As No One Person, Brand or Theory Has Cracked the Adherence Code, now Technology Takes Its Turn

Pill cpunter

Novartis Developing Chip to Remind Patients to Take Pills
Patients who often forget to take regular doses of medicines will now be reminded by a "chip on their shoulder". Switzerland's Novartis and technology company, Proteus Biomedical have joined hands to develop the innovative idea, reports Britain's Telegraph newspaper. The sensor would also help doctors keep a check on their patients' medication regime. (

I was fortunate that last Fall co-led a two-day conference last fall called, "The Barriers to Patient Non-Adherence." Thirty-seven patient advocacy group representing over 50 conditions, all came together under the umbrella and good grace of this major pharma company to try and debunk the myths and come to some core beliefs across groups about what action to take.

Technology never came up. Oh sure, everyone talked about email and Internet, but I do not consider that technology. Everyone focused on behavior, money and communication. One thought leader we invited spoke to Value-Based Insurance Design as one solution; another went the route of behavior modification.

This week's news that Novartis was developing a technology reminder that was cleverly called, "chip on your shoulder" was fascinating in many ways, and perhaps inevitable. E-CRM programs are hard to measure and only a portion of patients and caregivers will join. Direct mail is old world and effective, but only the economic efficiencies of on-demand digital printing has made it possible for so many brands to create their own 'magazine."

But technology. Could this be the answer? Let's look at the wide range of devices that are in the market to help patients stay adherent. Just go to a big pharmacy and walk down some aisles, or this stuff is usually nearer to the counter. Lots of watch reminders — set the time, it beeps, you take pill. Pill cutters. The 7-day brightly colored pill box, each days' letter on top of each sequestered chamber. Then there is the pill bottle coming with the chip sensor in the top, to record wireless-ly the number of times it was opened. Debit and co-pay cards that track usage bt tracking transactions. Ttelephone reminder messages. 


Pill counter cap

Is it me, or is something missing?

If you want to really think about non-adherence, you need to first start out, as demeaning as this sounds, thinking of the patient as a ill behaved teenager. Why? Because nothing you do seems to make a big difference. It's like no matter what you say or do – consequences, hope, fear, bribes, on and on, none do the trick. They might move the dime 5% one direction, but that is it. Why are we just such knowingly mis-behaving creatures?

Behaviorists, like Prochaska, and my friend who worked with him, Dr Cynthia Willey, an epidemiologist out of University of Rhode Island, would sum the problem up in book-ending the patient behavior: if the patient does not "accept" the diagnosis and the need for treatment, then they will not be compliant. Equallyy, if they DO accept, and stick with the medication regimen for 6 months and make it a part of everyday habits, then they will succeed.

My own research at Ryan TrueHealth has shown that people also have a myriad of human and historical barriers nothing can overcome. Influences like, how their family perceived health and medicine growing-up, or Influencers like the lack of a pharmacist attention or the negative reactions of family members.

So, as we look at what is currently in the market, no one has ever implemented the right mix of behavior models, human touch, use of online and offline media, and co-opting the Influencers to build a holistic approach. (MS may be closest.)

Now, why if we have not gotten even proven that the right mix of these insights and devices — from call center, to live chat, to co-pay cards and emails — why would we believe that a wireless chip will crack this code?

The real solution, like so many things, is a human-based one. And that means that if people will not comply, if they will knowingly act against their own self-interest, in this case their health, it does mean that all is hopeless. It just means we cannot be seduced by the hubris of portable wireless technology as the missing piece.

I like the chip idea. I think its cool. It will be even better if it attaches to the emerging EHR technologies. But there are so many other barriers we need to address first, and use technology as a platform for a "human" solution — one that offers a range of means to convince the patient early, and support them at key intervals through multiple channels — this is the answer we should focus on.

And you know what seems to be the most effective tool used to date? That darned weekly pill holder. Ugly, bad product design, yellow or some tacky color, cheap and intrusive. For those of us with elderly parents, it works.

I do not have the answer, but I see the ingredients. And it begins and ends with human insights, all else is a tool. The final caveat: has anyone really thought about who and how many will actually wear this chip? Hmm. Maybe calling "chip on your shoulder" may not be the best name.







Oncology Web sites: The Good, the Bad and the Ugly.

Oncology got me into the pharma/biotech marketing business. Well, I guess a more honest statement is someone who had cancer got me into this business. My sister. She had melanoma. Now since I usually write about marketing, why the heck am I indulging my own experience?

Because it is as universal as it gets. And the need for oncology patients is greater than ever, the engaged patient is not getting the education and emotional support they need. But we can get back to that.

I just spent 4 hours surfing oncology Web sites, as if I were a patient or caregiver. I crossed nearly 10 different forms of cancer. I walked in the patient's shoes, or my own from years ago…and while the treatments for so many forms of cancer have advanced, the Web site experience just reeks of not getting that these are people who are scared, perhaps being told they will be given your brand…it simply has not gotten much better.

When I was designated the "family researcher" for melanoma in the middle stages of her condition — lymphh node removed from original site, chemo begun — I felt powerful;; Ha, I was the only family member smart enough about the Web to find what we really needed: the Answers. The Holy Grail of the Internet — that deep seated irrational belief that if you keep Searching, the truth, some truth, will be revealed. And you can sit back and say, "Ha, I found it! As much as you hid the information, or buried it, I rooted it out and found it!"

But what I found was of little or no use; my Mom would ask, "Could you look up side effects for this type of chemotherapy? Your sister is feeling awful." I would immediately dive right in. Back then everyone used Yahoo – and I searched and searched page listing after page listing. I went to .org's, .gov., foreign sites, message boards, on and on…and then I would just stop. Exhausted. Frustrated. Angry at what I had to do next: call my mother and give her some lame, nearly useless advice I'd printed from some lame nearly useless Web site.

So, as the questions piled on from the immediate family, the answers got harder and harder to find. And everything was in text, and often led to a labyrinth of links here and there and more often than not, nowhere.

Melanoma was particularly hard — all there was was IL-2. Now, so many once-untreatable cancers have choices they never had before. The patient can actually have a greater degree of hope than ever, education and self-empowerment. But do the Web sites reflect that excitement?

I have had the fortune to pitch, work on, study, oncology brands. But when it comes to Internet presence and branding and information, I'd be hard pressed to tell you many Web sites I'd recommend.

And what makes me saddest of all — yeah, throwing in a little more emotion — is that there is no greater need for human engagement than a patient and family suffering from cancer. What seems to have occurred from a marketing perspective is that many brands have figured out financial reimbursement is huge, and that is surely a Best Practice. Others? Patient hot-linesstaffed with nurses. Patient videos that are genuine. Side effect management. Teleconferences. Online "buddy" matching.

But the Worst Practices still reign on a  majority of brand sites. No video. Cold, antiseptic text that is often so unfriendly to read and awful to print and written as if each word was tortured. PDF's that have happy smiling faces of bad stock photography. And the sites are so lightweight; it really seems to a sufferer that the company just does not care, and that all authority and education lies in the hands of the oncologist and their team. (What really amazes me is also that e-Detailing has become so engaging, but those same lessons of how to engage the doctor also apply to the patient, yet no one seems to have connected those dots.)

And that insight is so untrue, so full of the blinders of science over emotion. The oncologist and their team vary in what they can offer. Will someone realize that in this world, even the desperate patient will get angry and resentful at being made more a victim by not having access to EVERYTHING they need — and for most oncology patients, that need evolves over time. Ever Stage IV drugs should service that.

And the needs are so humanly basic and yet so ignominiously ignored.

I need to understand what I have. What are my options? How do they compare? What will it cost? How will I feel? What can I learn about the science? Ar there others like me who have gone through this and survived? Are there support groups? Can you send me emails that help me? On and on…the needs are so evident. Universal. Common sense.

BUT, a text-based, flat, cold, information-driven site is not a brand experience. It is not helpful. It is the opposite. Do not confuse a thorough Navigation Bar for a good patient experience. A list is not what people need. They need to be engaged, spoken to, helped. If anything a cold site speaks volumes about a different form of efficacy — the efficacy of compassion. Does this company, this drug, even care about me, the patient?

One category "gets it." Breast Cancer. Almost any site — branded, unbranded — is engaging and offers good information and some support. Herceptin ( is particularly strong. Other models? The epilepsy category does engagement and has a patient sensitivity that is very well done —,, Or ADHD —, among others. Alzheimer's Web sites are also worth reviewing.  Also, some of the depression sites and RA sites are excellent. They get the mix of emotional and rational information and engagement needed.  

So, although I never do this, I have call out a few brands that need to hand over their sites to patients and an advocate. These brands need to find the power of the heart to help patients, the use of video and other learning techniques to increase information retention – Nexavar, Sutent, Affinitor, Gleevec, Revlimid, Avastin – actually the list is too long. Why?

Because I was that caregiver. And the lack of engagement, the lack of clear, usable "answers", prevented me from helping my sister in the way I had been asked to. The lack of humanity, the poor, unsatisfying Web experiences, wore me out then and they have now.

This was unlike any blog I have ever written. Why? Well, last week was about story-telling, and I just told mine. But there are thousands and thousands of people suffering from the most awful diseases, and what do they get? Here, print this out.

My advice? Walk in your patient's shoes.

Learn more about how branding works to your advantage.

Think about what you would want and do it.

My families story does not end, though my sister's life did. In her last months, she used her energy to create a foundation for melanoma —— and worked to get the famous WISTAR Institute and her employer and everyone she ever knew, involved.

Once sitting in a room of desperate, depressed and yet hopeful melanoma sufferers, one said, "I have looked for answers everywhere, and I feel like I can't get any, I just don't expect anything anymore."

She looked up, and quipped, "Expectations? I'm just happy if they validate my parking."

Maybe this was her story, not mine.

Brand Building Through Story-telling

This week, we take a turn from Direct Marketing — hard core, practical and always useful — to a more intangible approach to communication to patients and doctors: Story-telling.

I came across this great treatise by a Michael Margolis ( and it is soooooooooooo missing from pharma/biotech and yet so completely applicable and compelling.

Story-telling. The eight precepts he focuses on are a bit revolutionary for pharma/biotech:

  1. The very act of naming something transforms our relationship to it.
  2. Brands (just like the naming process) are the symbolic and psychic containers for communicating the meaning of stuff.
  3. A Brand’s Story equals the collective sum of perceptions and representations of the brand as told by everyone.
  4. Every storyteller has a brand, just as every brand has its stories.
  5. Origins – Create a back-story for your brand with a clear sense of beginning.
  6. Ethos – We all need something to believe in. Distinguish yourself with personality.
  7. Cultural Contribution – Brands live and die within a cultural context.
  8. Just as we are hard-wired for storytelling, we are hard-wired for brands.

Why this could be so powerful is simple and we see some basic uptake of this approach in Web sites using video to tell their stories from a patient perspective — Wyeth does it for the hormone replacement franchise, or UCB for Vimpat and companies like Snow & Associates have done very well with bringing humanity and empathy through grass roots patient events.

But that is the surface level of what story-telling is all about.  Social Media, the current darling and devil-in-the-details for pharma/biotech, is about story-telling, but it is unfocused, all over the place; and while it has the mantle of authenticity, Social Media has a random, uncontrolled feeling to it, whether it is Facebook or a message board on

True story-telling is how a brand helped create or facilitate something greater in one's life. And with our industry, the stories are everywhere, the belief in a brand that helped someone get to a better place in their life are rife.

I happened to interview four post-kidney-transplant patients over the past few weeks. What amazed me was how little they all spoke about their kidney and how much they spoke of the people who helped them, the experience of feeling free (of the dialysis machine) and how they were exploring so many new and different avenues that they had not before. Now the drug we market helped make these dreams and aspirations possible; they were all energized and inspired. One was exploring a new career as a translator; another was helping write patient brochures from is perspective to help people…on and on. But their was no emotional connection or recognition of that Brand's role. Imagine if there was.

And story-telling is a multi-platform strategy — Inner Space ( did it on documentary form. But it can be done online easily — like ethnography's. Or what about a vanity press book of patient's stories. Or a video blog which feeds into your unbranded patient site.

But what is the deal-killer here is that many pharma/biotech people are too careful and thus suck the authenticity out of a person's story. Suddenly it feels "canned", artificial, over-produced. So, when you see those patient videos on product Web sites, although those voices can add credibility, the perfect production values, the smooth editing and the short, neat video clips can come across as phony. Exactly the opposite of what you are trying to convey. Whatever you do, do not confuse a patient testimonial with story-telling.

I think the pursuit of Social Media is a great way for clients to learn how to embrace story-telling and authenticity; it is the baby step. Seriously, read those 8 rules and ponder your brand plans, patient plans, your Social Media — are you doing it in the best way? Are you mucking up a great strategy with phony execution? 

Direct Marketing: A Lost Art? Part 2. The Mail Package Sequence

My friend and expert in Direct Marketing is going to share some of her incredibly comprehensive experience on the blog. Direct Marketing is incredibly important for pharma/biotech; and even though it is used prevalently, it is not used with a formal discipline. Claudia Long ( knows more about DM than nearly anyone I know. We all can learn. And hopefully, she will have more"lessons" to share. For any client-side folks reading this, I urge you to challenge your agencies to show their real DM understanding. It has a direct impact on the ROI of your work.


I want to thank Alfred for inviting me to post on the topic of direct marketing. Having been a marketer for more than two decades, I welcome the opportunity to share my experience.

But where to start?  I chose ‘sequence,’ or ‘flow’ because it demonstrates a core principle of direct – a holistic approach that is rooted in ‘reaching out and touching someone.’


In pharma particularly, we must recognize and adhere to the regulatory environment we operate in, while still creating work that is empathetic and patient-centric.

I think of every good direct piece as a journey on which you lead your prospect/reader, with a distinct starting point – in the case of mail, the OE– then specific touchpoints along the way to create interest and inform, all with a strong, clear drive to the destination – the call to action.


My advice to clients when initially presented with a concept is to FIRST put yourself in your reader’s position. One reader, that is. A letter is a convention, a communication from one person to another.  Whom are you talking to, who will most benefit from what you have to offer? You must understand your prospect as completely as your product.

Imagine them at their mailbox. What is their state of mind as they see your package? If you were him/her would you open it? That’s the first test. If it fails, it doesn’t matter what’s in the rest of the package.


The second step on the journey is the letter, which should be the next thing they see. The headline, or whatever pops first graphically, should be directly related to the OE teaser and be compelling enough to move them forward into the package.


I learned the craft of letter-writing from Emily Soell of Rapp and Collins, a DM pioneer. One of the first things she taught me was creating the voice of the letter writer. Who is this individual? Your reader needs to know who is talking to them and why, immediately.

Once you establish the voice, you begin to develop credibility and connection. You must convince your reader that you know who they are, what their issues are, that you care and have something valuable to offer.


Your letter persona must come across as a human being, not a corporation. This is the emotional, bonding part of the experience. If you are successful, your reader will then go to the brochure to learn more, or respond immediately. Trust is key to this process, and the letter has to establish it.


Sequence is important in the brochure as well. I see many that don’t track properly, that don’t lead logically to the next section of information. Make sure your reader never gets confused or bogged down, or you will lose them. If they think “this is too complicated, I’ll get back to it later,” most of the time they won’t.


Finally, all pieces in a package must contain a strong, graphic call to action, with as much immediacy, incentive and authenticity you can muster. Your reader must feel something important is at stake, and it must be easy to act on right now.


Direct marketing is, at its best, not about rules and conventions, but rather about establishing intuitive and emotional connections.


Finally, a word about a specific type of DM package – the fulfillment effort.  I have seen too many that are complicated and unwieldy. Too much information overloads and overwhelms. Never include more than 3 or 4 pieces in a package, and make sure they relate graphically.


Mailing too much defeats the purpose of building a long-term relationship. Offer limited materials and provide easy ways for your reader to interact before you send more. This optimizes your mailing costs and more easily allows a two-way relationship to be built.

The Future of the Web User Experience? And What Does It Mean Now?

You have to use the link below to take you to Aurora, the future of the Web. This is an amazing video. I got in from Craig DeLarge, a real Thought Leader.

But when I wrote that subject line of this entry, I thought, "User experience or Web Browser"? But then I realized that my very question defined my own limitations on understanding not just what is possible, but what is coming!

You watch this and realize that we are all living with our limitations and this also applies to marketing. As everyone does their brand plans, how about one innovative idea in the mix? How about something that has no firm ROI? I do not mean just Social Media — what about having a brand team up with a spa? Or a cereal? Or work with Pepsi and their wellness group? Or develop a book of the published stories of patients? 

This demo tells me that pharma/biotech marketing has the opportunity to work very well with the future as painted by the Aurora browser. At the core of a patient experience, especially early on in their experience as well during periods of stress, is the need for immediacy. 

A psychologist once told me that the key behavior that a patient goes through is they are told something by the doctor, they follow those instructions and then the questions start; who answers those questions? And by not being able to get those answers immediately what is the impact of those festering questions, which turn to doubts which, inevitably, becomes non-adherence. How about offering a handheld technology to oncology patients after a transfusion that is a patients form of ePocractes? Immediacy. (And great PR for the company among doctors and others.)