Focus on Engagement 2/15/13

If you believe the “distribution drives product” method described in my last post, it seems that focusing on engagement might be premature for consumer health tech. With connected health and most patient-facing health technology, we’re still trying to solve the problem of distribution. That’s why we have such low rates of adoption, an incredibly scattered and fragmented product environment, and very little at scale.

Despite that, I thought writing another "Focus On" post would at least give the week a theme and maybe clarify some of what I wrote in my last post.

If you look at the landscape of connected health for patients, most of what you see in terms of successes — and it’s still a small number of successes — are services that are transactional, or episodic. I always reference iTriage, which I consider to be a pretty huge success, but it’s transactional. You have a sore throat or hurt knee, you fire up iTriage, search for your symptoms, get validated evidence from third-party sources, get a listing of providers and facilities in your area, and are then given the option to book or check in for an appointment to certain premium iTriage listings. That’s great and makes sense as long as you remember to search iTriage when you have an acute problem.

Another transactional service that I’ve used a few times and love is GoodRx. I’m not sure how many people are using it, but it compares prescription drug prices. Other companies are doing this, but GoodRx has always worked well for me so I’ve never looked elsewhere. I recently used it to refill a prescription that I’d been out of for about three months despite the daily reminders that I get on my phone. On GoodRx, I searched for the med, found the best deal at an online partner of GoodRx (50 percent less than my local pharmacy), and ordered the quantity I wanted with a set refill frequency. My meds shipped the next day after being transferred from my local pharmacy. I’ve told my wife and some friends about GoodRx and several of them use it to help patients find cheap meds.

ZocDoc is another good example considering it claims that 2.5 million people use it every month. And maybe virtuwell, which published a study of 40,000 virtual visits last week. I’m sure there are some other examples (Healthtap, maybe), especially in the virtual acute visit category, but all of these examples are transactional.

All the success in health has been like OpenTable, but nobody has succeeded with continual engagement like Facebook or even e-mail or SMS. Maybe the problem — at least if you believe Reid Hoffman, LinkedIn founder and prolific investor — is that we’re not appealing to any human vices when we offer health services.

We look at connected and mobile health as having tremendous potential for several reasons. One of the big ones is that it enables providers and our health system to stay in contact with and provide continuous care to chronically ill patients. I’m not taking anything away from services like GoodRx or ZocDoc or iTriage, all of which have potential to help patients and reduce cost in our system, but I’m thinking about the 800-pound gorilla those services are missing. Everybody writes about all the incredible potential of improving health once we have continuous monitoring and big data analytics, but I still struggle with that being enough to change behavior day to day. It definitely needs to be stepwise, but I struggle to see how we take the first few steps.

One exception to this may be aging in place. Companies like Independa are focused on ongoing monitoring and connectivity to remote caregivers and providers. I’m not sure how broadly these services have been adopted, but I also think of them as a specific niche in our system.

The first hurdle is distribution, getting ill consumers (does ill consumer = patient?), whether they know they are ill or not, to actually use a health-related service. To succeed at distribution, you need to engage parties like providers, payers, and employers, but you also need to build the service around a specific transaction. Make it simple and valuable. That’s what Google did with search, and then they jumped into e-mail and a host of other services (Google+ is getting better by the week, by the way, with additions like communities, events, and hangouts).

Then, how do you keep patients and consumers engaged once you’ve gotten them to download and hopefully open your app? Assuming distribution is going to be solved — whether through providers or consumers realizing one day they need apps to help them get healthier or consumers incrementally trying new services from companies like iTriage and ZocDoc — how do you get users to keep coming back?

Everybody, myself included, always writes about adding social and gaming features to keep people using health services. While this works well and is being done effectively with quantified-self services (Nike+, Runkeeper, Fitbit, LostIt!, MyFitnessPal, etc), I don’t think it’s as simple with unmotivated users.

People also talk about designing our way to a healthier society. I’m a big fan of good design, but even the best designed apps won’t get people to use things they don’t think they need or they don’t want. To be honest, we have well-designed and social and gamified apps right now for tracking weight, nutrition, activities, blood pressure, and glucose, so I don’t think those are the problem. At least design, gaming, and social are not what is limiting distribution. Since we haven’t gotten past distribution, it’s hard to say if these will drive engagement.

There’s obviously the financial incentive, which payers and employers are uniquely placed to integrate into health services. Lowering premiums based on maintaining or achieving some level of activity, or just continuous logging, seems like it might motivate people. But I’m skeptical that this will be effective in the long run at engaging consumers and driving behavior change.

Beyond the go-to answers of design, gaming, social, and financial, I wonder about other issues related to engagement like data ownership and data portability. Even though I’d want my providers tied into services I’m using, personally I’m extremely unlikely to use something that is tied exclusively to my providers’ systems. I want something that is primarily centered on me and that I can take with me longitudinally. This perspective may be unique because I can’t really imagine having continuity with my doctor, other than my wife, I guess. Unfortunately I’ve given up hope of having one doctor for an extended period of time.

My gut tells me that to engage consumers in their health, we’re going to need different approaches tailored to the individual motivations of the person. Maybe family integration is key for some people, or gaming is key for others. Maybe a sense of continually connectivity to a doctor is all some people need to motivate them. Maybe a combination of all of these is what is required.

No matter how you slice, it I don’t think it’s easy. I don’t think overcoming the problem of distribution automatically overcomes the problem of continual and long-term engagement. What approaches do you think will win out long term?


Travis Good is an MD/MBA involved with health IT startups. More about me.

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