The OnDigitalHealth Blog

My latest thoughts on the industry I love.

DIY Hacking​ Digital Health: Engagement

Welcome to the second installment of an ongoing series of LinkedIn articles on the topic of…well, this is a tough one…what the heck! How about we continue with the theme of digital health, Alex?

So, true story: I was in the midst of penning a few words on the digital health industry’s favorite four-letter word: E-n-g-a-g-e-m-e-n-t. Okay, so that’s a few more than four letters. But then this great – and very timely – article (“Why Real-World Results Are So Challenging for Digital Health“) came out recently, and I thought, hey, why not riff off of Dr. Kvedar’s sage words…and maybe just solve the whole entire issue?! Hmmm. Well, that does sound a little hyperbolic, now that it’s out there. But I do have some thoughts – based on some common sense, some very real-world experience (“RWEx”) and the empirical evidence that I’ve garnered over the past six years in the space trying – along with many others – to make a difference in people’s lives (and in some cases, actually succeeding).

The issue of engagement in digital health is a complex one, primarily because it involves human beings and healthcare, two pretty complex entities in and of themselves, let alone when combined together in a technological mashup across disparate systems and stakeholders. And while it is “hard” to win at engagement, it is certainly one of the most significant impediments to widespread adoption of digital health solutions, and ultimately, to the kind of success this industry is capable of (which is of the “super awesome” variety, in case you had any doubts). And yet, I think it’s an issue that this not talked about nearly enough! Perhaps because it is “hard”, and people don’t have the [fill in the blank] to fix it.

Check this out: I strongly believe that a good portion of the $13.2B in VC money injected into digital health over the past three years could have been put to better use elsewhere (beyond temporary job creation and some moderate level of tech innovation, that is), if investors had really understood the fundamental issues associated with (successful) consumer engagement in healthcare, as compared to engagement in other industries. Healthcare is and always will be different. Anyone who says otherwise, is either holding a party line, fooling themselves, or just plain ignorant of the realities. When we are faced with making decisions about our healthcare, we are not buying shoes. We are not sending pictures and videos to our friends and family. Some very smart people have invested billions into companies that have no real chance of success, because they don’t have a firm, firsthand grasp and understanding of why healthcare is so complex, for the provider just trying to help their patients, for the consumer just wanting to feel better and live a long and happy life, and of all of the component pieces of the processes and systems working in concert behind the scenes to accomplish these seemingly very basic and straightforward goals (or should I say “aims”, as in three of them?). The “build-it-and-they-will-come” model may work for haunted baseball fields and other industries, but it has not proven out for the overwhelming majority of digital health players. Similarly with the model of buying growth and/or revenue with follow-on venture money (if you made it to the VC feed trough); These are short-term, short-sighted, unsustainable strategies.

I am also of the opinion that what investors have unwittingly accomplished is to create a cacophony of “noise” in the rapidly-burgeoning and white-hot space, i.e., too many point solutions that simply cannot be successful in the long run because they are either too narrowly focused in the broader healthcare continuum, or they do not have the requisite product or expertise to generate sustained engagement. As a result, a couple of things will or already have come to pass: 1) when you are looking for such a solution it is extremely time consuming to sift through and vet such solutions, to get to the “right” one for your use case and needs (even if you know what you are doing), and 2) there are a lot of zombie start-up and growth-stage companies out there (series E, F, G, H, etc.), that are simply going to disappear, as some already have. Yes, there are a limited number of exit slots available via acquisition and industry consolidation, but how many of these exits have been truly value creating, meaning that the value of the buyer has been measurably enhanced, or that the transactions have met or surpassed their modeled IRR’s or ROI’s? I’ll wager that not many people know the answer to that question – I certainly don’t (And how often is this measured post-deal, anyway, particularly in the helter skelter world of digital health startups?). But I’ll also wager that it’s in the ballpark of average telehealth engagement rates (so, low, then ;-). And, I do know of several real-world examples of promising technologies being mothballed or shuttered because the acquiring entity simply didn’t know how to integrate the acquisition in a value-enhancing and/or synergistic fashion. But I digress – a topic for yet another article!

So as an investor or as a prospective digital health solution customer, how do you predict or gauge a particular offering’s ability to engage consumers? Well, you start with informed due diligence, frameworks and checklists. You need to actually ‘look under the hood’, so to speak, and ask all of the “hard” questions. Some companies will tell you that they may not have an answer for you yet (essentially), but that they are working on it (“that capability is planned for our next release cycle”). If that’s the case – and you are certain that this particular solution meets your needs in every other way – you need to hold them 100% accountable to those time frames.

Let’s take pilot studies or clinical trials as one of those example checklist items in the due diligence or even the product development process. Good/great clinical trial results are, alas, no guarantor or harbinger of real-world success (precisely because of some of the reasons Dr. Kvedar elucidated). That said, positive results are a definite step in the right direction, and I would wager that ‘good’ clinical trial results are a better indicator than most. They may also be a requisite checklist item if one of your chosen customer segments is the payer market. But here’s the issue: The kind of attention to detail, the resource requirements, the controlled environment of a clinical study are not scalable to a population of any size, because such an operating model just wouldn’t be profitable enough. SaaS-based digital health companies (and their investors) want margins in the 65-70% range, at a minimum. You cannot achieve those kind of margins when you employ clinicians to reach out and interact with consumers on a one-to-one and as frequent a basis as is typically required in a clinical study.

Ultimately, in order for it to be successful in any meaningful way, a digital health solution needs people to do something, and on a recurring basis, whether that’s clicking, sharing, reading, moving, exercising, dieting, monitoring, logging, making (more) informed decisions about their health and ideally, feeling more empowered – and less fearful – about making these (sometimes actual) life-and-death decisions themselves, or as part of team that has their best interests at heart. And oh, yeah, I almost forgot – actually feeling and being healthier! Well, ideally, all of the above. And even more ideally, in an as automated and seamless a fashion as is possible. In the poignant words of David Lee Scher, MD, “…digital technologies are only tools. They will be utilized only if they appeal to patients and caregivers.”

So what’s the ‘secret sauce’ to engagement in digital health? How do you make these tools appealing (or even indispensable) to the people that you want to use them? [Editor’s note: Finally!] Well, as I and numerous others have conjectured and opined, there’s not a single recipe for success. There are many paths, many approaches, many subsequent business models. That said, I have seen the following elements ‘work’, whether in concert (ideal, IMO), or as requisite components of a system or platform (D’oh! Take a shot, if you’re playing the digital health “platform” drinking game! How many times have you heard “We built a platform…” from digital health cos, recently? A bunch, I’m guessing. So, perfect for a drinking game.). Here are some DIY hacking digital health engagement components, that you probably need in your platform (C’mon, drink!), if you don’t already have them.

  1. Oh, the humanity! – We human beings can rarely, successfully, continuously operate in a space devoid of human interaction (or a suitable proxy – see below). We need love, encouragement, validation (Hey, that reminds me – do you see the little “thumbs up” icon below? Yeah, well, could you click on it for me? It would really mean a lot to me – thanks!). Of course hugs are good, too, but at the very least, we need to know that we are not alone, and that someone (or something) cares about us, or at the very very least, that we perceive that such might be the case. At present, that is still actual human interaction, at least until gamification, avatars and AI’s such as Molly and Olivia and “Her” can take our place at the care management / clinical intervention table. Whether such interactions come in the form of general “health and wellness” coaching (covering education, exercise, nutrition, lifestyle factors, etc.), or is more focused on the management of a specific condition or set of comorbidities, we Homo sapiens, generally speaking, give credence to “expert” opinions, suggestions and guidelines, particularly when served up with the appropriate data on the side (Yes, exactly! Just like French fries!). Further, these kinds of interactions should be served up to us at precisely the right time (#2, below) and within the proper context (#3, below), to be at their most effective. Yet we know that there is an ever-increasing shortage of certain types of clinicians and particularly across our nation’s supply of stalwart PCP’s, and that the average physician spends only a few minutes a year with their patients. Sound familiar? Yes, these very phenomena were some of the original, primary market drivers of the digital health industry. And yes, the ultimate goal is automation of these kinds of interactions, enabled by technology. So wouldn’t it be cool if someone built a platform to do this? (Oh, hey, another shot. You’re feeling pretty good now, right? A little ’10 feet tall and bulletproof’?)
  2. (Near-)Real-time feedback – As in, you need some of this on your platform (Sorry!). A figurative and literal wealth of health-related data is being collected these days – by devices, trackers, phones, clicks, keystrokes, EHRs, all kinds of analytics p-words (I’ll give you a break, just this once.) – the list goes on – but it is rarely being utilized for anything that provides timely, tangible or ongoing benefit to the consumer. We need and want feedback (see #1), which supports, prompts, scolds, cajoles, alerts, reminds, etc., in a fashion concordant with our personality type and lifestyle factors (see #3), and which is delivered in an accurate, timely and contextual way, i.e., “context-aware systems.” Yes, a bit of a tall order, this one, but it can – and has – been done, even in a completely automated fashion, at least for a single condition. In the broader healthcare context, most feedback given to consumers is negative and very untimely. Six months or more in between physician visits, care management personnel that contact you months after an acute care utilization event, little to no feedback from many digital health platforms (Ugh, not feeling so hot now…). This is why traditional disease management programs (particularly telephonic) have largely gone the way of the dodo, because as you know, they relied on claims data and interventions from strangers delivered in a very non-contextual format – like phone calls while you are at the dinner table. What’s at stake? A share of consumers’ (very short) attention! Across each of these five components, you are competing directly against each and every exigency of people’s personal circumstances, i.e., everything that makes up their waking moments – and the choices that they make to either engage in a specific activity, or not. So, the more timely, the more relevant, the more impactful, the more useful…yes, the more likely you are to engage with and stay engaged with your end users. Because they believe (ideally fervently and unceasingly) that they are deriving something of value from using whatever it is that you’re providing to them. I’ve been to the homes of Medicare beneficiaries and have engaged in conversations with Medicaid beneficiaries who were home-less to talk about their healthcare and their very important role in it – can you imagine or perhaps you are already well aware – how basic, simple and pointedly effective a digital health solution must be to achieve engagement in these environments? You have to truly know these people, you have to know what their daily lives are like and what their competing priorities consist of, in order to even have a chance of being successful (something about real-world human-centered design). Going off on a bit of a related tangent, “But what about rewards and incentives?”, you may ask. Well, I’ve got this for you: “Carrots and sticks can make people click, but rarely will they change behavior.” [Editor’s note: Karl thinks he came up with that, but he was too lazy to Google it, so, my apologies and a forthcoming reference / retraction, if it was unintentionally plagiarized.] Now we’ve entered the complex realm of the psyche, and the Three Brothers Id, Ego and Superego…okay, let’s stop while we’re ahead. But we are now wading into the behavioral science waters of habit formation, extrinsic versus intrinsic movtivators, crowding out, operant conditioning, messaging, trust, social network effects and most importantly, the specifics of the incentives, the rewardable behaviors and the ultimate goal of the incentives (e.g., sustainable and lasting behavior change). Bottom lining it, incentives may help spark an initial response or intended behavior, and then perhaps, once an individual experiences a positive effect, their intrinsic motivation might reach critical mass, so to speak, to potentially help them continue with their improved habits…well, you get the picture. If you want to maximize your chances of success, maximize the consumer’s.
  3. (Meaningful) Personalization – You want to really make your solution ‘sticky’? Yeah, you betcha, personalize it. “Wait, how do I do that?” Well, I’ll tell ya, pilgrim: Make me believe that when you are asking me to input information, it will come back to me in a valuable, relevant and personally meaningful way, then prove it, time and again. Show me that you are learning from me on a continual basis. Surprise me – but maybe don’t freak me out – with how much you know about me, my life, my activity, my diet, my health status, even my family and loved ones. Turn that wonderful knowledge into context-aware suggestions, education, reminders, alerts and maybe even a little good-ol’-fashioned encouragement or humor. Become my ‘trusted advisor’, my consigliere, my go-to source when it comes to my health and well-being. Let me decide how and when I want to engage with your solution, but prevent those dreaded gaps in care on the back end, behind the scenes. Provide means for me to change settings, formats and options to suit my unique needs as an individual. A few of the vehicles currently in use for getting at these golden nuggets: Genetic testing/profiling, remote or continuous device monitoring, personality inventories, telehealth visits, interviews, surveys, traditional consumer analytics and databases, etc., etc. In my mind, this is the least mature component of the five listed here, as it’s arguably the most nascent, with the biggest potential for ground-breaking and disruptive technology breakthroughs (and new IP) in even the near future. We’re just starting to take those first, tentative steps on this one.
  4. Marketing – As in, more and better, particularly on the DTC front. The digital health industry (as healthcare overall) is in dire need of more sophisticated marketing and advertising ‘chops’. We need the kind of prowess and efforts applied to the space, as have successfully been applied to other industries (e.g., CPG, retail, auto, financial, etc.). Again, IMO, healthcare marketing is generally pretty ineffective (although a majority of physicians would probably tell you that they wished that the “ask your doctor” ads weren’t quite so successful in getting you to do just that), from an ROI perspective (Yes, a blanket stereotype, well knowing that there are numerous exceptions to this statement.). “Health and wellness” promotional efforts (unless perhaps specifically focused on some types of weight loss product purchases) are even worse. I believe that we are largely missing an emotional connection with the consumer, particularly at those critical times when the consumer is a patient. We need to provide more education and data. We need to get to a place wherein the purchase / engagement decision is seamlessly aligned with a very clearly-articulated – and well-understood – value proposition and measurable benefits for the prospective customer or engaged consumer, ideally of an aspirational nature. If you do ‘this’, Mrs. Smith, studies have shown that you can reasonably expect ‘this’. Of course there are quite a few examples by now of companies that promised the moon, sun and/or stars – and the FTC took a couple of entities behind the woodshed for fraudulent or misleading claims. A real-world example? I wish I could tell you otherwise, but I’ve been part of numerous digital health program or service deployments, wherein the participants (providers, consumers, even the implementation team) really had no idea “why” or “what” it was they were being asked to do. Guess how well those efforts fared? “Spectacularly” is a word that comes to mind…but unfortunately not in the positive connotation. I think the above falls at the feet of the marketing function. Which leads me to the last topic on our list, “platform.” Naaah, I’m just joshing – it’s…
  5. Education – I probably could have led with this one, as this single issue underscores and is woven into the fabric of all of the other components. If we are to be successful as an industry, we need to do a much better job of educating consumers on the topics of health and healthcare. Consumer healthcare literacy, knowledge quality and quantity are outrageously poor in the U.S.? Did you know that only 12 percent of U.S. adults had proficient health literacy? Hey, you know you’re right – that’s not very good! And the resultant, cumulative knowledge gap makes everything we do take longer – from sales cycles to outcomes – and cost more. I don’t have a blanket or a one-size solution for this problem. But I do have some idea of how to effectively and efficiently educate the critical stakeholders, across the spectrum of payers, providers, employers and most importantly consumers, on the product and corporate levels. We’ve got to start somewhere.

Of course all of these various components are integrally and inextricably linked to platform (Uno mas, for good measure!) architecture, design, your resulting UI/UX, your content, your data and analytics capabilities (e.g., db type, ETL, APIs, PROs), the kinds of devices your system can tap into, how easily you can make and add new connections, how you are set up to measure outcomes, satisfaction and other key metrics, the clinical, behavioral, design, operations and commercial folks that you are working with, among a few other important things I can think of. Then there’s the whole strategy / business model thing. But that’s for another day. I’m thinking you might need a nap at this point.

So, that’s it for this installment. Wow, you did it! You got through the whole article – or at the very least, just skipped to the end! Hooray! Say, why don’t you reward yourself with a shot? Seriously and most sincerely, thank you for taking the time to read this. Of course you really don’t have to ‘DIY’ hack digital health alone. And you probably shouldn’t, being wicked drunk and all – that’s just plain irresponsible. There are many amazing and expert folks out there that grok digital health, and can help you advance your cause / company / organization / project / product / service along the lines of what I’ve presented above or in other equally-critical capabilities and/or directions. And if you’d like to find one of those (self-appointed) experts, I know a guy

At the close of this article, I want to take just a moment to thank everyone who took the time to read my last article, “A (Love) Letter to Digital Health.” So, yes, a great big ‘thank you’ to all, especially to those who ‘liked’, shared, tweeted and commented. I love you guys! <3 Having gotten such positive feedback, it seems that I achieved the requisite 25K mph / sufficient encouragement to write another article. Who knows, I may be just as insuppressible as a certain U.S. President’s Twitter feed! Until next time, and if anything I said resonated with you, please don’t hesitate to get in touch. Would love to hear from you.

In Good (Digital) Health,