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Making Health Addictive: Use The Sentinel Effect

May 29, 2014

Since I gave a keynote at the 2013 Connected Health Symposium called “Making Health Addictive,” I’ve been posting on this topic in order to explain some of the concepts in more detail and to get your feedback.  Previous posts include a framing post, and further detail on what I laid out as three strategies to achieve addiction to healthy behaviors: “Make it About Life” and “Make it Personal” and “Reinforce Social Connections.”

In early February, I wrote about tactic one, Employ Subliminal Messaging, and last month on tactic two, Use Unpredictable Rewards.  This post is on the third of three tactics, Use the Sentinel Effect.  I realize there is a lot of required reading if you are just checking in to this series.  If you want to absorb the full concept, it is worth reading all of them. If you’d like the Readers Digest version, you can get away with the framing post as background.

Making health addictive is really about harnessing the power of our fascination with mobile devices, particularly smartphones.  We check these devices up to 150 times per day.  What if we put a personalized, relevant, motivational and unobtrusive message in front of you some of those times?  Could we induce permanent behavior change?  I am searching for examples of these customized mobile, personalized messages and any resulting behavior change, so if you know of any, please let me know.

The Sentinel Effect is: The tendency for human performance to improve when participants are aware that their behavior is being evaluated; in contrast to the Hawthorne effect, which refers to behavior change as a result of being observed but not evaluated.  Both are useful tools in the context of connected health.  I’ve emphasized the sentinel effect because in our experience, patients significantly increase their adherence to a variety of healthy behaviors when they know that their physician (or her agent) is watching.

About seven years ago, we began working on platforms to allow patients to upload biometric data.  These data act as both a feedback loop for patients themselves to use as a yardstick for health improvement, and also as a mechanism for patients to give their providers access to a richer tapestry of data on which to base care decisions.  This combination of feedback loop plus provider oversight worked well for us.  In the case of congestive heart failure monitoring, we saw a 50% drop in readmissions;  patients with hypertension achieved a significant drop in both systolic and diastolic pressure; and people with diabetes experienced a meaningful drop in HbA1c.

Because the hardest challenge for us to solve was the round-trip data connectivity — from the sensors in the home to the cloud to the EMR and patient portal — we assumed that this was the magic key to the success of these programs.  However, when we asked the patients and the nurses caring for them what made these programs work, we heard a unifying theme from both parties.  We learned, what mattered most, is that patients worked hard to improve their health because they knew their nurse was watching and didn’t want to disappoint her.  Some patients went so far as to say they’d only participate in uploading their self-monitored data if they knew that their doctor and/or nurse were looking at it.

Here are three video clips that illustrate this:

First from one of our patients, George Ruboy, who talks about his personal experience with Connected Cardiac Care, our heart failure tele-monitoring program:

The mirrored reflections of one of our nurses, Karen Federico, are presented in this video clip:

Lastly, from a pharmacist who has used our Blood Pressure Connect program to manage many patients with hypertension:

This most basic of human psychologies is related to strategy number three, Reinforce Social Interactions.  Some social interactions are motivating because we want to brag to our friends, because we want our friends to be a support group or because individuals in our social network are holding us accountable.

The Sentinel Effect is a really powerful tool, but is  based on a fairly primitive psychology. Essentially, we don’t want our parents to catch us falling off the wagon.

It’s great that we learned about the synergistic relationship between objective, patient-generated data and the Sentinel Effect.  If the same programs were based on self-reported data from patients keeping a written diary, for example, we’d have much weaker outcomes.  Patients would report those data that make them look healthy and ignore those that do not.

Now, we’re contemplating whether we actually need a nurse or doctor as the sentinel.  For these algorithmic conditions, like uncontemplated hypertension, could we employ software to do the monitoring, rather than having a doctor or nurse monitor the patient data.  But would patients be as responsive and diligent managing their own health?  Early results suggest this is possible.  It is the next generation of connected health solutions.

Let me know your thoughts.

14 Comments leave one →
  1. May 29, 2014 10:51 am

    Dr. Kvedar, once again you engage us in an appropriate dialogue. My personal answer, based upon our work here at Family Health Network is that well constructed software, perhaps even including virtual representations of the care team, can provide most of the sentinel effect. There is little doubt that making the information available to the person’s health care provider increases the effect…from both sides. The provider can “prescribe” the software and its use, assure that it is appropriate, and multiply the touches by the care team. But today’s technology, including devices, enable real-time feedback not possible through traditional approaches.

    Just this morning, we are working on approaches that not only provide the sentinel effect but guide the next step in interactions of all participants based upon input from devices, patients, and others involved in their care. We think that we are just beginning to employ the effective integration of knowledgeable health care professionals and the opportunities afforded by emerging technologies. Please continue to lead these important discussions

    Harry Bailes, CEO

  2. May 29, 2014 6:22 pm

    JOE, you lost me.

    I don’t check my phone 150 times a day. I check it when it pings – a few times a day. You make me feel socially inadequate 🙂

    I am very fed up with all these internet people who send me messages on my PC/Ipad, most of which I never read. This is why I rely increasingly on my phone for the important stuff. (Now Facebook has taken over WhatsApp I fear the worst).

    My healthcare professional is someone I want to receive messages from. However they need to be specific, personal, and relevant. Quite a challenge!

    • May 29, 2014 8:06 pm

      quite a challenge, indeed. I don’t pretend to have it all figured out. And many of the companies out there are doing a terrible job of engagement. that said, your frequency of phone checking is below the norm 🙂

  3. June 1, 2014 8:38 am

    Joe, I believe the healthcare providers need the same kind of ‘Sentinel Effect’ as the patient.
    The belief that their successes matter both in doing good work and assisting patients to be healthier and delivering cost effective medical care. We all need to be acknowledged and affirmed for our effort and more importantly for our results. The side effect in contributing to ‘Big Data’ will make this kind of tech even more effective. Perhaps, randomizing the healthcare providers responses with virtual & human comments may be the most effective ‘addiction’ model. Keep up the good work, I’m following you. Dale

  4. July 6, 2016 12:31 pm

    Dr. Kvedar, I am trying to track down the studies you listed as supporting evidence for the use of the Sentinel Effect as an engagement tool. Would you please point me in the right direction?


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