Electronic patient records in doctors' offices across the country are being used by brand name drug companies looking to muscle market share away from generic competitors, a Toronto Star investigation has found.

Concerned physicians say a clinical tool they use to write prescriptions and care for patients is being co-opted, and they fear health records are being tapped so drug companies can increase profits.

In the battle for pharmaceutical dominance, this new tactic, deployed in software used by doctors, has allowed brand-name companies to capitalize on the moment a prescription is written.

Here's how it works:

The patient records are found in EMRs, or electronic medical record software, owned by Telus Health, a subsidiary of the telecom giant. The software is used by thousands of Canadian doctors to take notes during patient visits and to create a prescription to be filled by the patient's pharmacy.

To drive business their way, brand-name drug companies have paid Telus to digitally insert vouchers so that the prescription is filled with their product instead of the lower-cost generic competitor that pharmacists normally reach for.

The vouchers are known in the industry as "patient-assistance programs." It works like a coupon: If a patient's insurance does not cover the full cost of the pricier brand name drug, the drug's manufacturer will cover part or all of the cost difference from its generic equivalent.

The voucher feature is offered in a number of other electronic medical record systems, Telus said.

Doctors had to agree to the new feature in the Telus software before it was enabled on their systems, and physicians can opt out at any time.

But some physicians may not realize the implications of the vouchers when they click to accept the software's updated features, said Dr. Antony Gagnon, manager of the pharmacy program with the Hamilton Family Health Team.

"The brand name companies are basically using physicians to redirect their prescriptions of generic drugs to the companies' brand drugs," Gagnon said.

In an internal document obtained by the Toronto Star, the head of Ontario's doctor regulator, speaking generally, said vouchers being included on a prescription is "not appropriate" as they may lead patients to think their physicians favour brand drugs over generics.

Generics contain the same medical ingredients and can cost as little as one-fifth of the brand price. A former assistant deputy health minister, Helen Stevenson, said the vouchers can pile unnecessary costs on to private drug plans. These costs could ultimately be passed to the patient through higher premiums.

In an interview, Telus Health President Paul Lepage defended the program, saying thatelectronic vouchers streamline payment assistance programs already "used by millions of Canadians who really use them to reduce the cost of their medication."

In the past, drug company reps gave paper vouchers to physicians who in turn could hand them out to the patient.

With the updated software, the voucher can be printed right on the patient's prescription.

"Our physician customers who use these programs have asked us if we can simplify the process," said Lepage of Telus. "We're focused on offering cost-effective solutions to physicians and patients."

The voucher function has been "very positively received by the majority of our physician users," a Telus spokesperson said.

Why do brand name companies offer these vouchers?

In an effort to keep costs down, many drug plans encourage pharmacists to substitute a cheaper generic drug when filling a prescription for a brand drug, unless the prescribing doctor specifically requests otherwise. Without the voucher, even if a doctor uses the brand name on a prescription, pharmacists may substitute the cheaper generic.

But when enabled, the Telus software feature detects when a doctor is prescribing a drug by its brand name, such as cholesterol medication Crestor. The voucher is printed on the prescription and the pharmacist takes that as a specific instruction to dispense the brand name. The voucher is not offered if the doctor enters the generic name (rosuvastatin, in Crestor's case), Telus said.

The brand companies say the payment assistance vouchers are about giving the patient choice between brand and generic drugs without having to spend more money.

But for Gagnon, the vouchers are manipulating physicians' prescribing practices, adding that many physicians use a drug's brand name when writing a prescription out of habit and aren't necessarily instructing that a drug be dispensed over its generic.

The vouchers also reinforce a false premise that generics are inferior in quality to the original brand name drugs, say doctors critical of the program.

The first time Toronto physician Nav Persaud logged on to Telus' PS Suite after its recent update, a text box popped up notifying him of the new feature that could "lead to greater choice and lower cost for your patients."

But Persaud questioned how much his patients would get out of the vouchers.

"It wasn't clear to me who was going to benefit from it. Was it going to further the marketing of brand name products, which I think are prescribed without any clear reason, given that they have the same effects (as generics), and they cost more?" said Persaud, a family physician at St. Michael's Hospital.

He disabled the feature.

A Telus spokesperson said the voucher is offered only after a physician chooses a specific brand name drug to prescribe "so there is no influence on what drug the physician selects."

"As a technology provider, we are careful not to influence or restrict the clinical choices made by medical professionals."

Telus Health is a dominant player in Canada's electronic medical record industry. Its seven EMR systems impact more than 25 million patient-physician interactions each year.

Two of those programs — PS Suite and Nightingale — have the feature offering payment assistance vouchers. Telus plans to expand the feature to all of its EMR programs.

Brand companies pay on a "fixed-fee basis" for their vouchers being included, Telus officials said, but they refused to discuss the details of their agreement with drug companies, saying it was "subject to commercial confidentiality."

About 7,000 doctors across Canada use PS Suite, and roughly two-thirds have chosen to use the voucher function. The company said doctors were involved in designing the feature.

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In the medical practices of the Hamilton Family Health Team, a network of 165 physicians, some doctors were unaware of the voucher feature — nor were they aware that information about those vouchers was being shared with drug companies.

Some of those doctors send the prescriptions directly from their computers to the pharmacy fax machine and never saw the voucher that was included on the printout, said lead physician Dr. Monica De Benedetti.

Without the doctors being fully aware, they could not tell their patients about the program, De Benedetti said.

The health team encouraged its members to turn off the voucher feature. In 2016, De Benedetti, along with Gagnon and the Health Team's executive director, wrote a complaint letter to Telus Health.

"There will certainly be a number of physicians who will be concerned that they are inadvertently participating in contributing data to pharmaceutical companies," the letter read.

Telus said all doctors had to enable the new voucher feature by clicking "accept" in a pop-up text box.

Drug manufacturers paying to have their vouchers in the EMR receive "aggregated and anonymized, province-level statistics" on the total number of vouchers printed off for their products, the company said.

No patient or physician information is shared, Telus said.

Telus said payment-assistance vouchers are offered in a number of other electronic medical record systems offered by other companies.

The company behind one of those systems, however, says it will be ditching the vouchers from its software.

When Loblaw Companies Ltd. purchased B.C.-based QHR and its Accuro software in 2016, it already included a voucher feature, spokesperson Kevin Groh said in a statement. He said they plan to remove the function in the coming months.

"While some discount vouchers — commonly called 'brand cards' — offer valuable financial assistance to patients, many keep patients on higher-priced brand products when more cost-effective generic medications are available," he said.

"Brand cards can create confusion for patients, often leading to the perception that generic medications are inferior," Groh added. "This is a problem for a system reliant on savings from generics."

In an internal letter obtained by the Toronto Star, Dr. Rocco Gerace, registrar of Ontario's College of Physicians and Surgeons said vouchers, in general, should not be printed on prescriptions as they "may lead some patients to perceive that the physician is in a conflict of interest, or that they are recommending or endorsing the name-brand formulation of a drug instead of a generic or other alternative."

Gerace's comments were in a July 2016 response to the Canadian Generic Pharmaceutical Association, an industry group that contacted the College asking for the regulator's view on brand vouchers being included on prescriptions, which it says "appears to be increasing in frequency."

Telus says its voucher feature was not introduced until August 2016. That was after Gerace's comments. A Telus spokesperson said its software follows ethical principles not present in all EMR systems with voucher features, adding that the company sets "the gold standard on how things should be done."

In summer 2016, after learning about the voucher feature for Telus' EMR, clinical pharmacist Cora Van Zutphen crunched the numbers. She estimates that a regular patient with diabetes and heart problems could be billing his private drug plan nearly $3,000 a year in unnecessary costs by using the brand name drugs over their generic equivalents.

Van Zutphen wrote a letter to her colleagues with the Upper Grand Family Health Team, advising the network of doctors in communities north of Guelph to turn off the vouchers.

"When insurance companies pay for brand-name drugs over lower-cost generics, billions of dollars are added to the costs of private drug plans," she wrote to her colleagues. "Ultimately, those costs are passed on to employers and employees."

Voucher programs are not designed to add costs to private plans, a Telus spokesperson said. "Private plans choose what costs they will and will not cover," she said.

But in some cases, if the patient's private drug plan doesn't cover the full cost of the brand drug, then the patient's spouse's health plan is tapped as the next payer — not the drug company, an industry expert said.

"The brand manufacturer is typically the last payer. The claims system looks for every other payer first. It's a brilliant strategy for brands looking to grab market share but not for drug plans — it can unnecessarily raise costs," said Stevenson, former head of Ontario Public Drug Programs and CEO of Reformulary Group, a drug plan management company.

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