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Engagement is the Next Frontier for Connected Health

January 23, 2013

Seeing the fast-growing market for personal connected health devices displayed at the recent Consumer Electronics Show, I couldn’t help but reflect on how far consumer connected health has come. Not too many years ago we spent a lot of energy sorting out how we would get home-derived vitals signs out of a device, out of the home, and into our database.  We first used analog phone lines, which are increasingly going the way of the 8-track tape. Cellular communication is exploding so we’re focused in that direction now.  It’s not perfect yet, but it is a given that any tracking device you want to employ in connected health can and should be wirelessly enabled so you can easily move its data over the mobile internet.  Costs need to go down and there is still some unnecessary technical complexity, but this is problem that is almost solved.

Now what?  When you focus on solving a problem so intently it is sometimes hard to look beyond.  Wirelessly connected sensors enable an important design principle of connected health:  feedback loops.  Once you capture the data from these devices, the first important thing to do with it is feed it right back to the consumers/patients from whence it came. Why?

Feedback loops are great for establishing awareness and for changing your mindset about your health.

They help us keep our health top of mind.  There is a bit of narcissist in all of us and having the ability to gaze at our health data at a moment’s notice is compelling….for a while.

Inevitably we get bored or distracted.  More is required.  This figure from our paper on the use of text messaging to promote sunscreen use shows it nicely.  The control group (lower curve) had access to a classic feedback loop – a device that recorded each time they used their sunscreen. You can see how their adherence decays quickly.  We’ve seen this in many of our studies. It’s quite reproducible.  Psychologists call this habituation, meaning once you get used to something, you tend to get bored by it and move onto something else.  We are wired to pay attention to shiny new toys!  I read about this effect as applied to relationships recently and learned of another term, hedonistic adaptation.  I had to chuckle.

Sunscreen Adherence

For years when we were measuring the effect of an intervention (examples include virtual coaching, the varied, automated messaging that improved blood pressure and led to the founding of Healthrageous, or our use of text messaging to promote sunscreen use) we did not appreciate that each of these would predictably do better than a control group.  The commonality to all of these interventions is regular interaction with the study participants using some sort of changing messaging.  This leads to conclusion number 2.

Feedback loops plus varied, contextual messaging are much more powerful than feedback loops alone.

Another thing we noticed repeatedly is that neither of these effects is 100%. This is also illustrated in the above figure. There are always 10% or so of individuals who keep up with the feedback loop alone (they don’t seem to habituate) and we can only get about 60-70% of folks to stay adherent with any given population-based approach.

That leads to the question: how do we keep more folks maximally engaged and responsive to their tracking data?

My sense is that we’re all wired to respond to different motivators.  If we could learn enough about what motivates you to send you targeted, individualized, engaging messages on a regular basis that made your tracking data relevant, I think we’d achieve it. These messages would change over time as you grow and change in your quest for improved health.

We’re early in this journey, but I want to share two attempts to understand this phenomenon.

At the Center, we’re studying an algorithmic approach to engagement.  Taking in information on an individual’s motivational state and matching that with their measured activity level and location data, the algorithm sends twice-daily, automated, motivational text messages.  We’ve enrolled a panel of diabetics to test if such a tool can help them improve their activity level.  I can’t say how it works because we’re in the midst of the trial right now.

Healthrageous combines tracking and other data to offer automated coaching to its participants as well as opportunities for them to use other motivational strategies such as social networking, challenges, games and incentives.  I just saw an update on their progress the other day. They’ve enrolled over 12,000 individuals and have had great success in engagement (72% at week 16 and significant improvement in a number of health indicators such as activity and weight).  Their combination of objective, biometric inputs and motivational messaging is proving to be a winner at scale.

It’s still early going. But we must figure out the engagement trick and individualize it. It will improve the health of our population greatly. We don’t have a choice but to act.

24 Comments leave one →
  1. Carol Colman permalink
    January 23, 2013 4:18 pm

    Good blog! Your writing is getting more conversational….a real talent.

  2. January 23, 2013 4:22 pm

    Fascinating points about varying the message to encourage continued engagement.

    As a marketer, what I think you’re actually creating is a smart “marketing” “system”. Its marketing because it communicates with the patient b/c it talks about what is relevant to them specifically (both from a disease state and level of progress perspective ) Its a system because it is automated, in this case by algorithms. By making this a system, you have a consistent, and predictable way for keeping the user engaged in their health.

    Another article I saw stated that PHR’s failed not because they didn’t work well, but because patients were just not that interested or engaged in their health.

    If you can keep 72% of patients engaged after 16 weeks, it seems you’ve cracked the code on what it takes to keep them interested.

    I believe that what you learn from the initiatives at Connected Health and Healthrageous could be translated to many other aspects of telehealth utilization.

    Thanks for your pioneering efforts.

    • January 23, 2013 4:38 pm

      It will take many to get it right. I like the concept of a marketing system. Spot on. Thanks.

  3. Marc E permalink
    January 23, 2013 4:48 pm

    “They’ve enrolled over 12,000 individuals and have had great success in engagement (72% at week 16 and significant improvement in a number of health indicators such as activity and weight).”

    How are you defining engagement?

    • January 23, 2013 9:42 pm

      Continued participation in the program as measured by interaction with the website

  4. Jim Hutchinson MD permalink
    January 23, 2013 5:01 pm

    Seems it’s a societal thing. What has motivatred nearly 80% of the population to now fall into the non smoking group? Of course probably half the people were non smokers to start with and just suffered the smokers. We see more and more in the mainstream information areas about weight loss and popularizing healthy eating? Those that enter those groups become more popular and those that don’t less so. Smoking has beocome more expensive and less acceptable. There are penalities for the non smoker we would never have thought possible a few decades ago. Whether this will become true for the obese indiviual is open to question, but I wouldn’t bet against it somewhere down the line.

    Then there’s the carrot approach offered by providers and payers of if you can do this we can then do this for you. All of this takes time and progress seems glacial, but it reaches the tipping point and then accelerates.

    • January 23, 2013 9:41 pm

      Hoping to get beyond “societal” to individual. Public health plays a role, as does behavioral economics. But the next leap is understanding the individual.

      • January 31, 2013 11:59 am

        Individuals have internal motivations but they also are highly impacted by the community around them. It is much easier to be overweight if your friends are heavy. There are external as well as internal motivations that drive us. I do think that using technology to create a mass-customization approach to compliance is critical to broad scale improvements. I also believe that doing so in the context of the community within which the individual moves will magnify the results. Interesting to study how this might vary male to female or by ethnic group.

  5. January 31, 2013 11:28 am

    Hi Joseph, Good article. We should re-connect sometime.

  6. January 31, 2013 11:37 am

    Good stuff. Healthcare organizations evolve all sorts of best practices protocols that can be automatically invoked based on data triggers. Very easy to expand this.

    Doctor: I see you smoke? Are you interested in quitting” Patient: Yes. Doctor: How motivated are you? System: Patient is automatically streamed onto an appropriate workflow that automatically cycles around every so often and puts out motivational messages set up in a protocol.

    The messages can go out at point of service tasks such that if Pt responds to a message, the response goes to the task where the staff member performing that task can see the out-message and the in-message and take action.

    Nothing new here in general industry – process control is process control and has been a mature area for decades. As regards healthcare, whereas it used to be difficult/expensive to get orchestration and governance, this is no longer the case for any practice that has say 5 staff or more.

    Too many moving parts to recommend this to solo practitioners.

  7. January 31, 2013 12:20 pm

    Great work Joe, compliance to health regimes and threatment has always been the number one healthcare problem. Given the UK study on Clinical Effectiveness that found only about 25% of medical intervention was effective and 50% unproven, how would you use this to attack this type of waste? See:

    • January 31, 2013 9:16 pm

      Thanks so much for the comment and the link! My overall answer to your question is that the more we educate consumers/patients, give them context and motivation and hold them accountable, the more they will care for themselves

  8. January 31, 2013 12:39 pm

    Joe- Great post. These concepts of feedback loop and habituation have been on my mind since seeing the original sunscreen study results years ago. The other think I like about that study is that the SMS reminders to those subjects also gave them the UV index for the day (if I remember it correctly).

    Most patient-facing communications programs that I’ve seen focus on what you need the patient to do…not what motivates the patient to do what you need them to do.

    Thanks again for the great post!

    • January 31, 2013 9:19 pm

      Thanks for your perspective. One big problem we face is that we almost always communicate to folks in a way that makes sense to the provider, not necessarily to the patient.

  9. Ramesh permalink
    January 31, 2013 1:36 pm

    Thank you Dr. Kvedar for kicking off an important, and perhaps the most challenging question to answer. What gets people engaged, particularly in the world of device proliferation. And this is not just a problem in personal connected health, or healthcare, this is a universal challenge. Verizon is trying to figure out how they can keep their customers engaged without using free iphone as a subsidy. Businesses are trying to figure out engagement. As SaaS businesses are growing, users can sign up and drop off as easily creating a new email ID on yahoo, gmail or hotmail.

    So, this question requires a lot of examination, and it is going to be different for different domain areas. From our work in this space, all I can say is that different things engage different people. Some people are interested in information and graphs, others are driven by challenges, some are driven by social factors (reflected by number of gaming oriented wellness programs), some are tied to the rewards ($ or type).

    Fundamentally, segmentation and individualization is the key to engagement. Machine Learning offers the ability to develop options dynamically and serve these options (messages or alerts), and test them.

    Another important connection to make in healthcare is if this increased engagement leads to better outcomes.

    Would love to discuss these ideas further.

    • January 31, 2013 9:21 pm

      Indeed, in our studies increased engagement is correlated with improved health outcomes.

  10. Suneel Ratan permalink
    January 31, 2013 2:25 pm

    The Healthrageous data is fascinating. A lot of folks say that the people using self-tracking are people who would have been motivated to manage their health in any case, which would been in a guesstimated range of 20-30 percent of the population. The Healthrageous program is drawing in 72 percent?

    Rock on. That’s huge.

  11. February 1, 2013 7:37 am

    Reblogged this on lava kafle kathmandu nepal.

  12. Kathy Torpie permalink
    February 2, 2013 5:08 pm

    My understanding is that habituation means that a behavior becomes habit – or “habitual”. What you (and the Wikipedia source) are actually referring to is not habituation, but desensitization.

  13. February 27, 2013 12:31 pm

    Wow, this is a great article and really speaks directly to our spiraling health care costs challenges. If sedentary lifestyle is the biggest contributor to the problem, then changing behaviors is key. You are on the right track by calling out Healthrageous. They are actually a direct competitor of ours but you will never see me criticizing them because their mission in a noble one and we are all working hard to “change the game”. Not a lot of people have heard of our company yet because we started in Europe and are sold under a white label through partners. Here is how we are different. We strongly believe that you can’t manage what you don’t measure so we have developed and patented a Health Score that is integrated and holistic. We take who you are (age, height, weight, gender, medical history, how you feel (depression has a profound affect on you physically) and what you do (integrating just about any device consumer are buying) and express that to the consumer in a single number from 1-1000. Think credit score and apply it toward your health and you start with a great high level understanding of who we are and what we do. We give people an easy way to track and benchmark how everyday activities like exercise, nutrition, stress and sleep affect their health. Connecting that with medical professionals, nutritionists and fitness instructors is why we created the platform in the first place. Its your personal health dashboard so you can surround yourself with the community you build and not simply by other employees. I did not realize we were so further along than Healthrageous in overall numbers. We have thousands more active users on the platform today and we are adding about 1000/day. We have the two largest private health insurers in Europe (Nuffield & AOK) committed to rolling out our Health Score under their names to all their members. Other key wins in life insurance, fitness & wellness, pharmaceutical and retail pharmacy are set to explode our membership well into the millions. We will be announcing our first wins in the US and they are huge. My wife has 30 years in healthcare and is President of a $50 B US healthcare firm. She is one of our staunchest supporters and describes us as a game changer. Whether you are an insurance firm looking to build your own brand and be that health advocate or coach in your pocket or an individual trying to get and stay health, there is value here. If you like Healthrageous, you will love dacadoo.


  1. Engagement is the Next Frontier for Connected Health - The Doctor Weighs In | The Doctor Weighs In
  2. Emerging Technologies: For Patient Safety & Improved Outcomes - The Doctor Weighs In | The Doctor Weighs In

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