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[...] Read more: Those who need it most, aren’t interested [...]

Whilst I completely agree that the Harris Poll was overly optimistic in its projection of public interest in mHealth I also disagree with Chris Delaney.

Yes, there is a lot of good design, packaging and marketing work to be done before “The low activated population” is going to be interested, but when we get past these hurdles uptake can be unexpected and rapid. Good analogies of where this has already happened would be in the rapid adoption of the mobile internet by Smartphone users who found the iPhone browser intuitive to use and the inclusive AT&T data plan forgiving. Likewise Asustek’s ee PC “netbook” which opened up a whole new growth market that was previously being ignored by the stagnant offerings from laptop makers. These weren’t coincidental flukes… Asustek’s Jonney Shih and Jerry Shen specifically designed and marketed their product at an underserved demographic: young children, seniors and other inexperienced notebook users.

As the global recession continues to force the mobile industry to focus on their own neglected audience groups, we will inevitably see innovations that will conquer these adoption issues.

Hi David,

Not to speak for Delaney, but I think on the whole you both are on the same page when it comes to the need for marketing these products to those most in need in order to create interest and demand — once those are overcome, Delaney did not share his take as to how quickly uptake will happen among this group so I don’t see where you are disagreeing.

An elegant wireless health solution that also somehow convinces low activated patients that they can take care of themselves would probably be the closest thing to an iPhone-like catalyst for wireless health. I haven’t seen such a solution yet, though — let me know if you do!

“If I’d asked my customers what they wanted, they’d have said a faster horse.” – Henry Ford

Thanks Matthew! the problem I have is that there is a serious lack of quality in the original Harris Research and as a result “Those who need it most, aren’t interested” is a conclusion built on very shaky foundations.

We really shouldn’t be trying to draw conclusions from such seriously limited market research. Prospective patients of mHealth technologies have very little idea of what they want in such an unfamiliar domain. Even a well considered answer to “would you be interested in wireless health services” is going to be driven by a recent experience, which in most cases will probably be having to endure a long and uncomfortable wait for a consultation with a Doctor. Naturally that individual is going to think yes immediate 24/7 mobile access to my Doctor would be great ie. “I’m definitely interested”. But ask again a month later and you’re probably going to hear that they’d appreciate better access to specialists.

I’m not for one minute suggesting that patient interests aren’t a key feature of good design but you’ll learn a lot more about your patients mHealth needs by analyzing their behavior than by picking their brains!

@Brian: For an example of mHealth solutions that convince “low activated patients” to take better care of themselves (and reduces the costs for the care provider) look no further than the work being done today with SMS reminders or SMS smoking cessation programmes. Not new though… I remember HP launching these with a European paperless Hospital project back in 2005.

David,

I think text message campaigns are very promising and have seen results that back that up. I’m just not convinced those are the best way to reach most of these “low activated patients.”

I’d be delighted if you or someone else could prove me wrong, though. The recent smoking cessation programs I have seen are for teenagers — the recent New Zealand study is an example. My understanding is, however, that teens don’t make up a large percentage of the “frequent fliers” in the ER today.

I do believe that smart people and ever-improving user-centric technology will lead to applications that support individuals across their self-management abilities. And there are indeed limitations to research that was largely observational. But bringing focus to patient variation will be key and is supported by research that goes well beyond this Harris study.

Two key considerations come to mind — 1. Some of the biggest opportunities to address, at least in economic terms, include adherence and unwarranted ER and hospitalization. We’ve seen in a broad body of published research that the lower activated drive these costs, and are typically poor self-managers (this includes self-monitoring). Sustaining behaviors (eg. needing to do on a routine basis) are a particular challenge, and a competency that will be important to the success of Mhealth with the lower activated. ‘Build it and they will come’ will likely be a tough proposition for the lowest activated in relation to the management of chronic disease.

Second thought — to be successful we must address both health behaviors and their underlying causes. As an example, medication adherence has been a challenge for well over a decade with a variety of solutions and significant investment typically designed to help patients remember (phone calls, email, texting, paper mail, more informative pill bottles, etc.). Nonetheless, the low activated (level one) remain 30% to 40% adherent. For the low activated, addressing competencies (what makes us tick) as well as the behaviors we can observe will help mobile health be more successful.

[...] Those who need it most, aren’t interested: The subject of this past week’s newsletter column, Insignia Health CEO Chris Delaney offered readers a longer explanation of his take on the activation levels of various groups of patients, the opportunity for wireless health moving forward and what it might take to get there. Here’s a snipped of his comment from earlier this week: “I do believe that smart people and ever-improving user-centric technology will lead to applications that support individuals across their self-management abilities. And there are indeed limitations to research that was largely observational. But bringing focus to patient variation will be key and is supported by research that goes well beyond this Harris study. Two key considerations come to mind — 1. Some of the biggest opportunities to address, at least in economic terms, include adherence and unwarranted ER and hospitalization…” Have your say… [...]

I agree, there are different solutions for different groups of people and that a “build it and they will come” approach needs to be include hardware, software, professional support, and social networking.

However, it seems that we continue to spend time, money, and effort on presenting variations (eg phone calls, email, texting, paper mail, more informative pill bottles, etc.) of the same thing to people who clearly don’t want to become apart of the high-activated group through these similar advancements.

Here’s a success story of inspiring and motivating through “build something cool enough, marry it with a consumer device, and they WILL come” (low-activated included):
http://www.wired.com/medtech/health/magazine/17-07/lbnp_nike?currentPage=all

Hi Matthew, you’re not seriously suggesting that the Nike+ system is being used by the low activated?

David,

The simple question here is “HOW DO WE GET SOMEONE WHO DOESN’T CARE ENOUGH, TO CARE ENOUGH?”

I am suggesting that bringing this sort of NIKE+ platform will help both low and high activated patients.

Level 1 and Level 2 individuals tend to be passive with regard to managing their health, and may fail to see the connection between their own behaviors and health outcomes.

“Nike+ does something very different. Nike+ is about creating, and then meeting, a psychological need. ”

“For a lot of people, there’s something excruciating about exercise—it’s right up there with balancing your checkbook, visiting your in-laws, and flossing your teeth. That was the case with Rick Law.
‘I used to complain about how inactive I was and wish there was an interesting way to become more physically active,’ says Law… In 2007, Law’s wife gave him a Nike+ system for Christmas, hoping it would motivate him…By tracking his effort—enhancing an analog experience with digital technology—Law found that running could be as interesting as his work… Law got feedback as he ran and enjoyed the sense of accomplishment that came from charting his progress as he got more and more fit.”

I’d be interested in hearing your thoughts on why this sort of system if applied to mobile health self-management and covered by payors and promoted by doctors, would not catch on well with the low activated.

Hi Matthew, have you actually tried the Nike+ system?

To my mind the devil is in the detail and in my personal experience there are far too many barriers to adoption with the Nike+ system that would make it unfeasible for Doctors or Payors. Not least among these are the costs, hardware required and IT proficiency.

I have been involved in the development of a mobile health solution that has already been launched and it has several advantages over the Apple system. The project involved a collaboration between Adidas and Samsung and you can find out full information on it at http://www.micoach.com

An important lesson I have learnt is that we need to bring this functionality to standard phones (eg. preinstalled or made available as a downloadable application) before there is a good chance of it catching on well with the low activated. Mobile operators (carriers) have an important role to play in this and it would be a very good idea for them to work with health system payors as there is lots of value they can add (eg. making the apps available in the first place and white listing the connectivity for the app so customers are encouraged to try it out).

David,

I am not, in any way, suggesting that Nike+ is the answer to any of our Mobile Health prayers.

The purpose of using Nike+ as an example is to provide a product that has taken the right steps to engage people who never wanted to exercise, to begin exercising. After all, this article is entitled, “Those who need it most, aren’t interested.” Nike+ does indeed interest people who need it.

I could not disagree more with your statement, “We need to bring [health] functionality to standard phones (eg. preinstalled or made available as a downloadable application) before there is a good chance of it catching on well with the low activated.”

I believe, we need to look forward instead of backwards. Standard phones are clearly a dying breed as a) smartphone hardware becomes cheaper and more widely adopted across all demographics and b) OS’s like Android (with their Android Market) offer attractive options for manufacturers to ’sexy’ their phones up on the cheap. Every day, App Stores become more and more popular. Landing that big Verizon or AT&T deal isn’t as important as it used to be.

Your miCoach example is precisely the reason I believe so many mobile health companies will fail: It’s not just about the details of devices, it’s about the entire experience and it’s about accessibility. It’s about asking sick people to take the least amount of steps as possible to change their not-so-healthy lifestyles. It’s about connecting with peers, not just doctors, who are going through the same things as you are. It’s about recognizing that society as a whole, especially low activated, more likely to purchase an Us Weekly or People magazine than a novel. We need to embrace the paradigm shifts if we want Mobile Health to prosper across low and high activated, not fight it.

Here’s an example of a product that looks AMAZING on paper (speaking as a diabetic myself):
This product has substantial hardware advantages for diabetics.
It has lots of research and clinical trials and has spent plenty of money figuring out just what diabetics want.
It logs blood glucose results and can send them directly to your doctor.
It can send reminders and alerts.
It’s FDA approved.
It has a free web portal, too.
AND its website has 490 unique visitors last month. Why do you think that is?
https://my.glucophone.com/runscript.cfm?page=home.cfm

A cool product, very similar to the model that was released some years back in Korea by mobile giant LG Electronics. I don’t think we’re at a stage where there is one perfect solution and there are some very good rival offerings (eg myglucohealth.net). But here are a few barriers I see to the Glucophone.com offering:

1) “It has lots of research and clinical trials and has spent plenty of money figuring out just what diabetics want”

Unfortunately the US healthcare system is not just driven by what patients want. The needs of Distributors/Retailers, Doctors, Pharma and Insurers also need to be served.

2) “It logs blood glucose results and can send them directly to your doctor”

Does your Doctor have the ability to receive these and the tools to manage them? Would this extra work be reimbursed? etc etc

3) “490 unique visitors last month”

I have no idea how this statistic is supposed to make me think. With millions of diabetics in the USA it’s not a particularly revealing statistic.

We’re on the same page here, David. The purpose of showing 490 unique visitors was to demonstrate just how unsuccessful Glucophone is. Maybe I should have highlighted my sarcasm more.

“Glucophone is an example of a product that looks AMAZING on paper (speaking as a diabetic myself) BUT IS TOTALLY UNSUCCESSFUL AND WILL NEVER HAVE ANY SUCCESS…”

I’d be happy to discuss more via email mtendler@glucosebuddy.com

Chris,

Putting aside the limitations of the Harris study – it’s pretty much a waste of time to survey people on technologies they haven’t yet experienced in any significant way — the heart of the issue is still valid: how can we significantly increase adherence and self-care, and how can mobile technologies help?

You correctly note the importance of understanding underlying causes. As the Whitehall II study, in the UK, has shown, the work environment, notably the cultural environment at work, has a huge impact on health. In that study, the person’s job level was the most accurate indicator of health (the lower on the organization ladder, the worse the health). The person, the employee, has very little control over this major factor on their health. (This is very much in contradiction to the diagram on your company’s “About Insignia Health” page.) Our mobile health technology, will probably not do much about these underlying causes.

In addition, the increased busyness of modern life — ever more demands on our time, ever more interruptions, ever more responsibilities placed on the individual — makes it ever harder to be adherent to a health regimen. The daily logistics of self-care for those with chronic illnesses is an almost impossible task. Here at least, mobile health technologies could play an important role. Your point about the importance of addressing competencies hits the nail on the head. We must first ensure that people are *able* to carry out a health regimen, within the context of their already very busy life. Today’s “patient-oriented” technologies too often are designed from the perspective of the healthcare providers rather than from the people (the patients) themselves, too often focused on the little task than the entirety of the health regimen in context.

Brian wrote that your advice is to “find the doctors with patients that can benefit from these products.” This I believe is the wrong approach. Don’t start with the doctors. Start with the people. Understand their needs, their wants, and design products that truly make a difference in their lives. Treat this like any other consumer product — make products that are truly appealing, that truly make life better/easier/more joyful, and adoption will be far, far more likely than products designed the way someone else thinks people should use.

I am actually very optimistic. I believe that people do prefer to be healthier (just so they can get on with whatever else in life gives them pleasure), and that mobile technologies can make self-care much easier for most people, But, it won’t come from incremental changes to existing approaches — not mere email/SMS reminders and more tele-monitoring, not from disease-specific widgets (not another glucose & insulin tracking product!) that don’t acknowledge the entirety of a person’s health regimen. Rather it will come from products that fundamentally understands and addresses the person’s, not the doctor’s, needs.

Hi Rajiv,
Your points are well taken. I believe you are referring to the meta analysis pie chart that demonstrates the impact of individual decisions on health. The Whitehall study (with profound findings) drew out the importance of social structure impacts one’s health, but did not delineate the causal chain of how this happens if I remember correctly. The study did not address self-management which is very much the focus of our work. I would struggle with the notion that an individual cannot succeed in managing their health if their are low on the org chart. I believe the Whitehall study does point to the importance of control over one’s environment — those higher in the organization have more control over their environment.

A large body of peer-reviewed published research has shown us that demographcis/sociecomics account for about 5% to 6% of variation in activation scores. Well educated or not, high income vs. low income — we find these characteristics in all levels of activation. This is encouraging given that we can not alter these characteristics, any more easily than providing new jobs for the individuals/patients we support.

The thinking around the role of providers was this — the lower activated (and those who can benefit the most from Mhealth) are heavily influenced by physicians. So the idea of ‘prescribing’ Mhealth for those with chronic conditions feels important. These same clinicians also play a very important role in the feedback loop — helping a patient learn and respond to insight gained from a mobile health application. My other thought concerns the cost of some of these applications — will payors (employers, health plans, govt) require a prescription for some important applications? If so, physician engagement is important. But I agree with your point, either way these products must be designed with the end user in mind!

I enjoyed your comments. Thank you.

[...] fall, I interviewed Insignia Health’s CEO Chris Delaney who explained his firm’s categorization of “activated” patients: The lowest [...]

[...] dernier, j’ai interviewé Insignia Santé PDG Chris Delaney qui a expliqué la catégorisation de son entreprise de « activé » patients: [...]