I did a second stint on evening AM talk radio a few weeks ago for a program called Nightside with Dan Rea, which I really enjoyed. Dan’s callers represent a genuine, down-to-earth view of the reality of connected health adoption. The first time around, most callers were cautionary, raising concerns about data security and wondering about physician endorsement. This time the theme that spontaneously emerged was one of people telling stories from the heart, about loved ones who have benefited from connected health. That was uplifting for me.
As the hour came to a close, the last caller, a physician, voiced a concern I’ve heard from the medical community before. He suggested digital technologies could negatively affect the doctor-patient relationship. He argued that digital tools merely get in the way of cultivated, face-to-face relationship building. Because of time constraints, the only comment I could make was, ‘If we implement it that way, then we will have failed.”
After the show, my friend, colleague and coauthor Carol Colman asked me to expound upon what I had meant.
The question was a timely one. Lately, I’ve been thinking more about how to move the needle on physician adoption, and came up with a framework for general discussion. This is a topic of concern and of great interest.
As I often do, I turned to non-healthcare services to look at the integration of digital tools into previously analog service offerings. I can think of three types of resulting consumer experiences.
The first is what I’ll call complete replacement of analog with digital. One easy example is the ubiquitous phone tree you get when you call an organization for customer support or problem solving. These days, everyone wants you to solve your problems online, often with FAQs and chatbots first, then with an email. This makes human contact difficult, especially when the question you have can’t be plugged into this phone tree formula. For example, I recently forgot to renew my driver’s license before it expired. Although the Registry of Motor Vehicles was closed on Saturday, there was another company that could perform the renewal. I could not use their online option, because a new photo was required. So I called and went through about 10 minutes of the dreaded phone tree but could still not find someone to answer my questions about renewing an expired license. Exasperated, I got in the car and drove there. This is exactly the kind of experience the doctor who called into the radio show was worried about. Unfortunately, it is a very common one. As stewards of the implementation of connected health, we must do everything we can to avoid this experience for our patients.
By contrast, we now have several examples of optimized integration of digital and analog services. One of my colleagues had a recent experience with the online retailer Amazon that required changing an order. He was effusive in his praise for Amazon. Not only did he get to a person right away, the service representative knew him, his profile and his order history. His problem was resolved quickly and effortlessly. It may not be surprising that a company like Amazon, built on the idea of making it easy to do business on a new platform, is the model example here. Starbucks and Uber, like many other companies, also design their mobile apps to enhance our experience of what is ultimately an analog interaction. My doctor caller may not have had this type of experience, or perhaps he had yet to realize we could indeed provide healthcare this way.
There is also a middle of the road, which is increasingly common in today’s healthcare delivery model. I’ll call it side by side execution of both analog and digital. The best example is the current buzz around virtual visits. The offerings include video communication with an individual (patient/consumer) and, on occasion, a more email-like communication. When thoughtfully implemented, this type of service can increase both access and convenience for patients. Although it is possible, the overall care delivery experience (including virtual and the face-to-face interactions) may be a bit more efficient than our purely face-to-face process, most experts agree there is little gain. It really is an extension of the usual way we do business into the digital realm. The analogy would be if Uber was simply a way of speed-dialing your cab company. I want to underscore that virtual visits are an important advance, but we should think of this as only the beginning.
For years at Partners HealthCare, we’ve been remotely monitoring patients with congestive heart failure, using a combination of vital signs, patient-reported symptoms (the digital component) and a nurse call center run through Partners HealthCare at Home (analog component). These features work very synergistically. Our patients report feeling more cared for and more reassured than they did prior to being on this program. Interestingly, their comments belie how important the nursing component is. “They call me before I get short of breath,” and “I can’t cheat on my diet because my nurse knows right away,” are phrases commonly heard from patients.
These patients receive very efficient care. One nurse can oversee 100 or so patients at a time. Hospital readmissions are down and there is an improvement in mortality and lower total medical expenses in the monitored cohort. This is an example of successful integration of digital and analog. We still have improvements to make, so I can’t say ‘optimized,’ but it is an early success story.
Can we move healthcare into the realm where we optimize for the integration of digital and analog experiences? I think we can. We have a ways to go and healthcare delivery is slow to change.
I appreciated my caller’s concern. When connected health is correctly implemented, digital tools will not stand in the way of the doctor-patient relationship, but will strengthen and support it. Are you seeing evidence of that?
In 2011, my friend Andy Donner, then with Physic Ventures, and I both started noticing something exciting and puzzling was happening in the connected health industry. Non-standard entrants were coming into the field of connected health. The likes of Walgreens, CVS, Walmart, Avery Dennison and others were entering the field. Up until then, we had acknowledged the traditional participants (providers, payers and supply-chain vendors), but it was a new phenomenon for predominantly consumer companies to gain interest in the space.
Some progeny programs of that wave of non-standard entrants were Walgreen’s program to connect wearables to their app and give rewards points for healthy behavior. And of course, today’s myriad of virtual health offerings comes from all over the industry these days. My friend Andy’s vision inspired us to gather, semiannually, a group of these non-standard entrants so we could learn from them and they from us. Among the first to look at membership was PepsiCo.
You’d not be faulted for asking why a company known for sugary drinks and salty snacks was interested in connected health. It was for two reasons. First, a sincere interest in moving beyond this product set to a healthier product portfolio. Second, an interest in exploiting their sports drink franchise.
We talked about how to possibly put sensors in a Gatorade cap, whether there could be some way of checking in to a store display with one’s mobile phone, and many other scenarios. Although our imaginations were ample, nothing really came out of our ideas. The technology was unreliable and complicated. The sensors were too costly to be able to blend into the background. We abandoned our quest (and decided to remain friends).
In what seems like the blink of an eye, fast forward 5+ years and here we are.
Now, sensors in a Gatorade cap exist. Chips within the bottle cap can share real-time hydration information with World Cup soccer athletes and even analyze sweat type to determine fluid intake needs.
Here’s something similar that caught my eye recently. If you have not seen the hype around the smart Tostito’s bag released for Super Bowl Sunday, please do check it out. It is a brilliant marketing statement and a clever internet of things app – that even promotes good health.
How so? Each of these limited edition bags (not available in stores, but collector’s items) has a sensor that will register if your breath has any alcohol on it. If so, the bag lights up with a message: Don’t drink and drive. The next step is that you can tap your phone on the bag and via near-field communications, have an Uber summoned to your exact location. Each bag of Tostidos even has a unique bar code on the bag linked to a $10 Uber discount code, courtesy of Mothers Against Drunk Driving (MADD).
An ad featured on Tostido’s Twitter account even features Tennessee Titans football star Delanie Walker. “You should get a safe ride home. That’s the best bite,” he says. Walker’s aunt and uncle were both killed by a drunk driver after the 2013 Super Bowl.
It’s definitely a successful appeal for emotions. But what are the greater implications of its effectiveness and usefulness? The product may be gimmicky, but what a stroke of genius and a great example of the Internet of Healthy Things! Nonetheless, there are some caveats. Here is a look at both the positives and the cautions.
- In Chapter 8 of The Internet of Healthy Things, we talk about 3 strategies for engagement and 3 tactics. This gimmick takes advantage of them.
- Make it about life: Tostidos uses the opportunity of the Super Bowl to educate consumers about drunk driving. The ad campaign claims it will allow 25,000 fans to get a safe ride home the day of the big game.
- Make it social: If you are at a party and breathe into the sensor, all will see the result. Peer support and peer pressure come into play.
- Subliminal messaging – Although the novelty of the experience really has nothing to do with chips, the branding is indeed around chips.
- Unpredictable rewards – when you breathe on the bag you are not sure if it will turn green or red. Perhaps as the evening wears on it is more predictable.
- Sentinel effect – also maybe a bit of a stretch, but does it matter that MADD knows you’ve had too much to drink?
- The use of IOT and near-field communications is brilliant. None of this would have been possible in 2011 when we were still dreaming.
- The actual bag is in very short supply – being given away as a promotion we’re told. I went to several local grocery stores during the days leading up to 2/5 and though there were lots of Tostitos in evidence, none of the bags matched this description. This tells me that the cost of the technology (sensors, batteries, etc.) is still not low enough to be buried in the cost of a bag of chips.
- The whole campaign to promote better health is merely a novelty. The bag is technically not really a breathalyzer, but just an entertainment sensor. It cannot accurately measure blood alcohol level content. Will a hearty swig of mouthwash cause the sensor to change color?
- You already have your phone available to you to call an Uber. The bag just gives you a discount on a ride (minus the cost of the bag).
- Says one blogger who reviewed the product, Napier Lopez, the bag itself hardly contains any chips.
Predictions are something I make often in my line of work. As someone who has been making healthcare predictions for more than 2 decades – and keeping score of how often they come true – I admit it is a humbling pursuit. Some predictions end up being flat out wrong. Others turn out to be right, sometimes with a significant twist. For example, although many of us predicted in the mid 90s that video communication with patients would someday become ubiquitous, I daresay missed the power of the smart phone as a game changing device. I just re-watched the early 80s film Blade Runner (the action takes place in 2019) and chuckled at the scene where Harrison Ford’s character does a video conference with another character, but through a device that looks suspiciously like a pay phone!
When a prediction comes true, it is worth writing about. For several years now we’ve talked about the power of wearables to generate feedback loops. In some cases, those feedback loops can induce behavior change (the individual must be self-motivated and will use the feedback loop to measure progress). Often, some other motivational force must be applied to induce behavior change. For instance, many people will set up competitions with a friend or loved one. In any event, the sine qua non for a wearable is the feedback loop.
Another important principle is that shared data provides a window into the tracked individual’s habits and lifestyle, particularly about their technological engagement level and their ability to achieve personalized tracking goals. Humans apply filters and biases when they estimate about themselves. I’m no different. When my doctor asks me each year how much I exercise, I always reply, “Twice a week.” What I neglect to add is “…on a good week.” I’m not trying to deceive him, but that’s just how the answer always comes out. Now imagine how different that conversation would be if the dialogue were about total active minutes and he had access to my Fitbit data.
This realization sparks debate about both privacy and consternation about being held accountable for targets – and punishment for missing them. “Will my employer fire me for not walking enough?” “Will my insurer charge me more?” “This all sounds very creepy.” These are some oft repeated refrains.
A few years ago, I suggested people would be given wearables by their insurers and there would be some contract with the insurer around the monetary value of achieving certain health targets. At that time, Progressive Auto was already doing this in the auto insurance industry. I thought, “Why not?” This vision is even vividly laid out in the first chapter of The Internet of Healthy Things, where Sam the virtual assistant guides me toward better health in exchange for lower health insurance premiums.
The debate has become one about carrots versus sticks. Will we ever reach the time when an individual who ignores healthy lifestyle cues as measured by one or more of these devices is penalized in terms of covering his or her healthcare costs? I’m not sure. But what I am sure about is the world of rewards is here. Here are two exciting examples of this phenomenon – one from the health plan world and one from the retail pharmacy world. (There is a third from a company called Vitality whose services are embedded in Humana’s portfolio. I don’t know as much about them so I am not reporting on their work here.)
In 2014, Walgreens introduced a program called Balance Rewards for Healthy Choices. Members earn points, redeemable for store purchases, by making healthy choices like tracking exercise, body weight, blood pressure and glucose, connecting health devices and apps, quitting tobacco, and setting and achieving goals for behavioral health risks modification and chronic conditions management. If you own a tracker relevant to any of these goals, you can connect that device to your Walgreens app and accrue points for improved health. In 2016, at the Academy of Managed Care Pharmacy annual meeting, data on the program from nearly 7,000 participants showed participating individuals significantly improved adherence to anti-hypertensives, anti-diabetic meds, and cholesterol medications. Pretty impressive achievement with no directed involvement from the patient’s doctors!
United Health Group recently launched a program called Motion. They released their own proprietary wearable and challenged enrollees to meet three types of daily activity goals (as measured by the tracker). They are: frequency (300 steps in 5 minutes at least 6 times/day), intensity (one 30-minute walk of 3,000 steps/day), and tenacity (10,000 steps per day). Enrollees who meet these goals receive up to $4/day deposited into their health savings account. As with any health insurer model, this is done in collaboration with the enrollee’s employer. Employers can achieve a goal of a 6% premium cap if they achieve 60% compliance across all three goals among their employees. (Which reminds me of another prediction. In 2008 I visited a number of Boston-based large employers pitching the idea of using wearables to track various fitness parameters. Although there was a mix of enthusiasm and skepticism, one of the skeptics said, “If this is so great, why doesn’t my health insurer offer it to me?” Eight years hence, we are there!) Although the program is new enough that they don’t have outcomes just yet, some of the plan sponsors are quoting engagement rates of 85%.
The lessons here are not about who makes the most accurate predictions or whether or not they ever end up coming true. For me, three insights stand out.
- Wearables offer the opportunity to quantify important health-related information and mobile connectivity makes it easy to share that information. First we shared with ourselves, then with friends and loved ones. The next phase seems to be sharing with commercial entities in exchange for some value (not unlike when a retail outlet exchanges a coupon for your feedback on a new product). Many would like to share with their doctor, but doctors are befuddled right now, worried about liability and data overload. Let’s work together to build that future.
- With heightened fear and loathing surrounding things like data breaches and identity theft, people will share personal information when they see value in exchange. Most of us have been sharing intimate details for years with Google, because we get so much “for free” in return. Health information is different, yes, but perhaps the old adage, “Everyone has their price,” directly applies here.
- The world of connected health offers great opportunity for new ways of providing healthcare. Would you have predicted that a retail pharmacy chain would be competing with a health plan to encourage you to increase your activity level? That is a prediction I did not make! And we will nonetheless only continue making new healthcare predictions together in the years to come.
My children got me hooked on a smartphone app called Time Hop. It mines your social media posts and pictures and serves them up as a daily history, showing what you were doing one year ago, two years ago, etc. I find it loads of fun. Recently several of my tweets resurfaced from seven years ago. They all report my weight for the day and some included my step count. Seeing those tweets gave me a real appreciation for how far we’ve come in understanding how to engage consumers with connected health — and realize how far we still have to go.
First, let me explain the bizarre tweets. Time hop with me back 7-8 years. The Fitbit was a new device to track steps, but the first generation synched to your computer via a USB cable. The idea of wireless, effortless data transfer from wearables was still in its infancy. (Also, note I said ‘synch to a computer.’ Can you imagine a tool like that being released today that did not synch directly to a mobile device? But I digress….)
In addition, a company called Withings came out with a WiFi scale. We all know of their successes now, but this was cutting edge at the time. I was fascinated by a device that, with a small amount of set up, could automatically send your weight to the cloud and make it available for you to view. At the time, we were still using phone modem technology to upload vital signs in our Connect remote monitoring programs, so this seemed like a real breakthrough to me. (weight is the main variable in our home monitoring program for congestive heart failure patients). I saw many applications for these new tools.
But, our understanding of how to use the basic tools of mobile technology to engage our patients was at an even earlier stage. The Withings scale and the Fitbit were early examples of how technology can provide feedback loops of important data. They raise awareness; they help us set goals; and they help us measure progress.
I confess, I’m a quantitative person and am motivated to stay healthy. I was so enthralled by these new technologies and how easy they made the feedback loop, I figured we just needed to get them into people’s hands and we’d have a healthier population. I was excited enough to write my first book, Wellocracy: Move to a Great Body, with my friend and coauthor Carol Colman. Some of you may know of our website, Wellocracy.com, but I’m guessing very few know about the book. Both endeavors were set up to educate the world about the value of self-tracking. Neither caught on as we’d hoped. The book, which we published as an ebook only, sold a couple of dozen copies and though the website gained some early traction, it never became self-sustaining. Of course, not everyone is quantitative and, more importantly, not everyone is intrinsically motivated to stay healthy. These are important lessons learned.
But back to tweeting my weight. At the same time wearables were emerging, we had a notion that if feedback loops were accompanied by some sort of motivational companion, they would be much more powerful. Patients from our blood pressure home monitoring initiative reported that the program was extra work for them; those who stuck with it told us they did not want to disappoint their nurse or the doctor. Similarly, those who dropped out of the program said it was because they were embarrassed about their lack of adherence to care plan and did not want their physician to know. We later branded this phenomenon the ‘sentinel effect.’
At the time, I did not appreciate that this psychology had to do with exposing an authority figure to the same feedback loop you were exposed to — and thought it might extend to social networks.
The Withings scale was integrated with Facebook and Twitter, so I decided to try an experiment, tweeting my weight to see if my Twitter followers would spontaneously motivate me around this variable. Apart from getting a few chuckles and having people mention this at the time when being introduced as a speaker, nothing happened. One or two followers cheered me on, but most just congratulated me on not gaining weight. Looking back, there are so many reasons we could have predicted this would fail: Twitter is more broadcast than truly social media. I never tried Facebook, but I don’t think it would have mattered. I did not set it up with a message saying, “I am tweeting my weight and want to lose 3-5 lbs, so please help me.” Thus, people had no context. And there was no sentinel effect. I wasn’t particularly embarrassed by my weight and did not particularly care if my Twitter followers saw it.
Fast forward to today. At Partners Connected Health, we now spend most of our time and energy understanding and building software that is engaging and inspiring for our patients, and intuitive for them to use. In fact, we have a whole team of ethnographers, designers, sociologists, and psychologists that works very closely with target patient populations. And yes, everything is mobile. We still use feedback loops a lot, but we appreciate that their value alone is short-lived (the ‘new toy’ phenomenon) and they are relatively weak motivational tools.
We have a couple of different frameworks for designing engaging tools. One, which we published in The Internet of Healthy Things and a series of blog posts in 2015/16 has three strategies (Make it About Life; Make It Personal and Reinforce Social Connections) and three tactics (Employ Subliminal Messaging; Use Unpredictable Rewards and The Sentinel Effect). A newer framework promulgated by our design team seeks to build software that is motivational, empathic, gains users trust and elicits an emotional response.
Today, we’re also rebuilding the guts of Wellocracy to make it much more interactive and engaging and less about educating people.
What is on the horizon? We still struggle to engage people who are unmotivated. There is always a group in every intervention that does not engage. Keep in mind, those folks typically generate the most healthcare costs, so if we’re going to deliver on the promise of connected health, we must convert them. We still haven’t figured out how to make healthcare as exciting as Instagram or Snap Chat.
It is clear that we’ve gone from being focused on feedback loops with a poor understanding of motivation to being focused on designing tools that are engaging and inspiring.
We’ve started the journey to deliver that sort of inspiration using artificial intelligence. Our goal is to create interventions that are so customized and inspiring that even the unmotivated will get on board.
Maybe my Time Hop will jog my memory again in seven years and I’ll report on our learnings in that time frame.
Just a few weeks ago, we had our 13th annual Partners Connected Health Symposium. It was a success by all counts, with just under 1,200 attendees from around the world participating in this amazing event. Year after year, we take great care and significant pride in delivering unparalleled content and, based on feedback from attendees, this year was no exception. I hesitate to mention highlights as there wasn’t a weak spot on the program, but I particularly enjoyed JoAnn Jenkins, Charlotte Yeh, Nancy Brown, Zoe Chance and Dan Ledger. The panels were all well received too and our innovator-focused sessions — the annual Innovator’s Challenge; new CHIC Challenge; and the FitMind Challenge, which was sponsored by AARP — were highlights to many.
A number of folks pointed out to me how our focus for the Symposium has changed over the years. I’d like to think that our content and theme have reflected the state of the industry and provided an important look to the future. This year we focused on caring technology (motion sensing, wearables that provide insight) and technology as a tool for improved health as we get older.
Our broader focus at Partners Connected Health has always been — and remains — to educate, inform and inspire the adoption of connected health strategies. The Symposium has been an important way for us to achieve this goal. We’ve also always believed in advancing innovation through collaboration. At our 13th annual event, we announced a new partnership that will create the singular leadership event focused on the future of technology-enabled health and wellness.
As of 2017, the Connected Health Symposium will join forces with the Personal Connected Health Alliance’s Connected Health Conference (formerly the mHealth Summit). The merger of our events creates a platform with greater reach and significant opportunities to provide leadership, support innovation and bring together business, government and healthcare leaders to achieve the sustained adoption of personal connected health.
This combined event will be hosted by PCHAlliance (a HIMSS organization) with Partners Connected Health serving as the Organizing Partner, and will come under the banner of the Connected Health Conference. We are finalizing the dates and location for next year’s meeting, so stay tuned.
I was honored that PCHAlliance asked me to serve as Program Chair for the combined event. As you probably know, I have been extremely involved in shaping the content for our Symposium and look forward to doing the same for the new Connected Health Conference. That means you can count on a new look and feel to the combined event, and you’ll see evidence of my involvement in the content choices, organization and structure of the 2017 Conference.
The Connected Health Conference, currently in its eighth year, has built an impressive following. Our combined efforts will bring together major companies, investors, government agencies, consumers and, of course, healthcare providers, with the intent to inspire them to change the world by implementing insights gathered and lessons learned from our conference in their day to day lives.
We’re starting to work on next year’s program already. Our team at Partners Connected Health is excited about this new collaboration and DeAnna Grosbaum, who has done an outstanding job organizing our Symposium, will be working with the PCHAlliance team to help us deliver a dynamic, thought leadership program.
In the meantime, I will be at the 2016 Connected Health Conference next month in Washington, DC, and will be eager to hear your ideas as we build the largest event dedicated to digital and connected health.
I can’t wait. Stay tuned.
I recently had the opportunity to join Boston news media veteran, Dan Rea, on his AM radio program, Nightside with Dan Rea. It was a one-hour call in program, and an eye opening experience for me. Dan and I chatted about connected health and how it can truly disrupt care delivery and put the individual at the center of their own health. Then Dan opened the lines to the fine citizens of New England for questions, and the phones started ringing off the hook.
The overwhelming concern – actual fear — among callers was maintaining their privacy in an increasingly connected world, especially their personal health data. This is a topic I touched upon in my recent book, The Internet of Healthy Things, and one which I will explore further in my upcoming talk at our Connected Health Symposium in a few weeks. But I was so struck by the extent of concern, I thought I’d present a few theories I’ve been contemplating on the subject.
When it comes to privacy issues, the cyber world is typically characterized as a sinister place, where consumers are duped and exploited, their data leaked or stolen. What we unfortunately don’t talk about is what consumers have to gain by sharing their data. For instance, the same information that can be used to create highly personalized programs to help people stay healthier and happier, can also be a key factor in improving efficiencies and reducing healthcare costs. Further, it’s been shown that sharing data with providers, friends or social media groups can actually help people stay on track with their health and wellness goals.
Yes, there is always some risk sharing personal data – whether online banking or communicating with your healthcare provider. But there are also rewards. In my view, it’s a trade-off, and one that I personally am willing to make with my own health data.
As I see it, there are two main problems when it comes to privacy. First, many companies have not been forthright regarding their privacy policies, leaving consumers unaware of when and how their data is being used, sometimes in ways they may not approve of. Second, we are all too aware of some alarming data breaches that make consumers wary of posting or sharing their personal data.
We can combat much of consumers’ fear by making privacy policies transparent; putting a halt to spying on people without their consent and creating systems to keep data confidential. Bottom line, the rights of individuals must be protected, and organizations – healthcare providers included – need to do a better job explaining privacy issues and safeguards.
In my mind, privacy is not a complicated issue. In fact, it’s pretty straightforward.
So how do we increase consumers’ comfort levels and create more transparency around the red-hot issue of privacy? Here are two simple ideas:
For anyone who is in the healthcare space, whether you’re a payer, provider, business or entrepreneur developing connected health devices or programs for consumers, you should be very forthcoming about your data collection and privacy policies. And, by all means, provide this information in simple, easy to understand language and skip the legal jargon.
And, consumers need to understand that there’s no such thing as a free app. If it’s a free service, more than likely the business model will sell advertising – or data – including subscriber lists, to marketers. In most cases, without this revenue stream, there would be a fee attached to the service. This is a concept most consumers will understand. Some will opt for the free service with the understanding that they give up some privacy. Others will want a fee-based service that will preserve their privacy. Either way, it should be the consumer’s choice.
Is the privacy fear such a turn-off that consumers will never agree to share their health data? Or can we help individuals understand the trade-off?
I want to acknowledge the contributions my colleague Kamal Jethwani and his team made to this post.
The business value of medication adherence tools is coming into focus. For years, I remarked that, while we could create a case for why adherence was the right thing to do, we had great difficulty creating the right financial incentives to move these programs from curiosity to scale. That is changing now with the collision in the marketplace of new payment models and exorbitantly priced pharmaceutical products.
The poster child for this phenomenon is the drug Sovaldi, which represents a miracle cure for Hepatitis C infection but costs $84,000 for a course of therapy. But if the patient doesn’t finish the entire course, the money is largely wasted. In that context, the price of any adherence solution is small compared to the cost of a failed treatment.
Today, there are a large number of adherence solutions on the market. Two years ago, we found more than 100 companies offering products in the space. A more recent report lists 5 categories for addressing adherence: predictive modeling solutions, communication and education, smart pill bottles, smart tablets and apps.
In conversation with an influential senior executive at my organization — who I’d consider to be a connected health enthusiast but a realist — we debated the pros and cons of a simple text messaging solution versus one or more of these other approaches. I thought I’d share the highlights of our discussion in this post.
Text messaging has become easy to scale. We can now do it directly through our EMR, so the incremental cost of sending a reminder message is nil. We can reach hundreds of thousands of people easily using this approach.
The downsides are important to mention as well.
- Onboarding: The FCC mandates two levels of consent from patients. First, when patients share their cell phone number, they are required to consent to receiving text messages from our organization; and second, the first text message sent should always be an ‘opt-in’ message that the patient has to reply to, in order to initiate the messaging campaign. In previous studies, we have seen a 30% drop off rate at this second step.
- Regulatory considerations: Text messages need to be ‘HIPAA compliant,’ which means we cannot send anything that could possibly reveal personal health information, including the patients’ condition, should others have access to their phone/messages.
- Reminders only: Text messages are usually prompts that ask a patient to remember something, or take a certain action. In several cases, the barrier to taking action is a patient’s lack of information/knowledge/understanding, making it difficult to predict which individuals will fall into this category. The limited number of characters (140) can also render the text prompt futile.
- Message Fatigue: It is well documented that, over time, people will pay less and less attention to timed, similar messages.
- Other considerations include the cost an individual may incur per message received, as well as oft-changing phone numbers, common in certain patient demographics.
Mobile apps overcome most of these problems. Once you download the app, it is much easier to manage communication with you via notifications, and it’s also easier to secure the transmission of personal health information. Engagement is multifactorial in the app environment: we can remind but also educate and interact with the patient. Finally, apps can be free to download.
Of course apps are not a panacea. Patients sometimes have difficulty with the download process itself. Just as messages can cost users, use of apps can affect data plan expenses. Estimates of smart phone ownership vary, with most urban markets coming in around 80%. That leaves 20% of any given sample as unable to use an app.
So what is the best course of action?
Based on our experience and research with both texting and mobile apps, we recommend texting for simple, one-time interventions such as medical appointments, annual screenings, medication refills and flu shots. Text reminders can also be good for short-term campaigns for patients taking infrequent meds, de-addiction or rehabilitation programs, or for patients who do not own a smart phone.
However, for more complex treatment regimens or challenging patient populations, we believe, and have proven the effectiveness of mobile apps when sustained, long term patient engagement is required. There are a few examples that come immediately to mind, including programs that use sensors or collect patient reported outcome measures (PROMs), highly dynamic medical conditions that require just-in-time care, or programs targeting sensitive conditions such as HIV or STIs. Further, mobile apps can play an important role in patient education, improving patient-provider communication and passive data collection.
There is also a place for mobile apps in medication adherence, in cases when poor adherence is the result of factors other than forgetfulness. This may seem to be impractical advice, but I’m hopeful that as we continue to develop predictive algorithms, we will be able to better segment individuals to create more robust and effective engagement.
But for healthcare providers and executives, like my colleague, who are in need of immediate, cost-effective solutions to address critical healthcare needs, text messaging appears to be the answer. Our research and experience tells us that is not always the case.
What are your thoughts?