent in 2008 to 55 percent last year, drug companies have invested about a quarter of their marketing dollars into digital technologies.



"We do know from traditional marketing tools that their impact can be harmful," said article lead author Dr. Christopher Manz, who works at the department of medicine at the University of Pennsylvania. "But this digital marketing today has much more breadth and depth than the previous kinds of marketing. Now it's like having a sales rep in the exam room with you."



Here are the three new ways companies are secretly influencing your doctors' prescribing habits.

1) Electronic health records do more than digitize medical info



Electronic health records have been billed an advancement in health care: doctors have patients' medical histories at their fingertips, and that information can be accessed in any hospital to track not only patients' medical histories but also improve the quality of clinical interactions.



But EHRs are also powerful data generators about physicians' behaviors and the demographics of their patients — and they're becoming an advertising vehicle for pharmaceutical companies.



"EHRs are digital marketing tools," Manz said plainly. "For decades, companies have been able to tell which drugs I prescribe but with EHRs they can tell when and why I prescribe. This is like personalized marketing aimed at physicians."



In the past, marketing occurred outside the exam room. Today, marketing occurs right as the physician is ordering a prescription on the EHR in the form of targeted banner advertisements, e-coupons, or even curated drop-down menus.



"Before industry might have just my prescribing data, but now they have data for all my clinical encounters for my whole practice," said Manz. "This advertising can occur at the moment you're making prescribing decisions."



The data generated by EHRs is also a goldmine for industry. For example, an EHR company called Practice Fusion gives its software away to physicians for free — and makes money by selling anonymized clinical data back to industry.



"Is this good for patient outcomes?" asked Manz. "I suspect the answer is no. It's probably going to lead to over-prescription."

2) Social media applications gather data on your doctor





There are social networks targeted at healthcare providers, such as Sermo and Doximity, where doctors can learn about the latest medical news and connect to colleagues.



Pharma companies use these networks in various forms, from sponsored discussion forums to targeted advertisements. They also recruit doctors for focus groups and identify key opinion leaders in networks on behalf of Big Pharma.



Sermo has even game-ified its advertising. "One recent example was an 'Alzheimer's Challenge' that allowed physicians to read through clinical trial data (in a format similar to print journal advertisements) for a brand-name medication and answer questions about its indications to earn points redeemable for cash," wrote Manz in the journal.



But that's not all. Doctors using other social networks, such as Facebook and Twitter, are also being targeted. For example, Peerin is a technology that monitors Twitter and can create interaction maps that demonstrate how physicians are connected, which doctors start conversations that go viral, and who responds to them. Again, all this data is fed to Big Pharma to create very targeted marketing campaigns for physicians.

3) Medical apps target pharma advertisements



Epocrates is a company that makes free smartphone apps for doctors. On these apps, MDs can quickly look up information on drug dosing and interactions or insurance coverage.



But every time doctors look something up, that data is sent back to pharmaceutical companies who then target advertisements at them based on their profiles and previous searches.



"Few physicians know that every time they look something up on Epocrates, information gets sent back to a pharma vendor," said Georgetown University associate professor of medicine Dr. Adriane Fugh-Berman. "All of this information is used to sell specific drugs that may not be the best drugs for patients. Affecting information flow is pharma's best covert strategy."

Regulations need to catch-up

These digital marketing tools concern Fugh-Berman. "Drugs have risks and they have harms and they interact with other drugs. And one doesn't want to be on more drugs than are needed. Pharma companies control the discourse on drugs and diseases in both the medical and consumer communities," she said.



"This means that health-care providers don't know about non-pharmacologic therapies, doctors over-treat, and that they are much better versed on the benefits of drugs than they are on the harms."





What's more, history has proven that this marketing to doctors can have very harmful side-effects, from waste in the health system, to mistreatment of patients, and even avoidable patient death.



Regulators have tried to clampdown on bad beaviour, culminating in the passage of the Sunshine law in 2010. Part of the Affordable Care Act, the law required that every pharmaceutical and medical device company in the country disclose payments made to doctors and teaching hospitals for a range of activities — including promotional speaking, research grants, meals, and trips of at least $10 value.



But since the act was conceptualized, pharma has moved out of clinics and into digital world. As Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School, told Vox previously, "In the back of your mind, there's a concern that if you shed some light on one aspect of pharma marketing, that there will be ways, people will try to skirt or game the system to try to avoid the sunshine."



Regulators will need to catchup, but the target will always be moving.