COVID-19 Pandemic Learning: The Uprising of Remote Detailing in Pharmaceutical Sector Using Sales Force Automation and Its Sustainable Impact on Continuing Medical Education
Round 1
Reviewer 1 Report
This study presents studies the use of SSFA into work patterns in Turkey. This study compares the findings of internists and medical products that have been gathered from a pharmaceutical company’s SFA. The research mostly includes a mini-review of the literature and supports that SFA technologies can be expanded and advance medical knowledge of physicians. The present study is interesting, includes lots of data, and manages very well. Therefore, this study can be published in the ''Sustainability'' after minor revision.
All the abbreviations should be explained where presented for the first time.
The language of the manuscript should be controlled thoroughly and simplified as needed.
Table 2 and Table 3 should be replaced with Tables 3 and 4.
Table 4 should be cited in the manuscript before Table 4.
Table 7 should be given before Figure 1.
The conclusion can be summarized since the conclusion should include the findings of the present study and no introduction is needed.
Author Response
Dear Reviewer 1, thank you very much for your kind suggestions. Me and my co-authors, we revised and explained the abbreviations below where presented for the first time:
1) IT is revised and explained as "information technology" at the end of the first paragraph of Introduction.
2) OECD is revised and explained as "Organisation for Economic Co-operation and Development" in 7th line of the second paragraph of Introduction.
3) SWOT is revised and explained as "strengths, weaknesses, opportunities and threats" at the end of 2.3.2nd sub-title's text entitled "Effective and electronic detailing".
4) USA is revised and explained as "United States of America" in 3.1st sub-title's text entitled "Data Collection and Sample".
5) UK is revised and explained as "United Kingdom" at Conclusion.
6) US is revised and explained as "United States" at Conclusion.
Table 4 is cited in the manuscript before Table 4 with these sentences:
"The results, shown in Table 4, indicate that the data do not follow normal distribution according to the Kolmogorov-Smirnov normality result (p=0,00 < 0,01). In Table 4, alternative hypotheses (H1, H2, H3) are tested with the nonparametric method, Mann Whitney U, and the results are given".
Reviewer 2 Report
Comments for author File: 
Comments.pdf
Author Response
Dear Reviewer 2, thank you very much for your kind suggestions. Me and my co-authors, we revised and explained the abbreviations below where presented for the first time:
- We wrote the elaborative form of OECD as "Organisation for Economic Co-operation and Development" in 7th line of the second paragraph of Introduction, in first use.
-
We replaced the sentence “This study aims to...” with “This study was aimed to...”.
- We revised the text belonging to “Data collection and sample” sub-title and we transformed these sentences from present tense to past tense.
- We used “in the present study” instead of “in our study” in Limitations and future research section.
Reviewer 3 Report
The theoretical part is consistent and synthetically presents the relevant information.
A set of clear objectives (from which the working hypotheses are derived) at the end of the theoretical part would have been much more useful.
3.1. Data collection and sample
The data presented for the participants is not clear.
If information about research participants is not relevant, this should be briefly explained. Was there a clear method of sampling?
Repeating the hypotheses in section "4 - results and discussion" is unnecessary. It would be appropriate to reformulate them in the text as a preamble to the statistical analyses.
Non-parametric statistical methods are used. Does the statistical data have a non-parametric form?
I think the explanations of the results should be rewritten to make the text more coherent.
The conclusions are consistent.
Author Response
Dear Reviewer 3, thank you very much for your kind suggestions.
1) You have mentioned that a set of clear objectives (from which the working hypotheses are derived) at the end of the theoretical part would have been much more useful.
Thus, we added this informative section below to be able to explain more clearly our objectives designing this study.
“The COVID-19 pandemic has presented numerous obstacles for health care systems and healthcare professionals. Healthcare providers (HCPs) give frontline care to patients with COVID-19 in difficult conditions which include insufficient staffing, unknown treatment protocols, prolonged periods of hard work, wearing mandatory safety equipment, and an ongoing risk of infection. Among the physicians participated media interviews, some of them expressed dissatisfaction with the frequent change of protocols, prevention and treatment methods and the attendant negative effects of this on their performance. In the present study, we also measured the behaviors and attitudes of 816 physicians who are visited jointly in a wide-ranging medical field such as internal medicine and pre-and post-COVID-19 periods. With the help of this tool, we were able to measure not only the skill of SFA but also the attitudes and behaviors of physicians during the pandemics when there were uncertain treatment protocols.”
2) You have mentioned that the data presented for the participants is not clear.
We would like to detail you the structure of the selected sample.
We would like to underline that we did not select the participants who made up the sample we included in our study, and we did not obtain the data through face-to-face interviews. The participant data analyzed here belong to the regular physician visits of the medical representatives working in the pharmaceutical company.
The number of physicians working as internists in Turkey is around 7000-7500. But, we included internists who have regularly visited in the first three months of 2020 and 2021 by medical representatives working in the pharmaceutical company that shared their data with us. According to this, in our study, the visit details of a total of 1682 doctors for the first three months of 2020 and a total of 835 doctors for the first three months of 2021 were analyzed. It is important to notice that 816 of the internists visited in these two years were the same. So, they have visited in both years.
3) have also asked if was there a clear method of sampling?
We preferred full count sampling method to determine the sample. Because this census sampling method as a type of purposive sampling technique that involves examining the entire population (i.e., the total population) that have a particular set of characteristics (e.g., specific attributes/traits, experience, knowledge, skills, exposure to an event, etc.). is more appropriate for our present study.
4) You have noticed that repeating the hypotheses in section "4 - results and discussion" is unnecessary.
You are right, we deleted the hypotheses and we have only mentioned H1, H2..etc.
5) You have mentioned that non-parametric statistical methods are used. Does the statistical data have a non-parametric form?
We added this detail “In Table 4, alternative hypotheses (H1, H2, H3) are tested with the nonparametric method, Mann Whitney U, and the results are given” before Table 4 in the manuscript.
And also, we have added this methodological detail before Table 1:
Non-parametric methods were used because eight variables (segment, customer, unit, brick, line, region, product, package) used in the analysis had categorical scales and three continuous variables (presentation time in a scheduled visit, presentation time in an unscheduled visit and total presentation time) are not normally distributed.
Author Response File: Author Response.pdf
Reviewer 4 Report
General Comments
The grammar needs to be significantly improved. The sentences are long and at times incomplete and incoherent. The use of present and past tenses in the same sentence and paragraphs needs to be addressed.
The introduction states uncreased growth in 2020, however the first sentence suggests that growth is due to recovery from Covid-19 please clarify. The study aims to investigate SFA tools in CRM for CE as stated, what is the purpose of this investigation? Are the authors trying to ascertain the effectiveness or efficacy of the tool? The research question is not clearly defined. The hypotheses as stated are simply factual statements because there is no defined research question it therefore makes it difficult to generate proper hypotheses.
In section 2.2 The role of a medical/pharmaceutical representative is to promote products to healthcare professionals. The application of the laws that restrict advertisement would therefore not be valid in this context. I am also not sure what the authors is trying to say in this section about CLM.
Section 2.3: It is not clear what statement the author is trying to make about the usage of SFA? Is it the usage pre or post covid?
Section 3.1 Is the author referring to the product or prescribing habits of the internist.
Tabel 2 ; There is no legend for the table to show what the rows represent for the variables and the lines. The previous table state that the lines represented the medical representative. What do the Greek letters suggest?
Comments for author File: Comments.pdf
Author Response
Dear Reviewer 4, thank you very much for your kind suggestions.
1) You asked to clarify the first sentences of the introduction section stating that “uncreased growth in 2020, however the growth is due to recovery from Covid-19”.
We would like to underline the importance of adaptation capacity of the pharmaceutical companies to digital technologies and solutions. Because health professionals access was already declining and pharma sector had to reinvent the way to reach them. Perhaps the largest and most obvious change brought on by COVID-19 is the emphasis on pharma communicating with health professionals electronically and virtually. Although electronic methods of communication are not new, the pandemic has forced the issue by requiring much of the communication between pharma and health professionals, which previously took place in person, to take place electronically and virtually. This includes emailing, texting, calling, and video meetings.
Traditional face-to-face detailing methods with paper brochures have been steadily replaced by electronic detailing. E-detailing is a new communication channel to promote pharmaceutical products to physicians using digital technology, including the internet, video conferencing, and interactive voice responses. Concerns regarding the global spread of COVID-19 have recently made it more difficult for medical representatives of pharmaceutical companies to physically visit hospitals and meet physicians than ever before. In the contactless era, most marketing activities are based on information and communication technologies, mainly internet and mobile devices. Electronic interactions between pharma and physicians are required because the pandemic has caused shifts in workflows and operational aspects of physicians’ practices. As a result, health professionals want to interact with pharma and medical representatives in the most time-efficient manner possible.
Medical representatives spend their days chasing down health care providers, visiting medical practices, physicians’ offices, and labs. E-detailing, like remote detailing, involves making promotions and sales remotely but generally refers to introducing educational materials instead of pharmaceutical drugs. Remote detailing is the process of selling pharmaceuticals to medical professionals remotely. Relationships are more challenging to build remotely.
2) You also mentioned that “the study aims to investigate SFA tools in CRM for CE as stated” and asked “what is the purpose of this investigation? Are the authors trying to ascertain the effectiveness or efficacy of the tool?”
On the other hand, the analytics tool SFA integration helps in identifying the health professionals’ engagement levels with the feedback capturing feature. It facilitates collecting the physicians input during the remote calls or self-detailing from any device. It further helps in knowing the physicians’ preferences for face-to-face and remote calls so the pharmaceutical company can tailor the ratio balance accordingly.
The feedback, including call duration, devices leveraged for the meeting, interest during call duration, reaction to each slide, and percentage ratio of remote call vs. face-to-face meeting, plays a vital role in the marketing decision-making process. The flexibility to meet via remote calls increase the duration of call with health professionals, and contextual content intrigues the health professionals, which, in turn, improves the health professionals’ satisfaction.
With the help of this tool, we were able to measure not only the skill of SFA but also the attitudes and behaviours of physicians during the pandemics when there were uncertain treatment protocols.
3) You have mentioned that “in section 2.2 The role of a medical/pharmaceutical representative is to promote products to healthcare professionals. The application of the laws that restrict advertisement would therefore not be valid in this context”.
Article 13 of the Pharmaceuticals Law and the Regulation on Promotional Activities of Human Medicinal Products (Promotion Regulation) prohibits the advertising of medical products for human use to the public in Turkey. However, the Promotion Regulation introduces an exception to this rule. Information can be provided to the general public on products that are used in vaccination campaigns, organised actions to combat epidemics or other campaigns run by the Ministry of Health to promote health (as they are important to safeguard the public) with permission from the Ministry of Health and within the confines of principles and procedures set out by the Ministry of Health for the products.
Licensed (authorised) products can be promoted to healthcare professionals within the scope of the approved labelled information. The fundamental rule is that marketing authorisation holders and their representatives cannot provide, offer or promise benefits to healthcare professionals through promotional activities. Under the Promotion Regulation, products that are not granted permits or authorisation in Turkey cannot be promoted (off-label promotion is strictly forbidden), and advertisements directed at healthcare professionals must contain information consistent with the approved products, and an updated summary of product characteristics.
"Promotion" includes objective, informative and factual medical data to enable healthcare professionals to form their own opinion about the product. The promotional activities must:
- Not be used to encourage unnecessary use of a product.
- Delivered by certified representatives.
All promotion representatives receive certificates when they successfully complete training organised by the Ministry of Health or on submission of diplomas from the departments of universities educating medical sales representatives. The examinations required for certification are conducted according to guidelines published by the Ministry of Health and based on the Promotion Regulation. Individuals without the certification cannot work as promotion representatives for pharmaceutical companies.
4) You would like to learn more about CLM (closed loop marketing) saying “I am also not sure what the authors is trying to say in this section about CLM”.
Briefly, Closed Loop Marketing (CLM) is a feedback loop, a closed-loop marketing strategy that supports each future action with information from the previous touch point. In the pharmaceutical industry, where regulations are intense, the information obtained from doctor and pharmacist interviews used for e-detailing, and thanks to this e-detailing system, medical representatives can learn which drugs target doctors are interested in, which images in the promotional material, and which pages of the promotional material they spend more time on. Thus, they can offer personalized content to the target doctor in line with the information.
The idea in Closed-Loop Marketing (CLM) is to create a circle between a target and a multi-channel digital marketing tool aimed for promotion and sales. CLM captures the healthcare professional’s feedback, preferences and attitude while updating the information in real time during the marketing process. This personalizes the submitted messages depending on the collected feedbacks via digital tools such as SFA. The CLM takes into consideration the reaction of each healthcare professional to key information through multiple supports (videos, pictures, PowerPoint presentations, questionnaires, etc.) and adjusts the messages and the marketing strategy accordingly. The most important thing allowed by this system is to track the ability of the representatives to apply the message strategy decided by the marketing department and the behaviors of healthcare professionals. Other important and useful information relates to specific user flow and behavior patterns within the model, user acquisition channels, geography, time spent in particular model section, number of sessions, session duration, model views and other analytics metrics (as described in details in Table 2 in our study’s dataset). CLM offers great opportunities for pharma companies to develop a personalized relationship with each healthcare professional and to refine their marketing strategy so that every delivered key message hits its target.
According to the REGULATION ON THE PROMOTIONAL ACTIVITIES OF MEDICAL PRODUCTS FOR HUMANITY, published in the Official Gazette dated 03.07.2015 and numbered 29405 in Turkey, it is legal for medical promotion representatives working in pharmaceutical companies to promote health professionals. The relevant articles in the regulation are summarized below:
Scope and Principles of Promotional Activities of Products
Scope of promotion
ARTICLE 5 – (1) Promotion covers the promotion activities of the products within the scope of this Regulation to physicians, dentists and pharmacists.
(2) Promotion for healthcare professionals;
- a) By using promotional materials to physicians, dentists and pharmacists,
- b) By organizing or supporting scientific meetings and product promotion meetings,
- c) Physicians, dentists and pharmacists are visited by medical representatives, is performed.
Basic principles and principles of promotion
ARTICLE 6
(4) Promotion includes informative and evidence-based medical information about the properties of the product and in a way that will help healthcare professionals form their own views on the therapeutic value of the product.
(5) In case the promotion is made with a documentation prepared using citations, tables and other visual materials from medical journals or other scientific studies, these materials are used faithfully and by specifying their sources.
Medical Sales Representatives
ARTICLE 10
2) Medical sales representatives;
- a) Provided that they have qualification documents, they can work in companies with the title of medical sales representative.
- b) They cannot promote any product and similar products and cannot give promotional materials to healthcare professionals other than physicians, dentists and pharmacists.
The ability of medical sales representatives to promote human medicinal products in public health institutions and organizations during working hours is subject to the following rules:
- a) The relevant administrative chief allocates the most appropriate time, taking into account the working order, in order to ensure that medical sales representatives can hold meetings with healthcare professionals for product promotion. This allocation cannot hinder education services and health services provided to patients.
- b) Medical sales representatives explain which license/permit holder they represent at the beginning of the visit and show the product promotion representative ID cards.
5) You have mentioned that “It is not clear what statement the author is trying to make about the usage of SFA?” and you would like to detail if “Is it the usage pre or post Covid”?
The COVID-19 pandemic has presented numerous obstacles for health care systems and healthcare professionals. On the other hand, the Covid-19 pandemic has further increased the importance of digital marketing tools as customers have massively shifted towards digital channels to interact with businesses and sales.
Healthcare providers give frontline care to patients with COVID-19 in difficult conditions which include insufficient staffing, unknown treatment protocols, prolonged periods of hard work, wearing mandatory safety equipment, and an ongoing risk of infection. Among the physicians participated media interviews, some of them expressed dissatisfaction with the frequent change of protocols, prevention and treatment methods and the attendant negative effects of this on their performance.
In the present study, we also measured the behaviours and attitudes of 816 physicians who are visited jointly in a wide-ranging medical field such as internal medicine and pre-and post-COVID-19 periods. With the help of this tool, we were able to measure not only the skill of SFA but also the attitudes and behaviors of physicians during the pandemics when there were uncertain treatment protocols. In a post-Covid-19 scenario, SFA tool is expected to further influence and reinvent businesses and relationship management as pharma companies will need to review their marketing and sales strategies and contextualize them in the “new normal” stemming from the pandemic. It is expected that the need for updated communications in real-time will play a key role to facilitate business, starting with mapping the customer journey. We wanted to scientifically prove this assumption.
6) You would like to ask if “the author referring to the product or prescribing habits of the internist in Section 3.1”.
In this study, we are referring to the products of the selected pharma company. We did not look at the prescribing habit of the physician since we did not include the sales data of the pharmaceutical company. This could be the subject of another study.
We put forth that thanks to SFA tool abilities we have been able to analyse and compare the interest levels of the target physicians towards the products before COVID-19 and in COVID-19 scenarios.
7) You have mentioned that “Table 2; There is no legend for the table to show what the rows represent for the variables and the lines”.
The fundamental variables described in Table 2 belong to the parameters of a detailing visit to a physician such as; the segment, customer, unit, brick, line, region, product, package, presentation time in a scheduled visit, presentation time in an unscheduled visit and total presentation time.
8) You would like to ask that “The previous table state that the lines represented the medical representative. What do the Greek letters suggest”?
Promotion teams working in pharmaceutical companies are called "line". It is a sectoral statement. They are similar to departments or project teams in companies in other industries. The organizational structures of these lines in each pharmaceutical company are as follows: At the top is the business unit manager, below it is the marketing manager responsible for promotion. There are product managers of related products under the business unit managers. Under the marketing manager responsible for promotion, there are the promotion manager, under him the regional managers and his subordinates, medical sales representatives.
The number of people who make up Line varies according to the size of the pharmaceutical company and the geographical area it serves.
In our study, the line names working in the pharmaceutical company that provided us data set were defined by the company as Alpha, Beta, Delta, Epsilon and, Gamma. These line names differ according to the preference of each company. There is no particular reason why they have Greek names.
9) You would like to ask that “ambiguity of what?” for the sentence “Eftekhar Ardebili et al. [28] suggested in their study that physicians expressed their dissatisfaction with the ambiguity which was an inability to successfully treat patients causing negative effects on their professional performance during the pandemic” in 2.2.1. Continuing Medical Education section.
There was an ambiguity due to uncertainty in treatment protocols for COVID-19. When the first case of a new type of respiratory infection were reported to the World Health Organization (WHO) on December 31, 2019 (WHO, 2020), the outbreak was supposedly domestic, limited to Wuhan, China. This corona virus seemed to be far away and insignificant to most people and also to physicians around the world. Just a few weeks later, on March 11, the WHO declared the new disease (then named COVID-19) a global pandemic as the virus (also called SARS-CoV-2) spread rapidly around the world with huge infection cases and associated deaths in many countries.
The physicians were dissatisfied in pandemic period because clinical studies and vaccination studies were still ongoing faster. Currently, “effective infection control intervention is the only way to prevent the spread of SARS-CoV-2. The most appropriate prophylactic regimen for patients under observation due to COVID-19 related disease was unknown. For this reason, treatment protocols should be planned by following the current guidelines” (Turkish Academy of Sciences). Physicians are interested in different products according to the symptoms they encounter in COVID-19 period, regarding their own experiences.
Author Response File: Author Response.pdf
Reviewer 5 Report
I have enjoyed reading the paper and please see my attached feedback. I would make sure you ask at least 1-2 friends reading the paper thoroughly to make sure it is at a much better level, especially for minor language issues.
Comments for author File: Comments.pdf
Author Response
Dear Reviewer, 5, thank you very much for your kind suggestions. Me and my co-authors, we revised and edited some language issues. Since you indicated that you prefer coloured text, we have highlighted yellow our revisions and attached the revised file on the system.
1) You would like to ask editing this sentence “This study aims to fill a gap in the literature by investigating the use of SFA intowork patterns such as health professionals’ loyalty and involvement in their medical knowledge inTurkey allow for differentiating training from marketing.”
We edited and re-wrote in the manuscript as “This study aims to fill a gap in the literature by investigating the use of SFA in work patterns such as health professionals’ loyalty and involvement in their medical knowledge in Turkey allows for differentiating training from marketing”.
2) We revised and explained the abbreviations below where presented for the first time:
- IT is revised and explained as "information technology" at the end of the first paragraph of Introduction.
- TL is revised and explained as “Turkish Lira”.
3) You have proposed to prefer “During the Covid-19 pandemic..” or “related to the pandemic...” instead of “Due to the effect of the COVID-19 pandemic,” designing our hypotheses.
Me and my co-author, we would like to clarify that we would like to keep “due to the effect of the COVID-19 pandemic” because the data in the present study covers the first three months of the year 2020, when medical representatives had a normal daily routine, and that of 2021, when Turkey experienced the most powerful surge of the Covid-19 pandemic. Thus, we aimed to compare these two years regarding to monitoring product, physician’s segment, medical representatives’ behaviours and continuous medical education process of physicians with SFA.
4) You noticed that we have used references in text; you are right. We apologize for that, we removed all references in text. Ex: [26] [27] [28] and [30] are revised.
5) You would like to asked to check the segmentation parameters such as geographic basis, …etc.
We re-wrote these parameters in italic for the reader to follow easily.
6) You have strongly suggested us to call future researchers to use Online Photovoice (OPV) to conduct research on the same or similar topics.
We have read the two articles that you have suggested and we have cited these two articles below:
Tanhan, A., & Strack, R. W. (2020). Online photovoice to explore and advocate for Muslim biopsychosocial spiritual wellbeing and issues: Ecological systems theory and ally development. Current Psychology, 1-16. https://doi.org/10.1007/s12144-020-00692-6
Doyumğaç,İ., Tanhan, A. and Kiymaç, M.S. (2021). Understanding the Most Important Facilitators and Barriers for Online Education during COVID-19 through Online Photovoice Methodology. International Journal of Higher Education, (10)1. 166-190. https://doi.org/10.5430/ijhe.v10n1p166
We added the importance of providing new educational methods in order to conduct more efficient online education.
Tanhan, Doyumğaç and Kiymaz [29] suggested that institutions that switched to online and remote education without preparations during the COVID-19 pandemic, should provide flexibility for the students, employees and/or instructors, provide technical support to conduct more efficient online and remote education services.
We have also referred Online Photovoice method for further studies in similar topics.
Tanhan and Strack (2020) developed Online Photovoice (OPV) method to reduce costs and time spent for online interactions where face-to-face interaction is impossible or very difficult due to a pandemic or endemic, security problems, conflicts or natural disasters. For further studies, online photovoice may be a new research method for hospital meetings organized periodically by pharmaceutical companies in order to reach diverse healthcare providers.
Author Response File: Author Response.pdf
Round 2
Reviewer 4 Report
I thank the authors for their response which was basically a review if what was in the paper. The research objective is still not clearly defined and the hypotheses are merely aims of the proposed work being done .
