An Evolving ‘Opinion’ Landscape New Paths—and Synergies—for Pharma KOLs & DOLs

The pharmaceutical industry has often utilized the expertise of key opinion leaders (KOLs). These thought leaders and healthcare professionals (HCPs) could be helpful in guiding new drug discoveries or getting the word out about a new commercially available treatment. In recent years, however, a new kind of thought leader has emerged in this space: the digital opinion leader (DOL).

Pharmaceutical Executive® brought together a panel of industry experts to discuss how the roles of KOLs and DOLs are changing and how they are coming together in efforts to improve brand awareness and engagement.

Pharm Exec: How has communicating with KOLs changed or evolved in recent years?

CARY CLAIBORNE, CEO, ADIAL PHARMACEUTICALS: We launched our Phase III trial in February 2020, which was just as the [COVID- 19] pandemic began. So, of course, technology had to change and adapt and so did our role with KOLs. Most of our KOLs are in Europe—so, a big driver in the change was communicating over video. We’ve adapted very well to that. The technology has helped a lot, and we are going to continue to use that going forward. It allows us to meet with our KOLs every other week without the travel costs involved, have more robust discussions, and get more involvement, because KOLs are very busy [as a lot of them are treating patients]. This allows them to be able to make more time available to us.

NATALIA FORSYTH, SVP, HEAD OF DIGITAL STRATEGY, GREEN ROOM COMMUNICATIONS: The biggest difference I’ve witnessed is that now we need to have two strategies: one for KOLs and one for DOLs. While they seem like they might be the same thing, we lean on them for different purposes.

KOLs could be the most credible scientific voice in that community, but DOLs also have that online reach, that social media reach that allows you to disseminate broad-based messages. It’s like two different channels we now have that we didn’t have previously.

RITA DALAL EXECUTIVE MEDICAL DIRECTOR OF ONCOLOGY, ALKERMES: We launched our Phase III trial in 2021. And as you might all have experienced, initially launching the new trial was kind of difficult. This is where the DOLs and KOLs who have a presence both in the digital world as well as in-person became very critical for our success since our trial was a global trial as well. It just makes more sense to sometimes use the technology to our advantage and meet them where it fits for the kind of meeting. Sometimes, you need the experience of a DOL and their expertise, and then you may need more in-depth/detailed interactions where you might want to meet in person.

In the past, most meetings were face-to-face; however, during COVID-19, most of these meetings became virtual. Now, it’s becoming a hybrid of the two. You are setting up your interactions with KOLs and DOLs with the idea of what fits the purpose.

JOE WELLINGTON, SVP, MANAGING DIRECTOR AND HEAD OF MEDICAL, EVERSANA INTOUCH: HCPs, like everybody else, have become more digitally mature, and KOLs are on the leading edge of that spectrum in forward thinking. Foreign organizations have embraced this. At EVERSANA INTOUCH, we’re working with several clients in spearheading omnichannel scientific exchange to increase insight velocity in fluid data environments, like oncology. What really excites me the most in terms of what’s changed is that we’re doing so much more co-creation of content through these platforms, not only on things like scientific platforms and medical education, but beyond the purely scientific engagements into areas like [diversity, equity, and inclusion] and shared decision-making initiatives. It’s an exciting time.

ROB ETHERINGTON, CEO, CLENE NANOMEDICINE: I think the [KOL] is still as important as they ever were. And, yes, I concur with Joe. They’ve matured, and they now recognize [the need] to have an online presence. Even just the way they communicate with the pharmaceutical company can easily be [done digitally]. In fact, arguably many of them even prefer that interface, based on a number of the [KOLs] who we have historically worked with. Clene is in a rare space—amyotrophic lateral sclerosis, or ALS, a disease formerly called Lou Gehrig’s. There is a relatively small group of KOL individuals who drive many key decisions; they offer Zoom as an option every time we want to meet. Frankly, I think they may prefer it. But the criticality, the importance, [and] the relevance of KOLs haven’t changed at all. We just now have more methods by which we can communicate, learn together, and drive change clinically.

FORSYTH: You bring up a really interesting point about the disease areas and how DOLs and KOLs factor in. In rare disease, you have a smaller group of KOLs who you’re working with, and they may be more inclined to be KOLs and not DOLs; whereas, say you’re working in a condition like diabetes, you have hundreds of thousands of individuals to choose from and many of them have leaned on those more digital technologies to be DOLs. So, sometimes, being a DOL isn’t even an option for the disease state you’re working in.

EDITH PEREZ, CHIEF MEDICAL OFFICER, BOLT BIOTHERAPEUTICS: Maybe I can add comments from a slightly different perspective because I may say that I was considered a KOL before deciding to get into the biotechnology/ biopharma space. Having that perspective has been very helpful in my transition to biopharma. I had the honor to be part of the Mayo Clinic faculty for 27 years, leading and collaborating in many trials, working with a wide range of people around the world, and being a co-author in more than 450 manuscripts. Integrity, ethics, team work, and communication have been driving principles in this trajectory. No matter how much technology we’ve been able to take advantage of, it is amazing to me how important it is to try to still meet face-to-face when feasible. We still need to take advantage of what’s new and communicate it effectively.

A big difference is that sales representatives have had much more access to physicians in the past compared to what’s happening now. To me, there has been a major change. I think focused and targeted meetings, plus digital strategies, are going to become even more important than they were in the past.

KILIAN WEISS, GENERAL MANAGER, VEEVA LINK: One thing we’re clearly seeing from the engagement is that hybrid is coming back and is super effective. It’s more effective than just in-person or just digital, and we have very clear data. The other interesting thing, going back to the theme we already discussed, is there’s a bigger group of stakeholders now. It’s the different channels; it’s more fragmented themes; it’s the different roles of these people all the way through market access. And what we’re seeing with many companies is they’re expanding the pool. There’s still a lot of, I would say, randomness in the engagement patterns. We’re seeing that about 70% of the KOLs engage with one company. It’s super interesting, actually.

PEREZ: I can add something, and it is [about] how we can help disseminate or communicate our own data, our own platforms, [and] the science behind the work that we’re doing. Because, again, in the past there has been a tendency to keep everything internally for pharma. All the slides are confidential; and if everything’s confidential, then we’re not making information accessible so that others can amplify the message. I think [we must] consider early [on] what is confidential versus what can be shared with KOLs, with digital persons who can assist us. It’s going to be critical [to be] very open and transparent.

FORSYTH: Edith, you bring up a great point about safety. When it comes to opinion leaders, there is a higher risk inherently in working with a DOL than a KOL because something that can be said online can be shared at lightning speed. And we’ve seen it come back and hurt companies in the past. So, having those risk mitigation strategies, those very clear, concise messages that are approved, it’s really a different strategy—a different interaction. I did want to bring up that slightly elevated risk.

ETHERINGTON: We’re used to traditionally having a lot of control over what is said about our drug in our tightly regulated environment, and even the [KOL] is used to having a lot of control about what he or she says about a disease, about a drug. In this new era—which we’ve all dealt with in all different parts of our life with respect to social media—we have less control. It’s almost incumbent upon and critical that we carefully use the appropriate language. And, again, Edith, you’d made this point that we really consider if we’re going to help frame the argument, frame the conversation, and bracket it. [This is] so that we make sure it is done properly and within the safe boundaries that the regulatory agencies require. Then we need to be very forward thinking and cautious about what we present publicly and that we are careful to not present something that’s confidential. What we publicly say should be designed to influence the conversation because it’ll get used, picked up, and magnified.

One other thing to raise that, I think, is critical for [the] rare disease [space]—and we’ve kind of touched on this point a little bit—is that it’s not just physicians who have an important digital role. Now, the people who are devastated by rare disease, as well as their advocacy groups, are also important. In fact, for ALS, we’ve seen two approvals this year. There’s an advisory committee coming up for another ALS drug; and in both cases, there’s been a slew, a cacophony, a torrent of patient petitions, patient support, [and] patient testimonials. And the way that ALS progress and programs have been publicized digitally are such that even non- ALS patients have rallied around this possibility for approval. We’re going to see not just physicians driving, but patients, themselves, and advocacy groups in support of those patients and everybody who struggles with disease X, Y, or Z really making a push for having an influence and a power.

DALAL: That is actually very true for oncology drug development as well. Many times, the companies also collaborate with the patient advocates, and their digital platforms also help with the dissemination of information. It’s becoming a very digital world. Again, as I was mentioning earlier, those personal interactions are also important because there is that in-depth knowledge that we need to share and have a group of scientists in that same room talking to each other and trying to help the development of new therapeutics.

WELLINGTON: I would add nurse practitioners and nurses to this list as well. They continue to increase in importance as they help fill the physician shortages. They manage many chronic conditions and spend a significant amount of time with the patients, compared to physicians. It’s important that pharma companies communicate with these unique audiences, addressing their unique needs in an authentic voice versus taking this one-size-fits-all approach. I think that’s kind of what we’re getting at here, right? Everybody’s got unique needs. We have a collective goal in terms of better outcomes, but connecting with these audiences in an authentic way is very important.

FORSYTH: It’s almost as if digital and social media have allowed for the democratization of shared decision-making in collaboration. We have patient influencers with millions of followers who are now able to weigh in on the clinical journey and weigh in on the pricing strategy with advocacy groups. It’s a very different world we live in.

WELLINGTON: I’m so with you. That’s definitely one of my remits, especially when I work with medical affairs clients. Let’s get medical affairs right off the ivory tower and into the community— and where we can really make a difference.

CLAIBORNE: [When] treating an area like addiction, one of the issues we see is that for something like alcohol use disorder, only 5% of the people suffering seek medical treatment and most don’t because they don’t know medical treatments are available. So, I can imagine an influencer in the DOL space being able to reach a broad audience and let people know that there are options out there that are available, which is not the way you would see it being done through a KOL. [That is] because they’re experts and they do the trials. They have the knowledge, but they don’t have that broad reach to quickly get [information] out and get patients involved in the discussion and spread the word digitally.

WELLINGTON: And in terms of credibility, too. In the community of physicians, they have a high level of respect for KOLs. Not only the ones who have built up these impressive resumes in academia, but they trust the KOLs who continue to see patients and actually gain the trust of patients. That’s where you gain credibility. That’s where you say, “Okay, this person is living in the same world as I am.”

DALAL: I have also seen some DOLs pulling the KOLs in. I have seen many online discussions where one of the DOLs will get a group of KOLs into the same space and have a long conversation on a specific disease type from beginning to end. What’s the current standard of care, what’s coming up in the future, [and] what excites them about these new drugs or new therapies? I think DOLs have a very special role in the scientific community nowadays.

FORSYTH: One of my favorite tactics is to pair the credibility of a high-ranking KOL with a DOL to extend the message. There’s nothing better.

PEREZ: One thing that we haven’t talked about is how to monitor what’s happening out there in the digital space and who is mentioning our different technologies and trials. This is something that is really in my head quite a bit. What are people saying about our own work that we need to monitor, especially depending on the truthfulness of the information that’s out there?

FORSYTH: That is a great point. It’s something that I do for most of my clients. We monitor the online landscape because people want to know what is being said about them by KOLs, HCPs, [and] patient advocacy groups, and they want to know before their investors know. So, we do a lot of monitoring. My only caveat is that I will always look on public forums, but I won’t go into private Facebook groups or other private forums because those are places where patients like to have private conversations. I feel like there’s a little bit of an ethical boundary there; but otherwise, it’s so crucial in developing strategy.

WEISS: We’re seeing a similar pattern. We monitor about three million HCPs and what they’re saying on social [media], blogs, etc. We’re seeing almost two parallel universes. One universe is basically the scientific community, which is actually starting to communicate a lot via different digital channels. And then there’s another one, which is more of a new evolving group of let’s call them [DOLs] who are less connected to the scientific group. When we talk about [DOLs], there’s this group of traditional KOLs who sometimes have a huge digital audience, and then there’s a group of people who don’t have that academic credibility often, but they’re really important in the digital space. They’re very different groups, and we’re seeing their discussions and how the fusion of information through these networks is extremely different. I thought that was an interesting pattern.

WELLINGTON: KOLs and DOLs are not, at least by definition, mutually exclusive. So, ideally, your brand team or your medical affairs team can engage with a trusted leader in your disease state who also has an established online presence. And we’ve worked with many KOLs who have a passion for educating both patients and community HCPs online. We take pride in helping them translate the science by partnering with both our medical team and our behavioral science experts.

PEREZ: I was at a meeting [recently] where there were many, many people (KOLs, friends, etc.), and there were some opportunities from early pharma companies to present their data, and then the slides from the meeting were made available to everybody. I was shocked that some of the early pharma companies actually did not make the slides available. I thought, what a wasted opportunity. This person had a chance to present to 85 KOLs, and then they’re not making the slides available. It’s just to follow up on the conversation. We have to be part of what’s out there so that people can utilize it.

DALAL: I have seen that both ways as well. Sometimes there is confidential proprietary information that companies are unable to disseminate broadly. You do have to make a decision on which media you will use, how well you want to use it, and how far you want to use it.

I think it’s all about strategy and being

But I do want to bring up that point where we were talking about some KOLs also being DOLs. I think that is becoming more and more common because everybody’s understanding that the next generation who is coming in are going to be very efficient and very well-versed in technology. The one way to get their attention to influence or educate them is going to be through media. I think more and more KOLs who are interested in continuing to spread the knowledge will have to use multiple platforms, and they’ll have to get comfortable with the digital platform as well and kind of take on both roles. They’ll be a KOL sometimes and a DOL other times.

FORSYTH: I believe that DOLs are the future. I think we look at medical students in medical school, and they’re all digital natives. They’ve just grown up with that type of interaction, and that’s going to naturally bleed into their practice and how they learn and how they share information.

DALAL: They’re very comfortable having virtual meetings. I think about myself 10 years ago, and I know video conferencing was not as advanced. Also, you were very nervous about it. You were concerned about things like the background, if somebody’s going to knock on the door, or making sure that you have privacy. I think COVID pushed us into this new area where we just all became comfortable with it. We are fine having our cameras on or having a little background noise. We now have technology that cancels the noise, and we learned to work with it. I think the same goes for the KOLs because, remember, these are physicians who were treating patients, and they had to modify their habits along with their comfort level to even just do their job. They started treating and having consults online; they started looking at patients online. I think that transition during COVID helped them move into the DOL space as well.

CLAIBORNE: They’ve gotten used to it so much that they appreciate some of the time saving that comes along with it— along with the cost saving. They don’t have to disrupt their schedule to have an in-person two-hour meeting out of the country sometimes. So, I think it’s here to stay.

As others have said, there’s a balance that’s going to exist going forward.

FORSYTH: One other trend that I would like to raise is environment, social, and governance (ESG). When we think about the environment, sustainability, and all, these big companies now have these goals. They’re not flying KOLs around as much. There’s less physical presence at these different events.

Pharm Exec: Why do you think TikTok has become so popular with DOLs?

FORSYTH: I personally think it allows physicians who came online during the pandemic to correct misinformation, to vent, and to get through the experience as a collective group of HCPs. TikTok allows them to share their scientific information but to do so in a way that is human. It allows them to show their personality with that scientific credibility. And that’s what I hear again and again from physicians who engage on TikTok. That’s why it’s their preferred platform.

Pharm Exec: Social media, especially over the last year or so, can be somewhat volatile. How do you handle the constantly changing landscape of social media platforms?

WEISS: We’re monitoring a lot of these platforms and constantly have to make big investments and think about what areas we should be monitoring. We’re surprised by some of the things we’re seeing. One is that Twitter, or X now, is still being used a lot. It’s not a massive decline we’re seeing in the data, and then we are seeing increasingly fragmented platforms, some private. For example, video platforms like eCancer.

WELLINGTON: Even KOLs and DOLs have been actively championing a lot of changes on social media, such as platforms becoming more advanced or removing chatbots, de-amplifying hate speech, and even having input on algorithms. I’ve heard on Instagram, for example, the algorithm seems to be ever-changing. They’re all over it. In terms of how we see KOLs engaging in the social space, I think we mentioned TikTok quite a bit. But we also see [KOLs and DOLs] using features like polls on X and LinkedIn to gauge the knowledge base of their peers surrounding new clinical trial data. Drug announcements on Reddit with their ask-me-anything initiatives and the Q&A sessions, they can directly answer in-depth questions specific to disease states and patient journey experiences. They can reach a broader audience and correct a lot of the misinformation that’s out there while at the same time establishing their own personal brand as well as the institutions they represent.

FORSYTH: I think the X/Threads conversation we’re having right now is a great example of this. We saw so many people flock to Threads at the very beginning. We’ve seen a little bit of drop off since then, but it’s still a viable platform. We look at Twitter, which has declined month over month, unfortunately, since Elon Musk took over, for a lot of different reasons. However, I’m thinking about upcoming medical conferences, where Twitter was that central platform for communication. Are people going to go to Threads? I’m not seeing that as much. I’m not seeing as much HCP engagement there. I’m actually seeing HCPs flock to Instagram, of all places. I’m curious as to how that will shake out.

I think people will find their new homes. When we saw Twitter start to dwindle, we saw a huge pickup in LinkedIn for HCPs. It’s a migratory pattern, and people evolve and adapt.

ETHERINGTON: The more ambidextrous we are, I think, the better off everybody will be because the world is changing, it’s changing fast, and it’s not going to stop changing. For decades, the dynamic between pharma companies and [KOLs] was effectively the same. There were not a lot of differences the way most of our careers were for the first decade or two. Suddenly, in the last five years, everything changed. The more flexible that we are, the better off we are.

DALAL: The smaller companies must be even more nimble because they have to see wherever the KOLs and DOLs and the other scientific communities are leaning. That’s where you can’t get stuck with one platform. You just have to continue to explore and shift if need be.

FORSYTH: That research, that social monitoring, we do that for many clients. It’s a full-time job. You need to have those platforms to be able to do it. If you’re looking globally, you have to do it in multiple languages. There’s just a lot of considerations that go into it, and it takes time. It’s not just the mining of the data and the insights and the verbatims online. It’s that analysis that brings you to the insights that help form your strategy.

Pharm Exec: Lastly, I would like to talk about a new technology that’s gained a lot of attention in recent times. How does everyone see something like artificial intelligence (AI) impacting KOL engagement in the future?

FORSYTH: I have so many thoughts on this one. I use AI every single day in my work. I make sure that I disclose when I use it, but it is incredible for research, for authoring social posts, for authoring content, and things that DOLs really need to use. Where there are extreme risks is that sometimes AI will generate things that are false, inaccurate, or plagiarized. When it comes to a KOL or a scientific piece, you must make sure that you have those safeguards in place to ensure you’re not plagiarizing someone else or that AI didn’t just come up with a completely false precedent for you that ends up included in a medical piece or something of that nature.

WEISS: Where we are starting to see a really interesting potential is in helping to crunch all the data that’s out there and give very specific kind of recommendations on what to do. It all comes back to people. In the end, when I speak to a KOL, it’s common that they have a basic problem. They might have 20 to 50 people knocking on their door, and they don’t know what’s relevant and who can help them find the one relevant thing. I think that’s where AI can really help a lot because it’s less about creating that paper or creating that post that then goes out. It’s more for aggregating information and recommending maybe two or three relevant things. That’s what we see is probably the easiest application.