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Could Mobile Health Become Addictive?

August 20, 2013


The hype over mobile health is deafening on most days and downright annoying on some.  So it is with some reluctance that I admit that mobile has the potential to be a game-changer in health.  I’ve professed enthusiasm before, but that was largely around the use of wireless sensors to measure physiologic signals and SMS text as a way to deliver messages to patients and consumers.  For several years, the industry has been awash with smart phone apps (by a recent count more than 40,000).  At the Center for Connected Health, we started looking at mobile health as far back as 2008 and could not justify the excitement around smart phones and apps at that time, mostly because our patient population did not demonstrate significant enough adoption of smart phones to justify development in this area.

I felt very unpopular at all of the major conferences.  I talked about our success with text messaging as a tool for engaging pregnant teens in their prenatal care and helping patients battling addiction to stick with their care plan, while others were touting the virtues of their various apps.

It’s worth noting that our primary focus at the Center for Connected Health has been patients with chronic illness.  As such, we are every bit as concerned about the 85 year old with congestive heart failure as we are about the young professional with hypertension.  However, across the population of people with chronic disease, smartphone adoption has lagged.  I felt like our strategy was vindicated when my friend Susannah Fox published research showing that folks with two or more chronic illnesses (independent of other variables such as age and socioeconomic status) use technology in the context of their health less than others.

The world of patient care appears to be catching up to the rest of mobile.  Not that I would ever endorse the irrational exuberance shown for mobile health apps in general, but some recent data points that changed my thinking are worth noting.

The first was when Dr. Kamal Jethwani, our head of research, was telling me about close-outs for one of our clinical trials.  In this particular trial, the intervention involved twice-daily SMS text messages.  The patients were recruited from a neighborhood health center in an underserved community.  As part of the exit interview we asked informally about smart phone adoption.  We were surprised to hear it’s at about 60%!  Not only that, but several of the patients asked, “Why are you guys using texts?  Why don’t you have an app?”

This was a turning point for me.  Not long after that, I heard a compelling NPR story about making technology addictive.  It seems those of us who own smart phones check them obsessively (by some counts 150 times/day).  The reason seems to be that we are seeking either new information or new connections.  Looking at that tiny screen is, well, addictive.

We published a paper recently where we looked at two home-hub transmission technologies.  The context was a diabetes program where patients were asked to check their glucose twice a day and upload the results to our database (via the Internet).  Some folks had a device that required them to push a button to accomplish the upload and some had a ‘passive sensing’ device that required no button push.  The results were impressive.  Those that did not have to push a button were significantly more adherent to their plan and had better health outcomes.

The opportunity seems too good to pass up.  Contrast checking a screen compulsively 150 times/day with so much lack of engagement that merely pushing a button is too much to ask.

Mobile health offers us many transformational opportunities.  We can use smart phones as a data upload/home hub device.  We can use them as a device to engage the consumer around health content.  We can use them to display health-related information at  just the right moment in just the right context.  We can use the cameras to capture relevant health information (e.g., home test results).  We can use them to message you in the moment with contextually relevant, motivating messages.

Add to the list that we can harness the addictive properties of these devices to, perhaps, make health addictive.

I am really intrigued by this concept.  As I’ve done some early research on it, I’ve discovered that the term addictive is edgy and maybe even too controversial.  An addiction is something you can’t stop.  We’ve heard about folks who are obsessive about exercising or checking certain vital signs to the point where it is beyond healthy.

I don’t mean that.  But going back to that example of pushing a button, if I could make it easy for people to engage in their connected health data and improve their health as they are looking at their smart phone screens 150 times/day, that might make a difference.

What do you think?

42 Comments leave one →
  1. August 20, 2013 2:01 pm

    Who likes consuming healthcare or being addicted? Nobody, so the more passive the tech the better. The other question is do docs really want more data and what is just enough data to optimize care for the cost?

    • August 21, 2013 8:24 am

      My hypothesis is that the latest passive technologies – including sensors
      and cloud computing – have the potential to make taking care of our own
      health easier and easily integrated into our daily routines. Like we brush
      our teeth every morning, we can check our blood pressure or activity levels
      each night. Sometimes we can’t even remember if we brushed, it’s just part
      of our routine.

      As for your question about what is too much data, I think most healthcare
      providers would welcome more accurate, timely and conveniently available
      data upon which to base clinical decisions. The trick is going to be
      presenting this new data in a way that seamlessly fits into their clinical
      workflow, and is actionable.

  2. August 21, 2013 12:07 am

    Excellent observations. Creating less friction and being more intuitive is where popular apps succeed (ie, less tasks or as the previous comment stated, more passive). When we create apps that creates more work (as silly as that sounds), it’s still a task. We’ve just increased the amount of “work” required to obtain an outcome. That’s why I love apps that minimize work (less clicking, entering data, etc).

  3. Heli Tuomi Carlile permalink
    August 21, 2013 12:22 am

    One key to truly engaging people in their health using smartphones is authenticity and quality of content. I mean, are the messages you get as a recipient “significant” (either specific data about you, or a real message from a real person) or are they just auto-spew of inspirational messages and reminders from a database? I would venture to guess that people start very quickly to tune out the auto-spew once the novelty wears off (within a day or two?). What are we hoping for, at the end of the day, as we check our smartphones 150 times a day? Actual messages from people we know. Not data. Maybe some data, but that’s not the “premium” content we hope for. To that end, mobile health should never over-automate the experience and remember to keep human beings at the other end of that mobile interface. Secure social networks could be one successful solution: a trusted network of humans who communicate with you via a mobile app.

    • August 21, 2013 8:26 am

      Yes. it can never feel like ‘auto-spew’ (I like that term). The trick is that the messaging should be highly customized and the novelty can never wear off. A big challenge, but one that can be overcome, I’m confident.

    • Diana Robinson permalink
      August 27, 2013 12:28 pm

      Even targeted auto-spew is better than generic auto-spew. “Hey, your blood pressure is 10 points higher than normal today. What’s going on?” is better than “Don’t forget to keep calm!”, while both are capable of being automated.

  4. August 26, 2013 7:56 pm

    A technology that provides a very simple tool to establish a quick video chat with a smart phone user would eliminate the auto spew messaging concern and would connect the member with a real person. Think of it like checking into a hotel with a happy, smiling employee – when you see that person at the check-in desk the next day, you always say hi or bye or have a good day. When you have that personal connection, you are replacing the ‘app’ with a face and a voice and a personality. Virtual Medication Therapy Management seems like an obvious choice for this new cloud technology.

    • August 27, 2013 9:42 am

      The real question is when is this human connection critical to success, i.e. a need to have rather than a nice to have? We have to start leveraging our human resources to touch more patients more efficiently. Automation will play a role. We just have to figure out the best way to fit it in.

      • Diana Robinson permalink
        August 27, 2013 12:35 pm

        I did two weight loss/better health interactions with my insurance company. The first one involved weekly check-ins with a person (I called her my cheerleader) who provided positive encouragement and ideas based on the information I gave her. The fact that she cribbed one or two of my ideas for keeping me on track was a huge boost to me. She also provided sympathetic but firm support when I fell down on meeting my goals. I was quite successful with this program, until I had an issue with my knee and broke the cycle of exercise. The second one was all on-line, no human intervention. I had signed up with the program again to get that initial boost to get me going on regular maintenance after my post-op PT finished. This was a complete flop for me.

        I feel like coupling the weekly check-ins with the on-the-spot automations would be ideal, especially if your cheerleader was able to review your automated input before calling.

  5. Scully permalink
    August 27, 2013 9:22 am

    Great article Joe, “obsessed” might be a better word.

  6. August 27, 2013 9:34 am

    I was happy to read that No-Touch is much more user friendly than One-Touch. We have an app called Stay-in-Touch.ca which has a No-Touch user interface. Used in Elder-Care it can show family pictures, respond to Skype calls and Do a Phone-the-Deaf function all without laying a finger on the screen of the Android Tablet.

  7. Jim Hutchinson MD permalink
    August 27, 2013 9:38 am

    Apps are like a delicious stew boiling on the stove and constantly having new ingredients added. However, the “proof of the pudding is in the eating.” Over time there will be many different stews, eventually both the cook (developer) and the eater (patient/provider) will determine those of true value. Hopefully we won’t cut off innovation by devising rules and guidelines prematurely.

  8. Paul Allen permalink
    August 27, 2013 9:41 am

    I think if the application is simple and secure it can get over the two primary concerns of my non-IT friends who always tell me “Oh, it must be complicated” or….”I wouldn’t trust it as far as I can throw it”.

  9. August 27, 2013 9:44 am

    Do you think patient portals wil take off as destinations for patients tied to the smart phone and the new apps you mention ? Or will the effort be too much for patients to surf over (just like the one push of a button needed for the remote home monitoring devices)? There seems to be this buzz for them so patients could check labs, secure email, pay bills, make appts,look at own home monitoring data, etc. Shall we not bother as researchers with texting systems to engage patients and also building patient portals?

    • August 27, 2013 12:05 pm

      These are great questions and I can only speculate. More and more consumers (of which patients are a subset) are using internet portals to do more and more, and that is mirrored in using portals for routine transactions around one’s health care. In general we’ve found that patients are less likely to engage in health improvement activities than we would have predicted (hence the power of the one button story), so my instinct is that if your app architecture involves hopping from one site to another or from an app to a site, it will probably be less successful than one that is simpler.

  10. Paul Dattoli permalink
    August 27, 2013 9:58 am

    My opinion is that Mobile Health can and should become addictive. I also agree the mobile app is the key to making that happen. Who will come up with the best mobile app for tracking one’s health? The app must be easy to use (intuitive), as entertaining as possible, and highly available. These traits all appear within today’s mobile phones and handheld devices. Perhaps an app that simply presents an image of the human anatomy on the screen. If it is colored green (your good), yellow (something isn’t right), red (take immediate action). Of course to generate these shades of wellness, the app would require access to pertinent information and must perform the necessary processing. Thus passive sensing devices and other means of capturing the vitals would have to play in the “game”. In addition, authentication between the device owner and the device would be required. This could be accomplished by eye or fingerprint recognition software (more apps!). All the pieces are around, and now the vision is materializing to trigger the integration or should I say innovation. If I look at my smartphone screen anywhere near 150 times per day, would be great if a few of those views reminded me of my health!
    Thanks for more thought provoking stuff.

  11. Michael Laing, President permalink
    August 27, 2013 11:13 am

    I agree completely that an interactive mobile app that can manage a chronic condition, would enroll the patient in their well being and provide better health outcomes. To this end, our firm Genesis Total Patient Management has developed and now testing the web based patients/doctor portal version of Genesis TPM that manages PT/INR and Diabetic patients. We will have the tablet and smart phone application for this chronic care management program available in about four weeks. I invite anyone who would like to discuss this with me to contact me anytime.

    • August 27, 2013 12:06 pm

      Please keep us posted on your success!

      • Michael Laing, President Genesis Total Patient Management permalink
        August 27, 2013 12:35 pm

        Our beta test will conclude in 3 weeks and I will provide the feedback as well as the progress with the our program. Thank you for your interest.

  12. Diana Robinson permalink
    August 27, 2013 12:42 pm

    Any app that is intended to automatically manage your health needs to have hooks into whatever you’re using to track it. Currently, blood sugar monitors have a capability to transmit to a database that you can give your MD access to (as I understand them); presumably, there are similar systems for monitoring blood pressure. You’re going to want to leverage those APIs to get the data seamlessly into the app – linked through app name and user name, or through device type and whatever identifier goes with that. Link them, and let it run. I’m sure you already know this, but I don’t recall that it was explicitly stated in the article.

    • August 27, 2013 8:27 pm

      This is helpful. thanks

    • Gaurav Sharma permalink
      August 29, 2013 6:34 pm

      I think interoperability of data from various “devices” is going to be big thing to tackle. Also, I agree that more passive the approach, the better the outcome in terms of adherence. However, I wonder if this would also lead to increasingly sophisticated devices and then we run into the same issue that medical devices companies are having now – reimbursements.

      • August 29, 2013 7:40 pm

        If we really believe that “Pay for Value” is here to stay, device manufacturers will need to change their model

  13. August 27, 2013 2:32 pm

    Joe,

    re: apps – It’s not a SMS vs App discussion. You need to flip it from the user perspective: what is the level of tools that serve the level of engagement needed? It needs to be layered to take into account the nature of the notification or information, the behaviours established, the preferences of the user, and so forth.

    I worked in the mobile world for many years starting before GPRS and all the way to the iPhone early years. Key for me was understanding the Mobile Lifestyle, how mobile devices weave their way into the way we live and interact with things.

    I can think of many instances when a text message is more effective than an app. And vice versa. But I can list a few strong instances when both together are most effective.

    You do touch on this with the one-touch v no-touch and the like. And I know you and Kamal think this way (it’s what I feel is the core of all you do, BTW; and it’s evident in your work). I just wanted to be explicit that it’s not a SMS vs app discussion, but an exploration of the multi-modality of engagement woven into the background of our mobile lives.

    Regards,

    Charlie

    • August 27, 2013 8:29 pm

      I understand what you are saying but as I told the story, it worked out that way so I told it that way

  14. August 27, 2013 3:21 pm

    Just one comment: please review the “MedPod” at DayaMed.com

  15. August 27, 2013 8:32 pm

    Great post. One thing that’s rarely considered is just how much more effective asynchronous communications are in terms of resources. One of the most frustrating parts of health care is the need to call on the phone, you get transfered around, maybe they call you back, and when they do it’s at an inconvenient time. Think of digital vs analog, or tcp/ip vs a direct line. When someone has to be available for one to one communication on the other end an both parties must be coordinated in time, that’s a huge drain on the system, possibly an exponential drain. It’s also a large part of why people put off contacting their provider once discharged, so it could easily contribute to increased readmissions. If I could simply text or use an app to send my temperature, medications as I take them, pain level or sensor generated data like glucose, oxygen, heart rate or other, isn’t that easier than me making the decision that these are out of the range of normal and that I should see someone? Or notify when I’ve performed certain tasks as part of may care plan. For patients to have to make the call that a reading is out of normal, then have to get into a dead end phone tree is a lot of friction on the system, on both ends.

    I wrote about elements recently in shifting health communication from a liability to an asset (http://www.hl7standards.com/blog/2013/08/22/healthcares-new-os-shifting-health-communications-from-a-liability-to-an-asset/) , and we’ll write about my own experience coming soon.

  16. August 27, 2013 8:35 pm

    well stated on the case for synchronous!

    • August 27, 2013 9:19 pm

      I was trying to make the case for ansynchronous communications available, but OK.

  17. August 27, 2013 8:45 pm

    One more comment on the compulsive checking of email. Great chapter on this is Dan Ariely’s “Predictably Irrational” http://www.amazon.com/Predictably-Irrational-Revised-Expanded-Edition/dp/0061353248 Chapter 7: The Problem of Procrastination and Self Control”

    The key, like a slot machine, to induce this kind of addictive behavior, is to offer a reward at a certain irregular or random interval, just enough to keep responding.

    Maybe in the health context that’s just a not from your doctor saying “congratulations”, or from a loved one. Sure, you might not be able to get people to hit a button all the time, but experiment with unpredictable rewards, and you might be amazed at how often they’ll hit that button.

    • Paul Dattoli permalink
      September 5, 2013 11:00 am

      Make it a game and people will play !

  18. December 6, 2013 2:15 pm

    Heya! I understand this is somewhat off-topic
    however I had to ask. Does managing a well-established website such as yours require a massive amount work?

    I am completely new to running a blog but I do write in my journal every day.
    I’d like to start a blog so I can easily share my own experience and thoughts online.
    Please let me know if you have any kind of recommendations or tips for new aspiring bloggers.

    Appreciate it!

    • December 6, 2013 2:25 pm

      Would depend on how much you want to be involved and if you were to try and respond to every one who comments on your blogs.

    • December 8, 2013 8:58 pm

      My recommendations:
      1. post no less than twice a month.
      2. pay attention to and answer most comments. blogging is really a social medium, and conversing with commenters is part of the experience.

      it is a great overall experience and a good way to crowd source various ideas and concepts.

  19. September 10, 2014 12:20 pm

    I believe healthcare can be addictive on a smartphone, as long as it is easy and quick to access, input and review data , as well as interactive sharing capabilities between the patient and their caregivers. We all expect quick relevant results and this must be delivered or the ball is dropped.

Trackbacks

  1. Could Mobile Health Become Addictive? | The Doctor Weighs In
  2. Addictive mHealth Apps | Smart Phone Health Care
  3. Making Health Addictive | The cHealth Blog

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