Behavior Change

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Post or Perish? Disseminating Scientific Research and the Kardashian Index

Publish or perish has long been the mantra of academic research. While this used to be limited to peer-reviewed journals, researchers are increasingly needing to include public outreach through social media to their list of communication vehicles. A recent panel at the International Society for Environmental Epidemiology conference this week in Seattle tackled this problem with some practical advice. With a focus on the environmental factors that can impact public health, the researchers at this conference have a definite need to reach a broad audience base not just to justify their grant money but to positively impact public health and the environment with their findings.

Disseminating air pollution effects on public health

Disseminating air pollution effects on public health

Disseminating scientific research to the general population is not an easy task. Media outlets like easy wins and definitive statements, but research results often need the fine print to be fully understood, and the fine print often contains details like study methodology or influencing factors that either are too complicated for the general public or limit the results of the findings to very specific situations. For example, perhaps a drug proves effective but only in left-handed blind mice that could play the tuba. This might be a big scientific breakthrough pointing towards broader benefits, but it’s not conclusive enough for media that want to say things like “New drug 100% effective” not “Drug thought to be effective in tuba-playing left-handed blind mice.”

One audience member, who worked in communications for a large research organization summed up this problem as ‘if a headline meets my criteria no media outlet would pick it up.’ That is, by the time the headline was completely scientifically unambiguous, like our blind mice example, it didn’t seem like news.

The session featured real world examples and best practices from http://escapeproject.eu/ and from the NIH. The Escape project was a multi-year study to evaluate the effects of air pollution from birth to death across a wide range of respiratory and other illnesses. You can understand why getting this information beyond academic readers to the general public is so important.

Some tips:

  • The communications plan needs to be part of the grant-writing process, and for studies that impact public health, you need to think beyond PubMed to the general press and social media.
  • Know what channels your audience accesses. Are they on Twitter or Facebook or maybe print media?
  • Understand what larger story your research is part of and position it within that context. For example, for Escape, it’s the impact of air pollution on health.
  • Understand the implications of your research for the general public. What action do you want them to take based on your findings?
  • Avoid scientific jargon.
  • Make sure you can distill the main message from the study, and as conclusively as possible within the parameters of your research topic.
  • Leverage partner organizations for their press and communications contacts and to disseminate the message. For example, the Escape project used respiratory related health organizations to help spread the word about their findings.
  • Photos can be a powerful way to get attention and disseminate information. Here Escape found that photos of major cities obliterated by smog were very effective to accompany news articles about their study results.
  • Don’t dismiss the Kardashian Index. Some researchers downplay the value of social media because the most popular scientists on social media are often doing the least amount of research and possibly not the best researchers. However rather than making them shy away from social media as a result, the presenters urged the audience to participate more actively to make sure their voices and research were heard. Popularity and valid information do not need to be mutually exclusive.
Do's and Don'ts for Social Media for Researchers

Do’s and Don’ts for Social Media for Researchers

As active social media participants here at Wellpepper, we have a couple of additional recommendations for researchers:

  • Try not to name your study with an acronym. Studies usually have very long names and then acronyms are coined as a short cut. However, they usually don’t convey the actual meaning of the study. “Escape” is an acronym for European Study for Air Pollution Effects. How about “Smog Europe?” ;). A descriptive name with a subtitle is a lot easy for the general public and news media to grasp.
  • Infographics can be a great way to communicate a lot of data-rich information like this one from the NIH about social media influence within a online medical community. Put your contact and study information on the infographic and make it easy for people to redistribute. (We didn’t include the NIH graphic here because it required emailing them for permission.)

Even within the session attendees that represented researchers from across the globe and in all career stages, there was a great digital divide. One young researcher implored her older colleagues to use Facebook to engage with scientists and potential scientists of her generation. She also mentioned that it was a great place to recruit study subjects. Another researcher from Chile talked about the power of social media for collecting data: getting reports from people on the ground who were facing environmental health challenges. This could have been a topic unto itself, and if more deeply explored might have convinced some of the more curmudgeonly audience members who were concerned about the current proliferation of communications channels, lack of ubiquitous digital access, and a worldwide decline in scientific literacy.

In the age of social media, the idea of publish or perish takes on new relevance and meaning, and hopefully scientists and researchers understand that embracing these new ways to engage directly with the general public will amplify the impact of their work.

Posted in: Behavior Change, Healthcare Social Media, Healthcare transformation, Seattle

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A Tale of Two Sensors: Misfit Shine vs. FitBit Zip

On a 5-day back-packing trip in British Columbia, I put two sensors to the test. While neither were designed specifically for this purpose, my impressions are definitely relevant to the usability of the sensors in everyday life.

I’ve been using the FitBit Zip for over a year, and here at Wellpepper, we’ve blogged about experiences with sensors before. We integrated Wellpepper with FitBit for a Boston University study on engaging Parkinson’s patients and so the Wellpepper team all got FitBits to test the product and integration. BU chose the FitBit Zip because it had a long battery life and was easy to sync. They didn’t want study participants to have to worry about constantly charging the device.

For my trip, I decided to also try the Misfit Shine that I received as gift at the XX in Health Conference. I started on the trail with the Shine on my wrist and the FitBit clipped to my shorts. I had two main goals for the devices, which may be different than their intention but I thought they should work for the purpose: to tell time and to know how far I’d gone and how far I had to go until the next campsite.

I have to say, that sadly, I actually needed both devices to accomplish the task and there were problems with each.  The following is my review of how the devices stacked up for telling time, judging distance, ease of use, and form factor.

Misfit Shine

Telling time: The Shine shows you the time by flashing a light at 12, and then flashing the hour location and minute location using lights on a radius, because the time doesn’t advance the “hour” hand stays on the previous time until it hits the next full hour making 6:45 for example, look like 5:45. This made telling time an intellectual exercise. Maybe this was the point, but not being able to glance at the thing on my wrist to find out the time was pretty frustrating. It was also extremely hard to see the flashing lights in bright sunlight. So, for telling time, I’d have the Shine a C.

Misfit Shine

Jewelry? Hmm.

Distance: The Shine uses goals that are awarded according to points. This is so that you can track multiple activities. The problem is that by default it only tracks steps or distance but the reporting on the device is only how complete you are on your goal. This makes it actually impossible to use the Shine for distance tracking without syncing to a cellphone. (I did not bring a cellphone on the trip due to battery life and complete lack of wifi signal.) Tracking Distance: I’d have to give the Shine an F.

Ease of Use: To get information from the Shine, you double-tap it. This in theory is easy but sometimes it didn’t respond or because of the bright sunlight I’d miss what it was trying to tell me. However, syncing with the app was very easy and the app is reasonably usable (although I still haven’t figured out which night sleep tracking is showing). I didn’t find out until after the trip that in order to record other activities like swimming, I was supposed to tell the Shine that an activity other than walking had started. Ease of Use: B+

Form Factor: The Shine is an attractive metal disk. However, it’s on a rubber wrist band so to call it jewelry is a bit of stretch unless you live in Silicon Valley or maybe Seattle. The metal is smooth and pleasing to the touch but I really wish it told you some information when you look at it. Form Factor: A-

Other: The Shine tracks sleep, which is quite interesting. However, I didn’t have this information until after the trip when I synced it with the app. And, as mentioned previously, it’s hard to tell what night it’s showing. For example, it’s Thursday. The sleep tracking I see shows “Today” which I’d assume is “Wednesday night”, “Yesterday” which I’d assume is “Tuesday night” but then “Tuesday” is that “Monday night”? Again, the Misfit Shine feels like it makes me work too hard for the information.

Misfit Shine Sleep

What is restful sleep?

FitBit Zip

I’ve been using the FitBit for about a year, so I know the issues with it a bit better and have many friends that have the FitBit Flex or Zip. I bought I FitBit Zip for my mother specifically because it gives you information without needing to sync to an app. However, since I’ve been using the FitBit for a year, I’ve started running into some issues: I think it’s on its last legs.

Telling Time: Normally, the FitBit would have gotten an A+ in this category. However, after changing the battery and syncing with the phone, as soon as we got on the trail the time somehow changed to 3.5 hours later than the current time. Telling time: D

Distance: This is where the FitBit is awesome. It counts steps and distance. We relied on the distance tracking constantly to track progress on the trip. Distance: A+

Ouch. :(

Ouch. 🙁

Ease of Use: The FitBit wins here too. The display on the actual device shows you everything you need to know, and cycles through steps, time, distance, and an emoticon representing your daily activity by simply tapping the face. You don’t need to sync to the phone to get crucial information. I bought at FitBit Zip for my mother for this reason: simple and easy to use. Ease of Use: A+

Form Factor: The FitBit Zip is light and can easily clip to your clothes. On a backpacking trip it doesn’t matter if you’ve got a funny plastic thing clipped to your pants. In the city, it’s hard not to look like a bit of a dork. Recently, my FitBit lost its protective cover and now has some exposed prongs that have the potential to snag clothes. Also, it’s pretty easy to lose, either from it falling out of the case or putting it through the was on a pair of pants. Form Factor: B (until I get a Tory Burch FitBit.)

Other: The FitBit provides really great weekly summaries of your activity via email. It also enables you to challenge or track your friends activities. Downsides seem to be in durability. Both the Flex and the Zip only seem to last a year (based on anecdotal evidence from friends).

The reason so many friends on this list are “unranked” is that their FitBits have died.

FitBit Friends

The fallen

Neither of these devices were designed specifically with back-packing in mind and the Misfit Shine definitely was built with the assumption you would always have access to a phone to sync, however, it seems that each of them could have worked a bit better ‘off the grid.’ On the other hand, if my FitBit wasn’t approaching the end of its life, it probably would have performed very well.

Regardless even reviewing some of these glitches in the light of daily usage, it still seems we have a long way to go. We’re really just at the beginning of what’s going to be possible with self-tracking. Let’s hope devices get more durable, smaller, and easier to use.

 

Posted in: Behavior Change, Healthcare Technology, M-health

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Healthcare Transformation Summer Reading List: 7 Thought-Provoking Recommendations

FeetHeading to the beach, lake, or forest soon? Looking for something that will stimulate your thinking and have you heading back to work with inspiration and new ideas? Interested in new ways of looking at the world and ways to improve your organization?

We’ve rounded up some books that have inspired and even entertained us on big topics like motivation, behavior change, and the challenges and solutions in healthcare today. In no particular order, here are some ideas for summer reading that will get you thinking differently. (And no, we’re not an Amazon affiliate so we don’t make money if you buy after clicking through.)

Behavioral Health, Habits, and Economics

Nudge: Improving Decisions About Health, Wealth, and Happiness

Richard H. Thaler  (Author), Cass R. Sunstein

calmSynopsis: Research-based with practical examples of how small ‘nudges’ can alter behavior in predictable ways. Great for both micro-changes in your own behavior and thinking about human behavior as a whole. Unfortunately, like many of the books in this section, you’ll learn from this one that we very often do not make choices that are in our best interests.

Quotable: “The nudge provided by asking people what they intend to do can be accentuated by asking them when and how they plan to do it.”

Why You Should Read It: Who doesn’t want to make better decisions about health, wealth, and happiness? 😉

The Power of Habit: Why We Do What We Do in Life and Business

Charles Duhigg

Synopsis: Examines human behavior by looking at scientific research on habits, and even addictions, and combines that with examples of how companies have exploited these traits to ‘help’ us create new habits that include their products. Helpful to understand your own behavior and think about how to influence others either individually or collectively.

Quotable: “Studies of people who have successfully started new exercise routines, for instance, show they are more likely to stick with a workout plan if they choose a specific cue, such as running as soon as they get home from work, and a clear reward, such as a beer or an evening of guilt-free television.”

Why You Should Read It: Clearly breaks down behaviors and gives real examples of where we have all formed habits even without knowing it. Uses case studies from the masters of habit influencing: consumer packaged goods companies, with a particularly interesting story about why Febreeze smells the way it does.

GameFrame: Using Games as a Strategy for Success

Synopsis: This book tackles game mechanics and explains them in a way to make them applicable to anything you’re doing. It explains why games are addictive, but more than that equates them to behaviors and habits that we can apply to business and life. Although game mechanics are the framework for the book, it’s really about human behavior and motivation and how games capitalize on it.

Quotable: “Seeing progress is motivation. We derive satisfaction not from the moment, but from looking back and seeing how far we’ve come.”

Why You Should Read It: If you like games, you’ll understand better what makes them so appealing. If you’re not a gamer you’ll learn that gaming techniques and intrinsic rewards are part of everyday experiences that are pleasurable or sticky.

Predictably Irrational: The Hidden Forces That Shape Our Decision

Dan Ariely

Synopsis: Master of behavioral economics Dan Ariely explains why although we think we are making rational decisions we are actually making irrational decisions and yet there is still a method to this madness. That is, you can actually predict in what circumstances people will make irrational decisions that are potentially against their best interests.

Quotable: “money, as it turns out, is the most expensive way to motivate people. Social norms are not only cheaper, but often more effective as well.”

Why You Should Read It: Unlike many other books on behavior that provide a summary of research from many sources, in this book Ariely summarizes his own research which makes his insights both deeper and funnier. For example, this Duke University professor impersonates a waiter and takes beer orders in a pub in one experiment.

Healthcare Transformation

The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Healthcare

Eric Topol, M.D.

Synopsis: Not afraid to be provocative, and pulling no punches, Dr Topol takes on the US healthcare system and what’s wrong with the way medicine is practiced today both as a system and in individual patient/provider relationships. Topol is an early evangelist of how big-data can be used to deliver personalized medicine. If you’re interested in what all the fuss is on big data, this is a great primer.

Quotable: “Many patients now trust their peers on social networks—online medical communities such as PatientsLikeMe—more than their physicians.”

Why You Should Read It: Some of the examples, especially in genomics, seem far out, but they’re closer that you can imagine.

The Innovator’s Prescription: A Disruptive Solution For Healthcare

Clayton Christensen, Jerome Grossman, MD, Jason Huang, MD

Synopsis: Clayton Christensen turns his “innovator’s dilemma” theory towards healthcare with the help of medical experts Dr. Jason Huang and Dr. Jerome Grossman to shine light on waste and mis-incentives in the current system and provides strong cases for how to change it.

Quotable: “There are more than 9,000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.”

Why You Should Read It: In comparing hospitals to mainframe computers the authors use an already played out technology industry scenario to foreshadow what could happen in healthcare.

Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience

Charles Kenney

Synopsis: Virginia Mason Medical Center in Seattle is a leader in applying kaizen or lean manufacturing techniques to healthcare. This book chronicles how they went from near bankruptcy to becoming a model of efficiency. It provides real examples and pulls no punches on the bumps along the way.

Quotable: “Change or die”

Why You Should Read It: While the mechanics of how Virginia Mason improved processes with a lean model are fascinating, the culture and people change that had to happen for the new model is just as interesting.

If you don’t like any of these options, we’re also reading HL7/ASTM Implementation Guide for CDA® R2 -Continuity of Care Document (CCD®) Release 1 😉

Posted in: Behavior Change, Healthcare motivation, Healthcare Technology, Healthcare transformation

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Just Because You Can, Does That Mean You Should?

Facebook’s recent experiments in social media mood contagion got us thinking about user-based testing in general and especially how that applies in healthcare technology that is intended to influence behavior.

The Experiment

happyFor one week in January 2012, Facebook manipulated the feeds of users to show content that was either positive or negative and then looked at whether this had an influence on users. The main point of contention or dissention is that this was human subject research without consent from the subjects and without the oversight of a review board as would be expected for university research. If the research hadn’t been published in a scientific journal then there might not have been so much controversy. What is the difference between A/B testing and what Facebook did? In A/B testing, marketers test different landing pages or campaigns and see which one works the best for their desired goal. Consumers don’t know that they are part of an experiment to test messages. However, consumers did freely follow a link that brought them to the content. The difference with Facebook is probably first, that they have significant power due to the volume of users and more importantly what they know about those users, and second although Facebook lawyers will tell you their terms of use covered it, Facebook users probably did not sign up with the expectation that Facebook itself would actively attempt to make them happy or sad.

How Do You Test Behavior Change?

It’s an interesting question for those involved in healthcare, and in particular trying to help people modify their behavior. In our case, at Wellpepper we are helping people be more adherent to home treatment programs. To do that we use a number of motivating factors including personalization and notifications. As part of building our application we test which features are effective in motivating people. We continually improve and change the application based on what we learn. Is this testing on human subjects? Yes. Did we get permission? Yes. This is part of our terms of use and it is also an essential part of how the industry builds software that people will use: by testing that software with real users. When people start using our software they use it to help them with a specific problem and they are happy when we make improvements to make it more effective to solve that problem. We encourage user feedback and implement new features based on it. So while, we may test new features, it is part of the implicit agreement of delivering software to users. (If you’ve ever used software that was not tested with real end-users, you’ll know the difference.)

When we test and add features that help improve user experience and become more adherent to their treatment program users are happy because we have helped them with their goals for using our software and the implicit contract with them. If we started testing and adding features that made them less adherent or changed some other type of behavior that they weren’t trying to change using our application we would have broken that contract and they might vote with their feet or in this case fingers and stop using the application.

What’s Your Implied User Contract?

The same thing could happen with Facebook, and it stems back to what their intention is with this research. The unfortunate thing is that they probably have enough data to have figured out that positive newfeeds make you happy and negative newsfeeds make you unhappy without actually manipulating the feeds. The fact that they did this, and did this without consent, brings up a bigger question of what their intention is, and what exactly is the implicit contract you have with Facebook. What exactly is their motive in trying to manipulate your emotions? For marketing experiments of this type the motive is pretty clear: consume more of their product. For Facebook it might be the same, but the fact that they tested negative messages does cause some alarm. Let’s hope they use their power for good.

Wellpepper2-1216aFor software developers that aim at healthcare behavior change there is an additional challenge as we think about testing features with real users. In order to help someone change behavior you need to test what works and that does need to be with real users. In general software development there are industry best-practices, for example, where you test different designs to find out which is most effective. This may be considered “experimentation” as users will not see the same features and some of the features they do see may not make it into the final version of the product. When you are doing this type of testing, you are looking for what is most effective in helping users achieve their goals. However, this testing must be done while protecting personal health information and not providing any harmful impact to the patient. Software developers can partner with research organizations whose internal review board will ensure that research on human subjects is conducted in the right way. To prove out efficacy of an entire application, this is often the best way to go but not practical for feature testing.

Guidelines for User Testing in Consumer Healthcare Applications

While looking at specific feature testing, these guidelines can help make sure you respect your end-user testers:

  • Unless you have explicit consent, all user testing must be anonymous. This is because if you are dealing with PHI and have signed a HIPAA BAA you have agreed to only access PHI when absolutely necessary. If you need to know demographics of your users for user testing, then you should err on the side of getting their explicit consent. This could be either via a form, or simply a non-anonymous feedback form on your application or website. By providing you with direct feedback the user has agreed to not be anonymous. (The good thing here is that patients can do whatever they want with their own data, so if they give you consent, to look at it, you have it.) That said, if you are working with healthcare organizations you will also have an agreement with them about contacting their patients: you need to make sure they have agreed to this as well. When possible err on the side of making data anonymous before analyzing it.
  • Think about the implicit contract you have with the user. If you are providing them with an application that does one thing, but you discover it may have applications for something else, don’t test features for that something else without getting consent. That is breaking the contract you have with them. Let’s look purely hypothetical example: at Wellpepper we have an application that increases patient adherence to home treatment programs for those undergoing physical rehabilitation. Let’s say we found out that people in physical rehabilitation are also often fighting with their spouses and started adding features or asking questions about the user’s relationship with his or her spouse, users would find this both unnerving and intrusive because that was not their expectation that we would help them with marital issues when they signed up for the application. Obviously this is a bit far-fetched, but you get the point.
  • Don’t get in the middle of human-to-human communication. This is essentially where Facebook broke the implicit contract with users by dis-intermediating the newsfeed. Your expectation with Facebook is that it’s a way for you to communicate with people (and sometimes organizations) you like. By changing what showed up in your feed, Facebook got in the middle of this. In healthcare this is even more important: don’t get between healthcare professionals and their patients. Make sure it’s clear when it’s you (the application, the company) talking and when it’s the caregiver and patient.
  • Consider where you’d get more value by partnering with a research organization. Sure it will take longer and may require more effort, but you will be able learn a lot more about why or how people are using your features by getting explicit research consent. I am not sure if it’s a coincidence or not but about a month ago I noticed that my Facebook newsfeed was full of extremely depressing stories. I remember wondering what was going on both with Facebook and the world in general and I remember wanting to post something depressing but then thought, “No I don’t want to add to this. I will only post positive things.” It’s possible that I was part of another study by Facebook and if so, they didn’t get the full picture that they would have if they’d been upfront about it, got my consent, and were able to ask me questions later about my thought process.

There is no doubt that we will see more discussions of ethics and consent in the space of user testing, especially as it relates to consumer-facing health applications. Having no regulation or guidelines is not good for consumer. However, only doing research with IRB and third party researchers is also not good for the consumer as innovation that could really help them can be slowed dramatically. Most people, whether healthcare practitioners or entrepreneurs got into the space because they wanted to help people. If we remember this, and we consider the ethical implications of our actions, we should be able to balance the two worlds.

For more reading on this topic as it applies to the software industry, see:

http://en.wikipedia.org/wiki/A/B_testing

http://ai.stanford.edu/~ronnyk/2009controlledExperimentsOnTheWebSurvey.pdf

http://www.exp-platform.com/Pages/expMicrosoft.aspx

Posted in: Behavior Change, Data Protection, Health Regulations, Healthcare motivation, Healthcare Social Media, Healthcare Technology, M-health

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Big Distances Make the Case for Telemedicine: Recap from the Canadian E-Health Conference

Vancouver Convention CentreJust back from the American Telemedicine Conference, and we took a short trip over the border (and back to the motherland), to the Canadian E-Health Conference in Vancouver, BC. Due to the short timeframe between conferences, it’s hard not to compare and contrast the two, although the healthcare systems between Canada and the US could not be more different. The E-health conference had a broader scope than the ATA conference, with telehealth as a sub-topic and electronic records management featured more broadly, in fact, all the major EMR vendors were there, with the exception of Epic.

Know Me in Powerchart

Know Me in Powerchart

In a session sponsored by Cerner, Island Health CMIO and Acting Executive Medical Director, Dr. Mary-Lyn Fyfe shared their patient-centered approach to EMR implementation called “Know Me.” Island Health Authority has been a Cerner customer for 5 years, and have a robust implementation with plans to extend to patient recorded profiles. Dr. Fyfe talked about how what is most important to patients is not always evident or even apparent to healthcare providers, for example, a patient admitted for heart issues but who is more concerned about who will care for his spouse at home with dementia rather than his own condition. Only by treating the whole patient does Dr. Fyfe believe that healthcare providers can have real impact.

Although telehealth was not more advanced in Canada than what we’ve observed in the US, Canada has real financial incentives for telehealth. Vast distances and sparse populations make delivering a high-level of care in many parts of Canada very expensive. The more that can be done remotely, the better. One group covering First Nations groups boasted that they had delivered nine telebabies, that is babies delivered with the help of a doctor over telemedicine. Another doctor talked about how his being able to coach a medical assistant onsite through a video call prevented a $10,000 emergency helicopter flight. Others talked about the environmental benefits of thousands of car trips of 3-4 hours that were avoided by using telemedicine, not to mention the quality of life improvements for patients. Another benefit of telemedicine that we hadn’t seen cited before was doctor education, this is in the scenario where a local primary care physician calls a specialist and together they meet with a patient. In an in-person specialist care scenario the patient would not see these two physicians at the same time. Having both in the same patient visit enables knowledge sharing between the doctors, for the specialist more context on the patient, and for the primary care physician education about the specialist’s area of expertise and the patient’s condition. You could call this collaborative telemedicine.Hackathon

While telemedicine is well established in Northern Canada, it seemed that the benefits in parts of Canada closer to the US border where most of the population lives were not as well established, and a surprising number of telemedicine initiatives were still in pilot mode. Similarly there seemed to be a great disparity in electronic records management with some health authorities still entirely on paper.

Kicking off the Canadian Telehealth Forum, which was a pre-conference session and also an annual event, Joseph Cafazzo of the Center for Global E-Health Innovation showed examples of home monitoring technology that did not take into account the users, who are primarily seniors, and called on the audience to consider empathy in the design of products. One of the key reasons for this is that the only person capable of managing a chronic illness is the patient themselves, and yet many don’t want to identify with their illness or be reminded that they have it. Empathy to the patients experience can help in designing products that make it less intrusive for patients to manage their health. The Juvenile Diabetes Foundation has been putting pressure on manufacturers for this as teens in particular don’t want to take their blood sugar readings although it’s crucial to their health. The Center for E-Health developed an application that identified the times that teens really don’t want to take readings (at lunch when they are at school for example), and offered rewards like iTunes giftcards for doing so, a great example of a carrot that is attuned to the patient’s preferences.

Mobile health seemed in the same place as in the US: a lot of very interesting, patient-centered applications like the 30-day stroke assessment from the Center for E-Health and the Heart & Stroke Foundation of Canada, which used AirMiles rewards to entice a high-risk group of men to download and complete the assessment. Engagement was 12% across all groups, including seniors. One of they keys to the app was that it focused on a short-timeframe, although this does bring up the question of how to keep patients engaged over the long-run.

Not surprisingly a number of solutions were based on lowering costs of population health management. Because healthcare is government funded, unlike the US there are real incentives for decreasing costs as well as keeping the population out of long-term care. While many solutions addressing issues such as CHF and COPD are in early stages, we heard lofty goals of increasing the number of outpatients managed by one nurse to over 200, and also using wellness coaches to scale further.

Considering that unlike the US, all the economic and patient incentives are aligned for e-health, it was a bit surprising that so many of the solutions and presentations were about pilots rather than completely implemented systems. However, that might be a tradeoff of having government run programs. Regardless, the conference featured many passionate speakers who are using innovative solutions to both improve patient outcomes and experience while being cost-effective.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, M-health, Telemedicine, Uncategorized

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23 and Who? The results

This post is the 2nd in a 2-part series on our experiences with 23andMe.

Wellpepper: What made you want to try 23andMe?

Anne Weiler: I wanted to see what the customer experience was like. It seemed so simple. $99 and they promise to tell you about your ancestry and DNA.

Jacquie Scarlett: I was really interested in getting back the results and seeing if the information I received from 23andMe was consistent with what I already knew about myself and my family history.

Wellpepper: What did you think you would learn?

Anne: I was curious about my ancestry. I had a theory that somewhere in my family someone was Jewish. They weren’t.

Jacquie: I figured that I would get confirmation that I was mostly European and that arthritis ran deep in my history and would be a high risk for me.

Wellpepper: Were you surprised by the results?

Anne: Originally, I was surprised at being 99.9% European. People are always asking where I’m from and they aren’t satisfied with “Canada” as an answer. When I was travelling in Nepal people thought I was half Nepalese. However, since I originally received results, they have been refined, and I’m now only 99.5.% European. I am not sure if that explains anything though.Anne Weiler Ancestry from 23andMe

Jacquie: I wasn’t overly surprised by the results, but found some items very interesting. I knew that I would be mostly European, and I was – 99.7% (mostly British and Irish) – but it was fun to find out that I was .1% Jewish and .1% Native American.  It was also pretty cool to see 479 DNA relatives pop up in my results from all over North America and the UK.

Wellpepper: What was the most surprising result?

Anne: Most surprising were results that contradict my actual experience. For example, 23andMe says I’m at reduced risk for Psoriasis, a hereditary disease that runs in my family and that I do in fact have. This does make me question other results.

Jacquie: There were a few illnesses in the Elevated Risk section that took me back for a moment, but then when I dove into the results I realized that I was merely a few % points above the average for all people and I relaxed. It is a bit surprising to see those illnesses listed in front of you.

Wellpepper: What was the least surprising?

Anne: That I’m at risk for glaucoma. It’s hereditary and I’m familiar with my family history.

Jacquie: High risk for arthritis – very prevalent in my family history and I already have the illness.

Wellpepper: What is your understanding of the accuracy of this test?

Anne: I don’t know the statistical accuracy, but I know that 23andMe was trying to get to 1M DNA records sampled so that they could claim accuracy. I also saw the NY Times article showing the discrepancies between tests. Based on some of my results that are wrong it’s hard to know. The brain is funny though: I definitely want to believe that the results showing low risk for Parkinson’s or MS are correct even though I have other results that are incorrect based on my personal experience.

Jacquie:  I do not know. I have the understanding that the more DNA they receive from the population, the more accurate the results will be and the more information they will be able to find out. I took this as an opportunity to learn more about DNA and the possibilities of what you could learn versus that this is the absolute truth.

Wellpepper: What was it like to receive your results?

Anne: Anne Weiler Norovirus ResistanceIt was addictive. We all want to know about ourselves, and here it was, in great detail. I really loved the random things I found out, like I’m resistant to Norovirus (stomach flu) or that I am likely to sneeze in bright sunlight. I intuitively sensed those things, but had no idea they were genetic.

Jacquie: It was pretty fun and interesting. I love learning more about myself and family history. Even though there was a lot of information, I found myself wanting more and wanting to dive deeper. Every time there was an unknown listed – I wanted the answer – this is what keeps me coming back to the site.

Wellpepper: Since you have received your results how have you engaged with 23andMe?

Anne: They are very good at pulling you back in, either through relatives who want to connect or by releasing new test results. That’s the really interesting (and scary) part. Once your DNA is analyzed it remains on file and they run new tests or more accurate versions of previous tests on it. I didn’t realize that it was going to be such a sticky experience.Anne Weiler DNA Relatives

Jacquie: I have checked in from time to time to see if any of my results have been updated. I also really enjoy doing the surveys – I am very interested in the research that 23andMe is doing and want to help in any way I can.

Wellpepper: Have you shared your information with anyone? Who and how?

Anne: I’ve connected with two 2nd or 3rd cousins on the 23andMe website. I’m interested in finding my maternal grandmother’s family. We don’t know as much about them.

Jacquie: I have shared my results with close friends and family, mostly with family to entice them to do the test as well.

Wellpepper: Would you share it with your doctor?

Anne: If I thought it was relevant to symptoms I was experiencing yes, but otherwise not unless my doctor asked. Doctors are being overloaded with data these days.

Jacquie: I would share the results with them if they would find it helpful.

Wellpepper: Do you think 23andMe will continue to engage you?

Anne: I don’t seem myself using it all the time, but as I mentioned before they do a good job of bringing you back in, and maybe I’ll become more interested in genealogy as I get older.

Jacquie: I will check in here and there. I imagine that if I have a health situation, it will be helpful to be able to pull these results when needed.Anne Weiler Asparagus 23andMe

Wellpepper: Do you think people should have access to this type of personal health information? Is it dangerous?

Anne: They should definitely have access. I thought 23andMe did a good job of presenting potentially disturbing results with the appropriate cautions. For results for chronic and debilitating diseases they make everyone read information about the disease before they tell you if you have the marker for it. I think it could be dangerous if someone started to make changes before talking to their doctor, except for some basic things like avoiding tobacco or caffeine, which are good for you regardless of the markers you have.

Jacquie: Absolutely! I think it’s very beneficial for people to have the most information possible so that they know more about themselves and feel empowered to take care of themselves and their health.

Wellpepper: Based on receiving your results, will you make any personal changes?

Anne:  I will be more helpful to people with stomach flu since I know I can’t catch it, and I’ll be even more strict on my caffeine in the morning only policy.

Jacquie: The results weren’t surprising enough to cause any personal changes.

 

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Technology

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Seattle Health Meetup: Focus on Consumer Health and Wellness Technology Sector

Less than a year ago, I was at an event sponsored by the Washington Biotechnology and Biomedical Association, where a room full of health IT and consumer health startup CEOs bemoaned the lack of a healthtech community in Seattle. We have all the elements here: talent, world-class healthcare facilities, and b2b or enterprise IT pedigree. Events like Seattle’s Health Innovators Forum Meetup and Health 2.0 are trying to change that by bringing together startups, investors, and general health enthusiasts for learning and sharing. This month’s Health Meetup, organized by Edmund Butler, was focused on Consumer Health and Wellness, and featured local startups in this space. Speakers were:

54824v1-max-250x250Marcelo Calbucci (@calbucci) is Co-Founder and CTO of Everymove, a company that automatically integrates data from various fitness trackers and provides consumer rewards from its partners.

 

 

 

Julie Kientz (@juliekientz) is the director of the Computing for Healthy Living and Learning Lab (CHiLL), a group of UW researchers interested in designing, developing, and evaluating apps that aim to promote healthy lifestyles and education.

 

 

Rebecca Norlander (@rebatwork) is the Co-Founder and CEO of Health123,  a consumer health company that helps people make decisions and track the small changes in their lives that can make a big difference in their health.

The three speakers shared a passion for designing person friendly applications for consumers to manage and improve their health. The three talks provided different perspectives on the topics of how to engage users and overcome their barriers or burdens to both application use and improving their health.

Marcelo kicked it off with his “8 Pet Peeves of Health Apps.” (I’m sensing an Everymove love of numbers as I also attended another talk by CEO Russell Benaroya called 25 Reasons You Suck At Sales. They also like to have provocative titles. 😉 )

Here they are in order:

    1. Calling people patients. Marcello pointed out that for all other applications they are users. He prefers people or member. (Later Rebecca noted that some industry conventions need to stay in order to communicate with your target customer. Patients is a tough one. People don’t like to be called patients, but the entire healthcare industry refers to them this way.)
    2. Trying to be all things to all people. This was a criticism of apps that try to track too many things. Figure out what behavior you’re trying to affect and do a great job of that.
    3. Putting the organization rather than the person at the center. This would be designing for the healthcare organization rather than the patient or worse yet for the insurance company rather than the patient.
    4. Misaligned or misguided incentives. Marcelo used the example of paying people to track something for example finding out their BMI rather than trying to incent them to change something, like become more active (and then lose weight). Historically there has been an idea in the health and wellness area that if you have information you will change. Information is really only one component (as Julie elaborated on in her session).
    5. Health Risk Assessments. Marcelo thought that these were particularly dangerous as people tend to associate these types of assessments with tests and then inflate their answers and then assume they are healthier than they thought.
    6. Bad UX and bad visual design. Marcelo showed an EMR screenshot saying “the 90s called, they want their interface back”.
EMR Screenshot

Source, Microwize.com.

  1. Treating a person as a condition. The person’s condition is not who they are and is only one component of the information a healthcare provider or application needs to understand to care for or help support that person.
  2. Making you change to fit the application or service. Wearables still fall into this category. You need to remember them, you need to wear them, and in the case of the new FitBit force, you need to get medical attention after wearing them.

Julie Kientz was up next, and her human-centered design approach provided practical advice to solve many of the pet peeves that Marcelo mentioned. The goal of Julie’s research is to understand and reduce the burdens in healthcare design. She described 8 key burdens that can impact adoption of healthcare technology.

Physical: Is the technology comfortable to use or to wear? Does it fit in with my surroundings or what I am doing? With wearables, physical is obvious, but physical could also be how you access the application, for example which tasks are better for a mobile device versus a PC?

Privacy: Where does the data go? Who is able to see it? For applications that have social sharing, are others able to track you? (Did you call in sick and then go for a 15K run?)

Mental: How do you feel about the technology? Julie said she feels sad when she forgets to put her FitBit on, and often goes back home to get it. As well, she is on her 6th FitBit in 3.5 years due to losing them, so is also feeling some guilt about the loss.

Access: Is the technology designed for diversity? For example, many nutrition trackers do not include foods that are popular with different ethnic groups.

Time: How much effort is required to enter or review data? Julie personally doesn’t look at her FitBit data online, just at the step count on the display. The online reporting is too much effort for her.

Emotional: What is the emotional impact of not meeting the goals the technology is tracking? Do you feel like a failure?

Financial: How much does it cost? Does it require expensive equipment like a smartphone? Are there added costs like a data plan?

Social: Does others use of tracking make you feel better or worse? Do you feel guilty when someone posts their runs online?

Because these burdens compete with each other it’s impossible to design to eliminate all of them at once, and so you have to understand which are the most important or provide the biggest barriers for the audience you’re designing for. Julie and her lab published a paper on this if you want to know more “Understanding the emotional burden of health technologies”. She also provided some practical examples of how her team has developed technologies and studies to accommodate these burdens.

ShutEye

One example is the ShutEye sleep tracker that’s designed for people who have some trouble sleeping but are not motivated enough to seek professional help. ShutEye is an Android app that displays on the homescreen with recommendations based on the time of day. For example, it will tell you whether it is too late to have caffeine if you want to get a good night’s sleep.

Another application, BabySteps deals with the emotional component of child development, by displaying development stages as trees in different stages of growth. This removes the stigma of clinical terms like delayed. BabySteps is designed to be used over the first 5 years of a child’s life so the team is also experimenting with different interactions to keep parents engaged for example, a Twitter feed that asks questions about child development. You can find links to all of Julie’s research here.

Julie then summarized with these words of advice:

  • Embed actions in activities people are already doing
  • Provide multiple options for tracking/achieving goals
  • Balance between manual and automated tracking
  • Priortize which burdens you will resolve based on your user’s desire and what your application is intended to accomplish
  • Match the burden to the motivation level of your user

Rebecca took the stage next and tied the two previous talks together with examples from how they built Health 1-2-3 to overcome barriers to engagement in health. While 85% of people say they want to feel better, a number of factors prevent them from reaching that goal. The absence of the following can be barriers to wellness:

Awareness: Not knowing what the actual situation is. (See Marcelo’s Pet Peeve # 5 on Health Risk Assessments.)

Knowledge: Once you have awareness, what can you actually do? Health information is often not delivered in a way that is actionable.

Self-efficacy: People cannot make big changes all at once. How do you make small and incremental changes towards health?

Personalized Solutions: Generic solutions don’t speak to the person or help them take personal responsibility for their health. Personalized solutions are customized based on information about that patient and provide options appropriate for that person’s health.

Time: Solutions need to integrate with people’s lives. Behavior change cannot take so much time as to be prohibitive. What small steps can be integrated?

Support: What types of social support does a person need to make a change? For example, there are many great fitness and health communities, like Strava for cyclists, where people support each other’s goals. On the other hand, social support needs to be in the control of the person. Applications shouldn’t be posting updates on the person’s behalf.

Rebecca walked through all of the above in the context of a Health 123 demo that showed how they simply address the issues. For example, awareness takes the form of a series of simple health questions. Knowledge is tailored health information based on the questions the patients answered. Self-efficacy is addressed by making health challenges reasonable to fit into a person’s day and week.

If you’re interested in or working in health technology in Seattle, I highly recommend these meetups. The content and discussions are packed with inspiration and information, and the burgeoning Seattle Health IT community needs your support.

You can find out about the next meetup here.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, M-health

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APTA Session Recap: What We Say Feeds White and Grey

“Brain‐Enhancing  Strategies for Effective Therapeutic Communication”

Speaker: Karen Mueller, PT,DPT PhD

Therapeutic outcomes are as affected by the therapist’s ability to effect behavior change in their patients as by their clinical skills. However, many healthcare professionals don’t understand the basics. This session by Karen Mueller, PT, DPT, PhD focused on strategies to help improve patient care by examining principles from positive psychology and mindfulness to develop empathy for patients.

We know from research that feeling empathy from the healthcare provider is one of the key factors in patient satisfaction. We also know that a positive relationship between patient and provider is a key factor in improving patient adherence to treatment plans. How much do we think about the impact of the provider on the patient in daily care? Does a more positive and mindful healthcare provider get better results with patients?

The session started with some background research on positive psychology and mindfulness, with reference to renowned happiness researcher Martin Seligman, Director of the Positive Psychology Department at the University of Pennsylvania, in particular the impact of positive psychology in healthcare outcomes.  Unfortunately, our brains are naturally wired towards negativity, which may have been a primitive self-protection mechanism, and it takes a 3:1 ratio of positive thoughts to overcome negative thoughts so we need to actively cultivate positive thoughts to overcome this bias.

Why is this important? Positive emotions appear to create enduring personal resources including creativity, resilience, social relationships, and overall health and well-being.

“The way we choose our words can improve the neural functioning of the brain, in fact a single word has the power to influence the expression of genes that regulate physical and emotional stress” Andrew Newberg, MD

Next the session explored mindfulness, defined clinically as the “cognitive process of directing and redirecting focused attention on an internal physiologic process” and in layman’s terms of focusing and noticing the current experience without attachment, often by using the breath as a tool. Mindfulness has been studied for its impact in healthcare, particularly for managing chronic pain but patients using mindfulness techniques have also seen improvements in fatigue and depression.

Mindfulness has also been proven to be effective in therapeutic practice when used by healthcare providers. A study by Beach et all in 2013, showed that clinicians who practiced mindfulness had an easier time building patient rapport, more patient centered communication, and ultimately more satisfied patients.

Finally the session provided practical advice for people wanting to practice mindfulness when caring for patients:

  • Understand how you are feeling before you meet with a patient. Your negative emotions can have a big impact on them. If you are stressed or burned out, help yourself so you can better help your patients.
  • Speak wisely: express appreciation, speak slowly (slower speech enhances trust and reduces anxiety), speak briefly, check for understanding
  • Listen wisely: paraphrase, don’t interrupt, look at the patient, ask questions

The session provided a comprehensive high-level survey of the topic, and pointed to a wealth of information and research studies for those wishing to explore the topic further to improve their patient care.

Posted in: Aging, Behavior Change, Healthcare motivation, Occupational Therapy

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Infographic: Factors Related to Adherence

Just as no two patients are identical, the factors that affect adherence vary dramatically from patient to patient, and also importantly what type of treatment plan they are adhering to. Adherence to medication is often affected by medication itself: side-effects, contraindications, timing, and the way it is applied. Adherence to a physical rehabilitation program is affected by the function of the patient, very often by the level of pain they feel, and sometimes by the patients own belief in their abilities. Adherence to diet is affected by so many factors including, access to appropriate food and social pressure. Even with these differences, though there are a number of common factors that affect patient adherence, both negatively and positively.

The 2008 study “Factors affecting therapeutic compliance: A review from the patient’s perspective” provides a comprehensive review of research on the subject, and presents this view of the factors.

AdherenceFactors

As a provider, there are some areas that you can influence, and some that are data points that might help inform how you approach the patient. You probably can’t impact their socio-economic situation, but you can understand how it might impact their treatment. For example, how big of a factor is cost or transportation in their ability to adhere to a program? Trying to save money often results in patients trying to take fewer pills than prescribed. We spoke with one arthritis researcher who prescribed swimming for her patients, however, for many of them the cost of a gym membership and transportation to the pool was prohibitive.

When putting together a treatment plan for a patient, it’s good to keep all of these factors in mind, working with the patient to come up with a plan in which they are most likely to succeed. Tailoring the plan to the patient lifestyle, rather than the other way around.

Posted in: Behavior Change, Healthcare motivation, Managing Chronic Disease, Uncategorized

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Resolve to Create Better Resolutions!

Tis the season to regret all the cookies, chocolate, and rich foods you ate over the last few weeks and start the New Year off right! Resolution time is here. Do you make them? Do you think they work? Do you incorporate behavioral change methods in your resolutions? Simply deciding to do something new or stop doing something old without making corresponding changes in your ability to do so will not have the impact you’re looking for.

There are three key factors that facilitate behavior change:

  1. You have to have the capability to change.
  2. You have to have the motivation or desire to change.
  3. You have to have the opportunity to change.

If these three conditions exist, you can change. So let’s say your goal for 2014 is to sit less. However, you have a job where you sit at a computer all day, and while you know that sitting is not good for you, you like your job and quite frankly your family and mortgage like your job too. You might be motivated to sit less but unless your employer supports you in this desire for example by helping you install a standing or treadmill desk, or removing all the chairs from the conference rooms, you might not have the capability to change. Or let’s say you want to walk to work but your office is 20 miles from your home in an industrial park off a freeway. Again you might have the motivation, but not the opportunity unless you are able to change jobs.

Picture of cocktail

Cocktail source: Steamykitchen.com

One year I decided that I had become old before my time (in my pajamas by 9 on a Friday, if you must know), and I made three resolutions:

  1. Drink more cocktails
  2. See more films
  3. Go to more art galleries.

Now, you’re thinking, these don’t sound like good New Year’s resolutions, but according to the factors that facilitate behavior change, I was on the right track. I had disposable income, single friends, and lived in a large metropolitan area with plenty of theatres and art galleries. Friends were more than happy to help me keep these resolutions, and I got out of my hermit-like funk and was inspired by connecting with people, the vibrancy of the city, and by art.

If you need some help designing your resolutions, first off use the simple framework. Are you capable? Are you motivated? Do you have the opportunity to make the change? If any of these is no, consider whether these factors can change. This video by behavior change expert, BJ Fogg can also help you break it down to something that is manageable.

Finally, get help! Studies show that even if friends of your friends are obese, you have a greater chance of being overweight. The same is true with positive behavior. As a long time “left-coast” dweller, I can attest to the positive transformation that happens when people move here and are surrounded by those with an active lifestyle. Get some friends together who are working towards the same goal. Start a walking group at work. Employee wellness was one of the hot topics of 2013, and while some of the promise of employer-organized wellness programs have not come to fruition, there are simple things that employees and employers can do to facilitate change. We loved these examples from the BUPA HQ in London. If any employee has the motivation, the company facilitates the opportunity.

Eat more fruit!

Eat more fruit!

Take the stairs!

Take the stairs!

Psst. Over here!

Psst. Over here!

Best in 2014 from all of us at Wellpepper for a healthy and happy year!

Posted in: Behavior Change, Healthcare motivation

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